QTc-interval abnormalities and psychotropic drug therapy in psychiatric patients

Psychoactive prescribing for older people--what difference does 15 years make?

OBJECTIVE

The objective of the study was to review prescribing of psychoactive medications for older residents of the Tayside region of Scotland.

METHODS

The analysis used community prescribing data in 1995 and 2010 for all older residents in Tayside. For each psychoactive drug class, the name of the most recently prescribed drug and the date prescribed were extracted. The relative risk (RR) and 95% confidence intervals (CI) for patients receiving psychoactive medication in 2010 were compared with those for patients in 1995. Psychoactive prescribing was analyzed by year, age, gender, and deprivation classification. The chi-squared test was used to calculate statistical significance.

RESULTS

Total psychoactive prescribing in people over the age of 65 years has increased comparing 1995 with 2010. Antidepressant [RR = 2.5 (95% CI 2.41-2.59) p < 0.001] and opioid analgesia [RR = 1.21 (1.19-1.24) p < 0.001] prescriptions increased between 1995 and 2010. Hypnotics/anxiolytic [RR = 0.69 (0.66-0.71) p < 0.001] and antipsychotic [RR = 0.83 (0.77-0.88) p < 0.001] prescriptions decreased between 1995 and 2010. An increase in psychoactive prescribing is particularly marked in lower socioeconomic groups. Patients in the least affluent fifth of the population had RR = 1.25 (1.20-1.29) [p < 0.001] of being prescribed one to two psychoactive medications and RR = 1.81 (1.56-2.10) [p < 0.001] of being prescribed three or more psychoactive medications in 2010 compared with those in 1995. The RRs for the most affluent fifth were RR = 1.14 (1.1-1.19) [p < 0.001] and RR = 1.2 (1.01-1.42) [p < 0.001] for one to two, and three or more medications, respectively.

CONCLUSION

Psychoactive medication prescribing has increased comparing 1995 with 2010, with increases disproportionately affecting patients in lower socioeconomic groups. The availability of new psychoactive drugs, safety concerns, and economic factors may explain these increases.

Blockade of Kv1.5 by paroxetine, an antidepressant drug

Paroxetine, a selective serotonin reuptake inhibitor (SSRI), has been reported to have an effect on several ion channels including human ether-a-go-go-related gene in a SSRI-independent manner. These results suggest that paroxetine may cause side effects on cardiac system. In this study, we investigated the effect of paroxetine on Kv1.5, which is one of cardiac ion channels. The action of paroxetine on the cloned neuronal rat Kv1.5 channels stably expressed in Chinese hamster ovary cells was investigated using the whole-cell patch-clamp technique. Paroxetine reduced Kv1.5 whole-cell currents in a reversible concentration-dependent manner, with an IC 50 value and a Hill coefficient of 4.11 µM and 0.98, respectively. Paroxetine accelerated the decay rate of inactivation of Kv1.5 currents without modifying the kinetics of current activation. The inhibition increased steeply between -30 and 0 mV, which corresponded with the voltage range for channel opening. In the voltage range positive to 0 mV, inhibition displayed a weak voltage dependence, consistent with an electrical distance δ of 0.32. The binding (k+1) and unbinding (k-1) rate constants for paroxetine-induced block of Kv1.5 were 4.9 µM(-1)s(-1) and 16.1 s(-1), respectively. The theoretical K D value derived by k-1/k+1 yielded 3.3 µM. Paroxetine slowed the deactivation time course, resulting in a tail crossover phenomenon when the tail currents, recorded in the presence and absence of paroxetine, were superimposed. Inhibition of Kv1.5 by paroxetine was use-dependent. The present results suggest that paroxetine acts on Kv1.5 currents as an open-channel blocker.

Antipsychotic use and unexpected death: a hospital-based case-control study

OBJECTIVE

To examine the risk of unexpected death in patients prescribed an antipsychotic. Unexpected death was defined as death occurring within 7 days of the onset of acute symptoms.

METHOD

A case-control study conducted on events occurring between July 2009 and January 2011 in a UK mental health trust providing in-patient and out-patient services.

RESULTS

The study included 100 cases (deaths) and 436 unmatched controls. Current users of antipsychotics had a lower risk of unexpected death than non-users--adjusted odds ratio (OR) 0.48 (95% CI 0.24-0.94, P = 0.033). A significant reduction in risk was seen for second-generation [adjusted OR 0.42 (95% CI 0.21-0.86, P = 0.018)], but not first-generation agents [adjusted OR 0.83 (95% CI 0.31-2.20, P = 0.706)]. Treatment with antipsychotics for any duration was associated with reduced risk. Dose and route of administration did not affect risk. In a planned secondary analysis not adjusting for cardiovascular disease, prescription of an antipsychotic was not associated with increased risk of unexpected death [adjusted OR 0.56 (95% CI 0.28-1.08, P = 0.084)].

CONCLUSION

Our findings do not support an association between current antipsychotic use and increased risk of unexpected death.

Risk factors for sudden cardiac death among patients with schizophrenia

INTRODUCTION

Patients with schizophrenia suffer from excessive premature mortality, and sudden cardiac death (SCD) is receiving growing attention as a potential cause.

AIM

The present study investigated the incidence of SCD and its risk factors in a large schizophrenia cohort.

METHODS

We enrolled a consecutive series of 8264 patients diagnosed with schizophrenia (according to DSM-III-R and DSM-IV criteria) who were admitted to a psychiatric center in northern Taiwan from January 1, 1985 through December 31, 2008. By linking with national mortality database, 64 cases of SCD were identified. The standardized mortality ratio (SMR) for SCD was estimated. The cases were matched with controls randomly selected using risk-set sampling in a 1:2 ratio. A standardized chart review process was used to collect socio-demographic and clinical characteristics and the prescribed drugs for each study subject. Multivariate conditional logistic regression analysis was used to identify correlates of SCD at the index admission and the latest admission.

RESULTS

The SMR for SCD was 4.5. For the clinical profiles at the index admission, physical disease (adjusted risk ratio [aRR]=2.91, P<.01) and aggressive behaviors (aRR=3.99, P<.01) were associated with the risk of SCD. Regarding the latest admission, electrocardiographic abnormalities (aRR=5.46, P<.05) and administration of first-generation antipsychotics (aRR=5.13, P<.01) elevated the risk for SCD. Consistently, aggressive behaviors (aRR=3.26, P<.05) were associated with increased risk as well.

CONCLUSIONS

Apart from cardiovascular profiles and antipsychotics, physical aggression is a crucial risk factor that deserves ongoing work for clarifying the mechanisms mediating SCD in schizophrenia.

Increase of Heart Rate and QTc by Amitriptyline, But Not by Venlafaxine, Is Correlated to Serum Concentration

Electrocardiographic pathologies are a common problem during antidepressant treatment. The authors investigated the association of serum concentrations of antidepressants and heart rate, QT, and QTc. Polymorphisms of NOS1AP (nitric oxide synthase 1 adaptor protein) rs10494366 and rs12143842 as potential influence factors also were considered. In the amitriptyline sample (n = 59), significant Spearman ρ correlations were found between serum concentration and QTc (r = 0.333, P = 0.010), as well as heart rate (r = 0.407, P = 0.001). Patients with a serum concentration greater than the therapeutic range (>200 ng/mL) exhibit significantly higher heart rates (87.0 ± 13.3 vs 80.0 ± 13.9, U test P = 0.011) and higher QTc values (443.8 ± 28.8 vs 427.9 ± 20.6, U test P = 0.022). Excluding the 26 patients with a serum concentration greater than the therapeutic range, patients with rs12143842 risk alleles exhibit higher heart rates and as a trend lower QT intervals with no difference in QTc. In the venlafaxine sample (n = 81), no significant association between serum concentration and heart rate, QT, or QTc was revealed. In summary, the risk for relevant electrocardiographic alterations induced by tricyclic antidepressants, such as amitriptyline, is dependent on serum concentrations. NOS1AP polymorphisms may be a genetic vulnerability factor.

QT prolongation and torsades de pointes with psychotropic agents

The unexpected and catastrophic cardiovascular effects of psychotropic drugs are well described albeit uncommon. The list of drugs which have been associated with prolonging QT interval and hence potentially causing Torsades de pointes is exhaustive. The insight into the plausible mechanisms are largely unclear. However, the practical implications of anticipating and recognizing QT prolongation cannot be overemphasized.

Electrocardiographic Screening for Prolonged QT Interval to Reduce Sudden Cardiac Death in Psychiatric Patients: A Cost-Effectiveness Analysis

IMPORTANCE

Sudden cardiac death is a leading cause of mortality in psychiatric patients. Long QT (LQT) is common in this population and predisposes to Torsades-de-Pointes (TdP) and subsequent mortality.

OBJECTIVE

To estimate the cost-effectiveness of electrocardiographic screening to detect LQT in psychiatric inpatients.

DESIGN, SETTING, AND PARTICIPANTS

We built a decision analytic model based on a decision tree to evaluate the cost-effectiveness and utility of LQT screening from a health care perspective. LQT proportion parameters were derived from an in-hospital cross-sectional study. We performed experts' elicitation to estimate the risk of TdP, given extent of QT prolongation. A TdP reduction of 65% after LQT detection was based on positive drug dechallenge rate and through adequate treatment and electrolyte adjustments. The base-case model uncertainty was assessed with one-way and probabilistic sensitivity analyses. Finally, the TdP related mortality and TdP avoidance parameters were varied in a two-way sensitivity analysis to assess their effect on the Incremental Cost-Effectiveness Ratio (ICER).

MAIN OUTCOMES AND MEASURES

Costs, Quality Ajusted Life Year (QALY), ICER, and probability of cost effectiveness thresholds ($ 10,000, $25,000, and $50,000 per QALY).

RESULTS

In the base-case scenario, the numbers of patients needed to screen were 1128 and 2817 to avoid one TdP and one death, respectively. The ICER of systematic ECG screening was $8644 (95%CI, 3144-82 498) per QALY. The probability of cost-effectiveness was 96% at a willingness-to-pay of $50,000 for one QALY. In sensitivity analyses, results were sensitive to the case-fatality of TdP episodes and to the TdP reduction following the diagnosis of LQT.

CONCLUSION AND RELEVANCE

In psychiatric hospitals, performing systematic ECG screening at admission help reduce the number of sudden cardiac deaths in a cost-effective fashion.

Higher mortality after myocardial infarction in patients with severe mental illness: a nationwide cohort study

OBJECTIVES

The aim of this study was to explore the impact of severe mental illness (SMI) on myocardial infarction survival and determine the influence of risk factor burden, myocardial infarction severity and different treatments.

DESIGN, SETTING AND PARTICIPANTS

This population-based cohort study, conducted in Sweden during the period 1997-2010, included all patients with a first diagnosis of myocardial infarction in the Swedish nationwide myocardial infarction register SWEDEHEART (n = 209 592). Exposure was defined as a diagnosis of SMI (i.e. bipolar disorder or schizophrenia) in the national patient register prior to infarction. Bias-minimized logistic regression models were identified using directed acyclic graphs and included covariates age, gender, smoking, diabetes, previous cardiovascular disease, myocardial infarction characteristics and treatment.

MAIN OUTCOME MEASURES

The outcomes were 30-day and 1-year mortality, obtained through linkage with national population registers.

RESULTS

Patients with bipolar disorder (n = 442) and schizophrenia (n = 541) were younger (mean age 68 and 63 years, respectively) than those without SMI (n = 208 609; mean age 71 years). The overall 30-day and 1-year mortality rates were 10% and 18%, respectively. Compared with patients without SMI, patients with SMI had higher 30-day [odds ratio (OR) 1.99, 95% confidence interval (CI) 1.55-2.56] and 1-year mortality (OR 2.11, 95% CI 1.74-2.56) in the fully adjusted model. The highest mortality was observed amongst patients with schizophrenia (30-day mortality: OR 2.58, 95% CI 1.88-3.54; 1-year mortality: OR 2.55, 95% CI 1.98-3.29).

CONCLUSION

SMI is associated with a markedly higher mortality after myocardial infarction, also after accounting for contributing factors. It is imperative to identify the reasons for this higher mortality.

Assessing Prolongation of the Heart Rate Corrected QT Interval in Users of Tricyclic Antidepressants: Advice to Use Fridericia Rather Than Bazett's Correction

A prolonged heart rate corrected QT interval (QTc) increases the risk of sudden cardiac death. Some methods of heart rate correction (notably Bazett) overestimate QTc in people with high heart rates. Studies suggest that tricyclic antidepressants (TCAs) can prolong the QTc and increase heart rate. Therefore, we aimed to study whether TCA-induced QTc prolongation is a false-positive observation due to overestimation at high heart rates. For this, we included 12,734 participants from the prospective population-based Rotterdam Study, with a total of 27,068 electrocardiograms (ECGs), of which, 331 during TCA use. Associations between use of TCAs, QTc, and heart rate were studied with linear repeated measurement analyses. QT was corrected for heart rate according to Bazett (QTcBazett), Fridericia (QTcFridericia), or a correction based on regression coefficients obtained from the Rotterdam Study data (QTcStatistical). On ECGs recorded during TCA use, QTcBazett was 6.5 milliseconds (95% confidence interval, 4.0-9.0) longer, and heart rate was 5.8 beats per minute (95% confidence interval, 4.7-6.9) faster than during nonuse. QTcFridericia and QTcStatistical were not statistically significantly longer during TCA use than during nonuse. Furthermore, QTcBazett was similar for ECGs recorded during TCA use and nonuse after statistical adjustment for heart rate. According to our results, TCA use does not seem to be associated with QTc prolongation. Therefore, the current advice of regulatory authorities to restrict the use of these drugs and to do regular checkups of the QTc may need to be revised. Other formulas, like Fridericia's, might be preferred.

Are the safety profiles of antipsychotic drugs used in dementia the same? An updated review of observational studies

With an increase in the global prevalence of dementia, there is also an increase in behavioural and psychological symptoms of dementia (BPSD) for which antipsychotic drugs are often used. Despite several safety warnings on antipsychotic use in dementia, there is little evidence to support the efficacy of antipsychotics in individual BPSD symptoms or to evaluate the drug safety profile by individual antipsychotic drug. There is emerging but scarce evidence that suggests an inter-drug variability between antipsychotic safety outcomes in BPSD. The objective of this review was to examine the existing literature on antipsychotic drug use in dementia patients; in particular to see whether inter-drug differences regarding antipsychotic safety were reported. A literature search was conducted for observational studies published in the English language from 2004 to 2014 that reported the risk of all-cause mortality, cerebrovascular events, pneumonia and other outcomes such as hip/femur fracture, deep vein thrombosis (DVT) and hyperglycaemia. Six of 16 mortality studies (38%), 7 of 28 stroke studies (25%), 1 of 6 pneumonia (17%) studies and 2 of 6 fracture studies (33%) investigated inter-drug safety outcomes in elderly patients/dementia patients, while to our knowledge, there are no studies investigating the inter-drug variation of deep-vein thrombosis and hyperglycaemia risk. The results of the observational studies provide mixed results on the safety of antipsychotics in BPSD but it is clear that there are differences between the safety profiles of antipsychotic drugs. Robust evidence of such inter-drug variability could significantly improve patient safety as antipsychotics become more targeted to clinical risk factors.

Assessment and management of behavioral and psychological symptoms of dementia

Behavioral and psychological symptoms of dementia include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of inappropriate behaviors. One or more of these symptoms will affect nearly all people with dementia over the course of their illness. These symptoms are among the most complex, stressful, and costly aspects of care, and they lead to a myriad of poor patient health outcomes, healthcare problems, and income loss for family care givers. The causes include neurobiologically related disease factors; unmet needs; care giver factors; environmental triggers; and interactions of individual, care giver, and environmental factors. The complexity of these symptoms means that there is no "one size fits all solution," and approaches tailored to the patient and the care giver are needed. Non-pharmacologic approaches should be used first line, although several exceptions are discussed. Non-pharmacologic approaches with the strongest evidence base involve family care giver interventions. Regarding pharmacologic treatments, antipsychotics have the strongest evidence base, although the risk to benefit ratio is a concern. An approach to integrating non-pharmacologic and pharmacologic treatments is described. Finally, the paradigm shift needed to fully institute tailored treatments for people and families dealing with these symptoms in the community is discussed.

QTc prolongation in schizophrenia patients in Asia: clinical correlates and trends between 2004 and 2008/2009

OBJECTIVE

Little is known about the pattern of QT interval (QTc) prolongation in Asian patients with schizophrenia. This study examined trends of QTc prolongation in schizophrenia inpatients in six Asian countries and territories between 2004 and 2008/2009 and its independent demographic and clinical correlates.

METHOD

Data on 3482 hospitalized schizophrenia patients (2004 = 1826 and 2008/2009 = 1656) in six Asian countries and territories were collected by either chart review or interviews during a 1-month period. Patients' sociodemographic and clinical characteristics, prescriptions of psychotropic drugs, and QTc interval were recorded using a standardized protocol and data collection procedure.

RESULTS

The frequency of QTc prolongation (>456 ms) was 2.4% in the whole sample, decreasing from 3.1% in 2004 to 1.6% in 2008/2009 (p = 0.004) with wide intercountry variations. However, this decreased trend was driven by decreased QTc prolongation detected in China and Hong Kong (both p-values < 0.05). Multiple logistic regression analysis of the whole sample revealed that patients having more likely to have an illness lasting longer than 5 years and received antipsychotics classified as list-1 drugs according to the Arizona Centre for Education and Research on Therapeutics. Compared with 2004, patients in 2008/2009 were less likely to have QTc prolongation. Thioridazine caused QTc prolongation most frequently (odds ratio (OR) 4.4; 95% confidence interval (CI) 1.2-15.2), followed by sulpiride (OR 2.4; 95% CI 1.3-4.5), clozapine (OR 2.4; 95% CI 1.4-4.2), and chlorpromazine (OR 1.9; 95% CI 1.07-3.5).

CONCLUSIONS

Frequency of QTc prolongation was low in Asian patients with schizophrenia. QTc prolongation in schizophrenia decreased in China and Hong Kong between 2004 and 2008/2009 but increased in Taiwan over the same period, remaining low in the other countries.

Etiology of cardiovascular disease in patients with schizophrenia: current perspectives

Cardiovascular morbidity and mortality are important problems among patients with schizophrenia. A wide spectrum of reasons, ranging from genes to the environment, are held responsible for causing the cardiovascular risk factors that may lead to shortening the life expectancy of patients with schizophrenia. Here, we have summarized the etiologic issues related with the cardiovascular risk factors in schizophrenia. First, we focused on heritable factors associated with cardiovascular disease and schizophrenia by mentioning studies about genetics-epigenetics, in the first-episode or drug-naïve patients. In this context, the association and candidate gene studies about metabolic disturbances in schizophrenia are reviewed, and the lack of the effects of epigenetic/posttranscriptional factors such as microRNAs is mentioned. Increased rates of type 2 diabetes mellitus and disrupted metabolic parameters in schizophrenia are forcing clinicians to struggle with metabolic syndrome parameters and related issues, which are also the underlying causes for the risk of having cardiometabolic and cardiovascular etiology. Second, we summarized the findings of metabolic syndrome-related entities and discussed the influence of the illness itself, antipsychotic drug treatment, and the possible disadvantageous lifestyle on the occurrence of metabolic syndrome (MetS) or diabetes mellitus. Third, we emphasized on the risk factors of sudden cardiac death in patients with schizophrenia. We reviewed the findings on the arrhythmias such as QT prolongation, which is a risk factor for Torsade de Pointes and sudden cardiac death or P-wave prolongation that is a risk factor for atrial fibrillation. For example, the use of antipsychotics is an important reason for the prolongation of QT and some other cardiac autonomic dysfunctions. Additionally, we discussed relatively rare issues such as myocarditis and cardiomyopathy, which are important for prognosis in schizophrenia that may have originated from the use of antipsychotic medication. In conclusion, we considered that the studies and awareness about physical needs of patients with schizophrenia are increasing. It seems logical to increase cooperation and shared care between the different health care professionals to screen and treat cardiovascular disease (CVD)-risk factors, MetS, and diabetes in patients with psychiatric disorders, because some risk factors of MetS or CVD are avoidable or at least modifiable to decrease high mortality in schizophrenia. We suggested that future research should focus on conducting an integrated system of studies based on a holistic biopsychosocial evaluation.

Olanzapine induced Q-Tc shortening

INTRODUCTION

Prolongation of Q-Tc interval is commonly accepted as a surrogate marker for the ability of a drug to cause torsade de pointes. In the present study, safety of olanzapine versus risperidone was compared among a group of patients with schizophrenia to see the frequency of the electrocardiographic alterations induced by those atypical antipsychotics.

METHOD

Two hundred and sixty-eight female inpatients with schizophrenia entered in one of the two parallel groups to participate in an open study for random assignment to olanzapine (n = 148) or risperidone (n = 120). Standard 12-lead surface electrocardiogram (ECG) was taken from each patient at baseline, before initiation of treatment, and then at the end of management, just before discharge. The parameters that were assessed included heart rate (HR), P-R interval, QRS interval, Q-T interval (corrected = Q-Tc), ventricular activation time (VAT), ST segment, T wave, axis of QRS, and finally, interventricular conduction process.

RESULTS

A total of 37.83% of cases in the olanzapine group and 30% in the risperidone group showed some Q-Tc changes; 13.51% and 24.32% of the patients in the olanzapine group showed prolongation and shortening of the Q-Tc, respectively, while changes in the risperidone group were restricted to only prolongation of Q-Tc. Comparison of means showed a significant increment in Q-Tc by risperidone (p = 0.02). Also, comparison of proportions in the olanzapine group showed significantly more cases with shortening of Q-Tc versus its prolongation (p = 0.01). No significant alterations with respect to other variables were evident.

CONCLUSION

Olanzapine and risperidone had comparable potentiality for induction of Q-Tc changes, while production of further miscellaneous alterations in ECG was more observable in the olanzapine group compared with the risperidone group. Also shortening of Q-Tc was specific to olanzapine.

Droperidol for the Treatment of Acute Migraine Headaches

Objective: To evaluate the safety and efficacy of droperidol for the relief of acute migraine headaches. Data Sources: A MEDLINE search (1946 to August 2014) was performed using the following keywords and associated medical subject headings: droperidol, inapsine, headache, migraine, and migraine disorder.Study Selection and Data Extraction: The search was conducted to identify randomized controlled trials comparing droperidol with placebo or an active control in adult patients with acute migraine headaches that were published in English. Primary end points included acute headache improvement after the intervention. Safety end points included the frequency of extrapyramidal symptoms, somnolence, and cardiac adverse effects. Data Synthesis: In all, 5 manuscripts are included in this review. Patients presenting to the emergency department with acute headache desire rapid pain relief, which was the primary objective in each of the evaluated studies. Droperidol was better than placebo and at least as effective as comparator drugs such as prochlorperazine, meperidine, or olanzapine using droperidol doses of 2.5 to 5 mg, given either intramuscularly (IM) or intravenously (IV). The most commonly reported adverse effects were extrapyramidal symptoms and sedation. Cardiac adverse effects were not reported in any of the studies; however, only 2 articles described using cardiac monitoring. Conclusions: Parenteral droperidol is an effective option for the treatment of acute migraine. The minimum effective dose is 2.5 mg given IM or IV. Clinicians must be aware of the risk for adverse events, select appropriate patients, perform EKG monitoring for patients at risk of QTc prolongation, and institute treatment if necessary.

Risk factors for QT prolongation associated with acute psychotropic drug overdose

BACKGROUND

Antipsychotic/Antidepressant use is a risk factor for QT interval (QT) prolongation and sudden cardiac death. However, it is unclear which drugs are risk factors for QT prolongation and torsades de pointes in cases of psychotropic drug overdose.

METHODS

After correction of QT data by Bazett formula (QTc), QTc was classified into 3 categories (QTc<440 milliseconds, 440 milliseconds≤QTc<500 milliseconds, and QTc≥500 milliseconds), and the blood concentration of each drug was classified as not detected, therapeutic range, or toxic range. The association of the blood concentration of each drug with QTc was analyzed using the ordinal logistic regression model. Drugs that induced QT-heart rate pairs higher than the at-risk line of Isbister's QT-heart rate nomogram (QT nomogram) were further analyzed using the binomial logistic regression model.

RESULTS

A total of 649 patients were enrolled in the study. The independent risk factors for QTc prolongation were therapeutic and toxic range of phenotiazine antipsychotic drug (therapeutic range: odds ratio [OR], 1.56 [P=.039]; toxic range: OR, 3.85 [P<.001]), and toxic range of cyclic antidepressants (OR, 2.39; P=.018). In addition, toxic range of phenotiazine antipsychotic drug (OR, 3.87; P=.012) and tricyclic antidepressants (OR, 4.94; P<.001) were risk factors for QT higher than the at-risk line of the QT nomogram.

CONCLUSIONS

The possibility of QT prolongation and torsades de pointes due to overdose of phenotiazine antipsychotic drug or tricyclic antidepressants requires particular consideration.

Analysis of West Virginia medicaid claims data for the prevalence of medical conditions and use of drugs likely to cause QT prolongation in patients with schizophrenia

BACKGROUND

An important concern with antipsychotic drugs used for the treatment of schizophrenia is the prolongation of the QT interval on the electrocardiogram. Concomitant use of other QT-prolonging drugs and the presence of certain medical conditions may lead to excessive QT prolongation and subsequent cardiac arrhythmias.

OBJECTIVE

The aim of this study was to assess the utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation in a large population of patients with schizophrenia in practice settings.

METHODS

The study was conducted using West Virginia Medicaid claims data for patients aged 18 to 64 years with ≥1 medical claim for schizophrenia between January 1, 1997, and December 31, 1999. A comprehensive list of drugs and medical conditions causing QT prolongation was obtained from the literature. The drugs were identified in the prescription claims data using their specific National Drug Classification codes. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, were used to identify the medical conditions as described in the medical claims files. Descriptive statistics on utilization of drugs and prevalence of medical conditions were reported and demographic differences were examined.

RESULTS

The final sample consisted of 1699 patients with schizophrenia. The mean (SD) age was 40.8 (11.35) years (range, 18-63 years); 55% of the patients were women. A total of 76.9% of patients utilized ≥1 nonantipsychotic QT-prolonging drug in a year, with a mean (SD) of 2.1 (1.3) such drugs used per patient per year. A total of 15.9% of patients with schizophrenia had ≥1 medical condition associated with QT prolongation. Patients with ≥1 such medical condition had a mean (SD) of 1.2 (0.57) conditions potentially causing QT prolongation. The number of nonantipsychotic QT-prolonging prescriptions filled and the prevalence of medical conditions leading to QT prolongation were found to be significantly higher for women (both P<0.001) and patients aged 34 to 64 years (both P<0.001).

CONCLUSIONS

In this study, a high utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation were found. These results merit assessment of predisposing risk factors, such as concurrent use of other QT-prolonging drugs and the presence of cardiovascular and other conditions associated with QT prolongation, before prescribing antipsychotics, especially in women and older patients with schizophrenia.

Antipsychotic drugs: atypical advantages and typical disadvantages

Atypical antipsychotic drugs are recommended for the first line treatment of all patients with schizophrenia. This is because it has been demonstrated that atypical antipsychotic drugs are more effective across a broader range of symptoms of schizophrenia than typical antipsychotic drugs and because they are dramatically less likely to cause the extrapyramidal and endocrine side effects that greatly impair quality of life for patients and reduce their willingness to adhere to maintenance treatment. Atypical antipsychotic drugs are not perfect but they are the most effective and the safest treatment for schizophrenia presently available. The atypical antipsychotic drugs currently marketed in Ireland for the first line treatment of schizophrenia include amisulpride, olanzapine, quetiapine, risperidone and ziprasidone. These agents differ somewhat in chemical class, indications, daily dose range, need for titration, daily dosing regimen and available formulations (see Table 1). Clozapine is marketed for patients unresponsive to, or intolerant of, other antipsychotic drugs and must thus be regarded as a second line treatment for schizophrenia. Zotepine is not yet available in Ireland while the marketing of sertindole has been suspended following reports of arrhythmias and sudden cardiac deaths.

Withdrawal of antipsychotic drugs from adults with intellectual disabilities

Objectives: There is a view that antipsychotic drugs can be successfully withdrawn from people with intellectual disabilities with resultant health gain. This study critically examines whether antipsychotic drug withdrawal is beneficial.

Methods: 119 adults with intellectual disabilities were included in a programme of antipsychotic drug withdrawal.

Results: The clinical outcomes of this programme are poor. Only 7.6% completely withdrew from antipsychotic drugs, and 48.7% experienced onset/deterioration in problem behaviours or mental ill-health. Significant drug side effects with the introduction of new drugs were experienced by 23.3%. Resultant mean antipsychotic drug doses were higher compared with those at the start of the programme. The cost to the intellectual disabilities psychiatric service (over and above that of routine psychiatric care) was £258,050 (€391,693), and the human cost was considered high. Primary care, social care and family costs were not calculated. The only specific factors found to be associated with poor outcome were increased severity of intellectual disabilities and female gender.

Conclusions: The successful role of antipsychotic drugs in the management of problem behaviours in people who do not have verbal communication skills may relate to the pathoplastic effect of intellectual disabilities on clinical presentation, with problem behaviours being markers of eg. psychosis and anxiety disorders. Our original findings challenge the view that routine withdrawal of antipsychotic drugs is good practice; we reinterpret the existing literature, and recommend caution and vigilance in pharmacotherapy.

QT is longer in drug-free patients with schizophrenia compared with age-matched healthy subjects

The potassium voltage-gated channel KCNH2 is a well-known gene in which mutations induce familial QT interval prolongation. KCNH2 is suggested to be a risk gene for schizophrenia. Additionally, the disturbance of autonomic control, which affects the QT interval, is known in schizophrenia. Therefore, we speculate that schizophrenic patients have characteristic features in terms of the QT interval in addition to the effect of antipsychotic medication. The QT interval of patients with schizophrenia not receiving antipsychotics (n = 85) was compared with that of patients with schizophrenia receiving relatively large doses of antipsychotics (n = 85) and healthy volunteers (n = 85). The QT interval was corrected using four methods (Bazett, Fridericia, Framingham or Hodges method). In ANCOVA with age and heart rate as covariates, patients not receiving antipsychotic treatment had longer QT intervals than did the healthy volunteers, but antipsychotics prolonged the QT interval regardless of the correction method used (P<0.01). Schizophrenic patients with and without medication had a significantly higher mean heart rate than did the healthy volunteers, with no obvious sex-related differences in the QT interval. The QT interval prolongation may be manifestation of a certain biological feature of schizophrenia.

Frequency of use of QT-interval prolonging drugs in psychiatry in Belgium

INTRODUCTION

Drug-induced QT-prolongation is an established risk factor for Torsade de pointes and sudden cardiac death. The list of QT-prolonging drugs is extensive and includes many drugs commonly used in psychiatry.

AIM

In this study we performed a cross-sectional analysis of medication profiles to assess the prevalence of drug interactions potentially leading to QT-prolongation.

SETTING

6 psychiatric hospitals in Flanders, Belgium.

METHODS

For each patient, the full medication list was screened for the presence of interactions, with special attention to those with an increased risk for QT-prolongation. Current practice on QT monitoring and prevention of drug-induced arrhythmia was assessed.

MAIN OUTCOME MEASURE

Number of drug interactions with risk of QT-prolongation.

RESULTS

592 patients (46 % female; mean age 55.7 ± 17.1 years) were included in the analysis. 113 QT-prolonging interactions were identified in 43 patients (7.3 %). QT-prolonging interactions occurred most frequently with antidepressants (n = 102) and antipsychotics (n = 100). The precautions and follow-up provided by the different institutions when combining QT-prolonging drugs were very diverse.

CONCLUSION

Drug combinations that are associated with QT-prolongation are frequently used in the chronic psychiatric setting. Persistent efforts should be undertaken to provide caregivers with clear guidelines on how to use these drugs in a responsible and safe way.

Do antidepressants prolong the QT interval?

According to a recent cross-sectional study, some antidepressants, including amitriptyline, citalopram and escitalopram, are associated with QTc prolongation. However, the magnitude of this association is relatively small, and the clinical implications uncertain. In this article, the main strengths and weaknesses of this cross-sectional study are briefly analysed alongside recent warnings issued by regulatory authorities. Implications for research and practice are discussed.

Use and safety of antipsychotics in behavioral disorders in elderly people with dementia

In recent years, the use of antipsychotics has been widely debated for reasons concerning their safety in elderly patients affected with dementia. To update the use of antipsychotics in elderly demented people, a MEDLINE search was conducted using the following terms: elderly, conventional and atypical antipsychotics, adverse events, dementia, and behavioral and psychotic symptoms in dementia (BPSD). Owing to the large amounts of studies on antipsychotics, we mostly restricted the field of research to the last 10 years. Conventional antipsychotics have been widely used for BPSD; some studies showed they have an efficacy superior to placebo only at high doses, but they are associated with several and severe adverse effects. Atypical antipsychotics showed an efficacy superior to placebo in randomized studies in BPSD treatment, with a better tolerability profile versus conventional drugs. However, in 2002, trials with risperidone and olanzapine in elderly patients affected with dementia-related psychoses suggested the possible increase in cerebrovascular adverse events. Drug regulatory agencies issued specific recommendations for underlining that treatment of BPSD with atypical antipsychotics is "off-label." Conventional antipsychotics showed the same likelihood to increase the risk of death in the elderly as atypical agents, and they should not replace the atypical agents discontinued by Food and Drug Administration warnings. Before prescribing an antipsychotic drug, the following are factors to be seriously considered: the presence of cardiovascular diseases, QTc interval on electrocardiogram, electrolytic imbalances, familiar history for torsades des pointes, concomitant treatments, and use of drugs able to lengthen QTc. Use of antipsychotics in dementia needs a careful case-by-case assessment, together with the possible drug-drug, drug-disease, and drug-food interactions.

A naturalistic comparison study of the efficacy and safety of intramuscular olanzapine, intramuscular haloperidol, and intramuscular levomepromazine in acute agitated patients with schizophrenia

OBJECTIVE

This study was a comparative investigation of the clinical efficacy and safety of intramuscular (IM) olanzapine, IM haloperidol, and IM levomepromazine in acute agitated patients with schizophrenia.

METHODS

The subjects were 122 inpatients. Their clinical symptoms were assessed using Positive and Negative Syndrome Scale Excited Component (PANSS-EC), PANSS, and Agitation-Calmness Evaluation Scale, and their safety were assessed using the Abnormal Involuntary Movement Scale, Barnes Akathisia Rating Scale (BARS), and Drug-induced Extrapyramidal Symptoms Scale (DIEPSS).

RESULTS

The mean changes from baseline on the PANSS-EC, Agitation-Calmness Evaluation Scale, Abnormal Involuntary Movement Scale, BARS, and DIEPSS scores were significantly better in both IM olanzapine and IM levomepromazine than in IM haloperidol. Of these, the mean changes from baseline on the BARS and DIEPSS scores were significantly better in IM olanzapine than in IM levomepromazine. The mean change from baseline on the PANSS positive score was significantly better in both IM olanzapine and IM haloperidol than in IM levomepromazine.

CONCLUSIONS

The results of this study suggest the possibility that the anti-agitation effects of IM olanzapine and IM levomepromazine are more rapid than those of IM haloperidol. No worsening of EPS was observed. Our results also suggest that compared with IM levomepromazine, IM olanzapine is safer and affords greater improvement in symptoms.

Mechanism of hERG channel block by the psychoactive indole alkaloid ibogaine

Ibogaine is a psychoactive indole alkaloid. Its use as an antiaddictive agent has been accompanied by QT prolongation and cardiac arrhythmias, which are most likely caused by human ether a go-go-related gene (hERG) potassium channel inhibition. Therefore, we studied in detail the interaction of ibogaine with hERG channels heterologously expressed in mammalian kidney tsA-201 cells. Currents through hERG channels were blocked regardless of whether ibogaine was applied via the extracellular or intracellular solution. The extent of inhibition was determined by the relative pH values. Block occurred during activation of the channels and was not observed for resting channels. With increasing depolarizations, ibogaine block grew and developed faster. Steady-state activation and inactivation of the channel were shifted to more negative potentials. Deactivation was slowed, whereas inactivation was accelerated. Mutations in the binding site reported for other hERG channel blockers (Y652A and F656A) reduced the potency of ibogaine, whereas an inactivation-deficient double mutant (G628C/S631C) was as sensitive as wild-type channels. Molecular drug docking indicated binding within the inner cavity of the channel independently of the protonation of ibogaine. Experimental current traces were fit to a kinetic model of hERG channel gating, revealing preferential binding of ibogaine to the open and inactivated state. Taken together, these findings show that ibogaine blocks hERG channels from the cytosolic side either in its charged form alone or in company with its uncharged form and alters the currents by changing the relative contribution of channel states over time.

A naturalistic comparison of the efficacy and safety of intramuscular olanzapine and intramuscular haloperidol in agitated elderly patients with schizophrenia

OBJECTIVE

This study was a comparative investigation of the clinical efficacy and safety of intramuscular (IM) olanzapine and IM haloperidol in agitated elderly patients with schizophrenia at 2 hours postdose.

METHODS

The subjects were 23 inpatients who had been diagnosed with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Their clinical symptoms were assessed using Positive and Negative Syndrome Scale Excited Component (PANSS-EC), PANSS and Agitation Calmness Evaluation Scale (ACES), and their safety were assessed using the Abnormal Involuntary Movement Scale (AIMS), Barnes Akathisia Rating Scale (BARS), Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS) and laboratory tests.

RESULTS

The mean reduction from baseline on the PANSS-EC total score, the PANSS total score and the ACES score were significantly greater in the IM olanzapine injection group than in the IM haloperidol injection group. The mean changes from baseline on the AIMS score, the BARS score and the DIEPSS total score were significantly better in the IM olanzapine injection group than in the IM haloperidol injection group. No serious adverse events such as paralytic ileus, diabetic ketoacidosis, neuroleptic malignant syndrome or tardive dyskinesia occurred between the two groups.

CONCLUSION

The results of this study suggest the possibility that agitated elderly patients may result in superior efficacy and safety after IM olanzapine without serious adverse events in comparison with IM haloperidol.

Guideline-concordant antipsychotic use and mortality in schizophrenia

OBJECTIVE

To determine if care concordant with 2009 Schizophrenia Patient Outcomes Research Team (PORT) pharmacological recommendations for schizophrenia is associated with decreased mortality.

METHODS

We conducted a retrospective cohort study of adult Maryland Medicaid beneficiaries with schizophrenia and any antipsychotic use from 1994 to 2004 (N = 2132). We used Medicaid pharmacy data to measure annual and average antipsychotic continuity, to calculate chlorpromazine (CPZ) dosing equivalents, and to examine anti-Parkinson medication use. Cox proportional hazards regression models were used to examine the relationship between antipsychotic continuity, antipsychotic dosing, and anti-Parkinson medication use and mortality.

RESULTS

Annual antipsychotic continuity was associated with decreased mortality. Among patients with annual continuity greater than or equal to 90%, the hazard ratio [HR] for mortality was 0.75 (95% confidence interval [CI] 0.57-0.99) compared with patients with annual medication possession ratios (MPRs) of less than 10%. The HRs for mortality associated with continuous annual and average antipsychotic continuity were 0.75 (95% CI 0.58-0.98) and 0.84 (95% CI 0.58-1.21), respectively. Among users of first-generation antipsychotics, doses greater than or equal to 1500 CPZ dosing equivalents were associated with increased risk of mortality (HR 1.88, 95% CI 1.10-3.21), and use of anti-Parkinson medication was associated with decreased risk of mortality (HR 0.72, 95% CI 0.55-0.95). Mental health visits were also associated with decreased mortality (HR 0.96, 95% CI 0.93-0.98).

CONCLUSIONS

Adherence to PORT pharmacological guidelines is associated with reduced mortality among patients with schizophrenia. Adoption of outcomes monitoring systems and innovative service delivery programs to improve adherence to the PORT guidelines should be considered.

A naturalistic comparison of the efficacy and safety of intramuscular olanzapine and intramuscular levomepromazine in agitated elderly patients with schizophrenia

BACKGROUND

There have not been any reports in Japan clarifying the efficacy and safety of intramuscular (IM) olanzapine and IM levomepromazine in agitated elderly patients with schizophrenia. This study was a comparative investigation of the clinical efficacy and safety of IM olanzapine and IM levomepromazine in agitated elderly patients with schizophrenia at 2 hours post-dose.

METHODS

The subjects were 52 inpatients who were diagnosed with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV. Their clinical symptoms were assessed using the Positive and Negative Syndrome Scale Excited Component (PANSS-EC), PANSS, and Agitation Calmness Evaluation Scale (ACES), and their safety was assessed using the Abnormal Involuntary Movement Scale (AIMS), Barnes Akathisia Rating Scale (BARS), Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS), and glucose test.

RESULTS

The PANSS-EC total score, the ACES score, and the glucose level significantly decreased from baseline in both the IM olanzapine group and the levomepromazine injection group; however, no between-group differences were observed. Mean change from baseline in the PANSS total score, positive score, the BARS score, and the DIEPSS total score was significantly greater in the IM olanzapine injection group compared with the levomepromazine injection group.

CONCLUSION

The results of this study suggest that agitated elderly patients rapidly respond to IM olanzapine and IM levomepromazine treatment. Furthermore, these results suggest that IM olanzapine is safer than IM levomepromazine and causes greater improvement in positive symptoms.

Prevalence of QTc interval changes in acute psychiatric care: a cross-sectional study

INTRODUCTION

In a case series we examined the prevalence and incidence of QT changes during a 1-week interval in hospitalized patients in a general psychiatry ward during a 6-month period.

METHOD

This cross-sectional study was done on electrocardiographic QT interval of patients admitted to the Psychiatric Department of Taleghani Hospital during a 6-month period excluding subjects with underlying cause of QT prolongation.

RESULTS

Admission and follow-up electrocardiograms of 27 men and 47 women were studied, there was significant QT prolongation during hospitalization (P value 0.001) in approximately 30% of subjects, irrespective of type of administered medication.

CONCLUSION

Pro-arrhythmic changes as reflected in QTc prolongation and QTc dispersion in electrocardiograms are common in patients admitted in psychiatric wards irrespective of type of therapy and should be screened and followed by serial electrocardiograms to minimize untoward cardiac outcomes.

Validation of a population-based method to assess drug-induced alterations in the QT interval: a self-controlled crossover study

PURPOSE

The purpose of this study was to ascertain, in the context of an integrated health care delivery system, the association between a comprehensive list of drugs known to have potential QT liability and QT prolongation or shortening.

METHODS

By using a self-controlled crossover study with 59 467 subjects, we ascertained intra-individual change in log-linear regression-corrected QT (QTcreg ) during the period between 1995 and mid-2008 for 90 drugs while adjusting for age, gender, race/ethnicity, comorbid conditions, number of electrocardiograms (ECGs), and time between pre-ECG and post-ECG. The proportion of users of each drug-developing incident long QT was also estimated.

RESULTS

Two drugs (nicardipine and levalbuterol) had no statistically significant intra-individual QTcreg shortening effects, 10 drugs had no statistically significant prolonging effect, and 78 (87%) of the drugs had statistically significant intra-individual mean QTcreg lengthening effects, ranging from 7.6 ms for aripiprazole to 25.2 ms for amiodarone. Three drugs were associated with mean QTcreg prolongation of 20 ms or greater: amiodarone (antiarrhythmic), terfenadine (antihistaminic), and quinidine (antiarrhythmic); whereas 11 drugs were associated with mean QTcreg prolongation of 15 ms or greater but less than 20 ms: trimipramine (tricyclic antidepressant), clomipramine (tricyclic antidepressant), disopyramide (antiarrhythmic), chlorpromazine (antipsychotic), sotalol (beta blocker), itraconazole (antifungal), phenylpropanolamine (decongestant/anorectic), fenfluramine (appetite suppressant), midodrine (antihypotensive), digoxin (cardiac glycoside/antiarrhythmic), and procainamide (antiarrhythmic).

CONCLUSIONS

QT prolonging effects were common and varied in strength. Our results lend support to past Food and Drug Administration regulatory actions and support the role for ongoing surveillance of drug-induced QT prolongation.

Health conditions in methamphetamine-dependent adults 3 years after treatment

OBJECTIVES

: Medical conditions in methamphetamine (MA) users have not been well characterized. Using both self-report and physical examination data, the aims of this study were to (1) describe the frequency of medical conditions in a sample of MA users 3 years posttreatment; (2) evaluate the association between medical conditions and MA use frequency; and (3) examine the relationship of route of administration with medical outcomes.

METHODS

: MA-dependent adults (N = 301) who participated in the Methamphetamine Treatment Project were interviewed and examined 3 years after treatment. Medical, demographic, and substance use characteristics were assessed using the Addiction Severity Index and Life Experiences Timeline. Current and lifetime medical conditions, electrocardiogram characteristics, and physical examination abnormalities were assessed.

RESULTS

: Among the most frequently reported lifetime conditions were wounds and burns (40.5%, N = 122) and severe dental problems (33%, N = 99), and a significant proportion of the sample evidenced prolonged corrected QT interval (19.6%, N = 43). Although health conditions were not associated with MA use frequency during follow-up, intravenous MA use was significantly associated with missing teeth (odds ratio = 2.4; 95% confidence interval, 1.2-4.7) and hepatitis C antibodies (odds ratio = 13.1; confidence interval, 5.6-30.1).

CONCLUSION

: In this sample of MA users, dental problems and corrected QT prolongation were observed at elevated rates. Although posttreatment MA use frequency was not associated with a majority of medical outcomes, intravenous MA use exacerbated risk for dental pathology and hepatitis C. Longer term follow-up research is needed to elucidate health trajectories of MA users.

Agitation and aggression in people with Alzheimer's disease

PURPOSE OF REVIEW

Agitation and aggression commonly arise in people with Alzheimer's disease (AD) and other dementias. They are distressing for the individual and often confer risk to them and to others, as well as raising significant clinical challenges. This review outlines the current evidence for pharmacological and nonpharmacological approaches to the treatment of agitation and aggression in these patients.

RECENT FINDINGS

There is a growing body of literature supporting the use of nonpharmacological approaches as well as the treatment of pain as a first-line management strategy prior to psychopharmacotherapy. Antipsychotic medications are most commonly prescribed to address agitation and aggression. Evidence indicates this approach results in a modest but significant improvement in aggression in the short term (6-12 weeks) although the impact on other symptoms of agitation is limited. There is less positive evidence to support their use in the longer term, and prescriptions of more than 12 weeks and longer periods of prescription are associated with cumulative risk of severe adverse events, including death. Suggested pharmacological alternatives with the most promising preliminary evidence include memantine, carbamazepine, citalopram, and prazosin, but none of these agents have sufficient evidence in treating agitation and aggression to recommend use in routine clinical practice.

SUMMARY

Currently, the best approach for managing these symptoms is within a framework of good practice that promotes prevention, monitoring and the use of nonpharmacological alternatives, with judicious short-term use of antipsychotics, when appropriate.

Sex differences in the effect of four second-generation antipsychotics on QTc interval in patients with schizophrenia

OBJECTIVE

We examined sex differences in the effect of olanzapine (OLZ), risperidone (RIS), aripiprazole (ARP), or quetiapine (QTP) on mean corrected QT (QTc) intervals among 222 patients with schizophrenia.

METHODS

Subjects were patients with schizophrenia who were treated with either OLZ (n = 69), RIS (n = 60), ARP (n = 62), or QTP (n = 31). Electrocardiographic measurements were conducted, and the QT interval was corrected using Bazett's correction formula.

RESULTS

The mean QTc interval of the QTP group was significantly longer than that of the RIS group (p = 0.002) or ARP group (p = 0.029). The mean QTc interval of the OLZ group was also significantly longer than that of the RIS group (p = 0.006). In female participants, the difference in the mean QTc interval among the four second-generation antipsychotic (SGA) groups was statistically significant (p = 0.002), whereas in male patients, there was no significant difference in the mean QTc interval among the four SGA groups. Post hoc analyses showed that sex differences in QTc interval were observed only in OLZ treatment group (p = 0.007).

CONCLUSION

To our knowledge, this is the first study to demonstrate sex differences in the effect of four SGAs on the QTc interval.

Poisoning: fact or fiction?

Analytical toxicology is a complex discipline. Simply detecting a poison in a biological sample does not necessarily mean that the individual from whom the sample was obtained had been poisoned. An analysis can prove exposure and perhaps give an indication of the magnitude of exposure, but the results have to be placed in proper context. Even if sampling was ante-mortem an analysis does not necessarily prove the effects that the drug or poison had on the victim immediately before or at the time of sampling. Tolerance is one big issue, the mechanism of exposure (how the drug got into the body) is another, and of course with post-mortem work there are always additional considerations such as site of sample collection and the possibility of post-mortem change in analyte concentration. There are also questions of quality and reliability, and whether a particular analysis and the interpretation placed upon the result are appropriate in a particular case.

A randomized, double-blind, placebo-controlled study of rapid-acting intramuscular olanzapine in Japanese patients for schizophrenia with acute agitation

BACKGROUND

Olanzapine rapid-acting intramuscular (IM) injection is an atypical antipsychotic drug already used overseas and recently approved in Japan. The objective of this study was to confirm the efficacy of rapid-acting IM olanzapine 10 mg was greater than IM placebo in patients with exacerbation of schizophrenia with acute psychotic agitation by comparing changes from baseline to 2 hours after the first IM injection, as measured by the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) total score.

METHODS

We conducted a placebo-controlled, randomized, double-blind, parallel-group study in Japanese patients diagnosed with schizophrenia according to the diagnostic criteria specified in the DSM-IV-TR. Patients were randomized to 2 treatment groups: IM olanzapine (10 mg) or IM placebo. The primary efficacy outcome was the change in PANSS-EC from baseline to 2 hours after the first IM injection. Treatment groups were compared with an analysis of variance model which included treatment and site as factors. During the 24-hour treatment period, safety was assessed by clinical examination and laboratory investigations, electrocardiograms, extrapyramidal symptoms scales, and recording spontaneously reported adverse events.

RESULTS

Of the 91 randomized patients, 90 patients (45 IM olanzapine-group; 45 IM placebo-group) were in the full analysis set. The mean change of PANSS-EC total score from baseline to 2 hours after the first IM injection (mean±standard deviation) was -9.2±4.5 for the IM olanzapine group and -2.8±5.6 for the IM placebo group. The difference between treatment groups was statistically significant (p<.001). There were no deaths, serious adverse events, treatment-emergent adverse events (TEAEs) leading to discontinuation, severe TEAEs, or instances of oversedation in this study. There were no statistically significant differences between treatment groups in the proportion of patients with potentially clinically significant changes in laboratory tests, vital signs (blood pressure and pulse rate), electrocardiograms, and treatment-emergent extrapyramidal symptoms.

CONCLUSION

The efficacy of IM olanzapine 10 mg in patients with exacerbation of schizophrenia with acute psychotic agitation was greater than IM placebo in the primary efficacy measure, PANSS-EC. Intramuscular olanzapine 10 mg was shown to be generally safe and tolerable, and could be a new option for treatment of schizophrenia in Japan.

TRIAL REGISTRATION

NCT00970281.

A computerized physician order entry set designed to improve safety of intravenous haloperidol utilization: a retrospective study in agitated hospitalized patients

BACKGROUND

Intravenous haloperidol can increase the risk for corrected QT (QTc) interval prolongation, torsades de pointes (TdP) and sudden death.

OBJECTIVE

The purpose of this study was to examine the effects of implementation of a computerized physician order entry (CPOE) set on adherence to monitoring parameters, maximum and cumulative doses, and identification or mitigation of risk factors for QTc prolongation in patients prescribed intravenous haloperidol.

METHODS

A retrospective cohort study of medically ill hospitalized inpatients prescribed intravenous haloperidol was conducted. Data were collected for two distinct 1-year time periods: the pre-CPOE set period (30 June 2007 through 30 June 2008) and the post-CPOE set period (1 January 2009 through 1 January 2010). The CPOE set was implemented on 1 October 2008.

RESULTS

A total of 151 subjects were included; 84 subjects were in the pre-CPOE set group and 67 subjects were in the post-CPOE set group. Following CPOE set implementation, subjects in the post-CPOE group, compared with the pre-CPOE group, were more likely to receive a 24-hour cumulative dose of intravenous haloperidol <2 mg (Fisher's exact test; p < 0.048), have a baseline ECG (Fisher's exact test; p = 0.045), have a follow-up ECG within 24 hours of intravenous haloperidol administration (Fisher's exact test; p = 0.009) and have a magnesium value assessed at the time of intravenous haloperidol administration (Fisher's exact test; p = 0.004).

CONCLUSION

This study reports on the successful implementation of a CPOE set designed to improve the safety of intravenous haloperidol administration in medically ill patients.