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Khalid J, Aparasu RR. Adverse effects associated with antipsychotic use in older adults. Expert Opin Drug Saf 2024; 23:1157-1171. [PMID: 39076106 DOI: 10.1080/14740338.2024.2386377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 06/17/2024] [Accepted: 07/16/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION Antipsychotic (AP) medications are extensively utilized for diverse psychiatric and non-psychiatric conditions, but they are associated with significant adverse effects in older adults. This expert opinion review provides an updated profile of adverse effects associated with AP medications in older adults. AREAS COVERED This review specifically examines real-world evidence for adverse events associated with AP use, including all-cause mortality, falls and fractures, diabetes, cardiovascular and cerebrovascular events, acute kidney injury, venous thromboembolism/pulmonary embolism, extrapyramidal symptoms, and infections based on real-world evidence. EXPERT OPINION This comprehensive safety review of AP revealed multiple adverse events in older adults. All-cause mortality, more associated with typical APs than atypicals, underscores a dose-dependent risk, urging cautious prescribing practices and avoidance of typical APs. Falls/fractures associated with atypical APs highlight the importance of judicious dosing and -close monitoring, especially after initiation. Cardiovascular risks, particularly stroke, with AP use emphasize the need for vigilant monitoring. Extrapyramidal symptoms, more linked to typical APs, also pose a significant risk in older adults. Pneumonia and pulmonary embolism/venous thromboembolism demand cautious consideration of APs, prompting the need for additional real-world studies to inform clinical practice. Conflicting evidence on diabetes and acute kidney injury necessitates ongoing studies and further research in older adults.
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Affiliation(s)
- Javeria Khalid
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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Cirnigliaro G, Battini V, Castiglioni M, Renne M, Mosini G, Cheli S, Carnovale C, Dell'Osso B. Evaluating the 6-month formulation of paliperidone palmitate: a twice-yearly injectable treatment for schizophrenia in adults. Expert Rev Neurother 2024; 24:325-332. [PMID: 38445396 DOI: 10.1080/14737175.2024.2325655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Paliperidone Palmitate is the only antipsychotic that has been developed in three different intramuscular long-acting injectable (LAI) dosing regimen: monthly (PP1M), quarterly (PP3M), and from 2020 also twice-yearly (PP6M). The latter was approved for the maintenance treatment of adults with schizophrenia and clinically stabilized with PP1M or PP3M. AREAS COVERED Data from studies evaluating efficacy in the maintenance treatment of schizophrenia with PP6M are reviewed. Since no post-marketing safety studies are currently available, data from spontaneous reporting system databases, FAERS and Eudravigilance, are analyzed and the reported treatment-emergent adverse events of PP6M are discussed. EXPERT OPINION The efficacy of PP6M is comparable to that of PP3M in terms of relapses prevention in patients with schizophrenia previously stabilized on PP3M or PP1M. Also, the maintenance of clinical efficacy in the long term has been demonstrated. Data from pharmacovigilance analyses, as well as from phase 3 studies, show that PP6M is generally well tolerated, consistently with PP3M safety data. PP6M allows a longer dosing interval than any other LAI antipsychotics, potentially reducing nonadherence and disease relapses. In future, an increase in the prescription rates of PP6M is expected and real-world efficacy and tolerability studies will be conducted.
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Affiliation(s)
- Giovanna Cirnigliaro
- Department of Biomedical and Clinical Sciences (DIBIC), Department of Psychiatry, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | - Vera Battini
- Pharmacovigilance & Clinical Research, International Centre for Pesticides and Health Risk Prevention, Department of Biomedical and Clinical Sciences (DIBIC), ASST Fatebenefratelli-Sacco University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Michele Castiglioni
- Department of Biomedical and Clinical Sciences (DIBIC), Department of Psychiatry, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | - Marica Renne
- Department of Biomedical and Clinical Sciences (DIBIC), Department of Psychiatry, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | - Giulia Mosini
- Pharmacovigilance & Clinical Research, International Centre for Pesticides and Health Risk Prevention, Department of Biomedical and Clinical Sciences (DIBIC), ASST Fatebenefratelli-Sacco University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Stefania Cheli
- Pharmacovigilance & Clinical Research, International Centre for Pesticides and Health Risk Prevention, Department of Biomedical and Clinical Sciences (DIBIC), ASST Fatebenefratelli-Sacco University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Carla Carnovale
- Pharmacovigilance & Clinical Research, International Centre for Pesticides and Health Risk Prevention, Department of Biomedical and Clinical Sciences (DIBIC), ASST Fatebenefratelli-Sacco University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Bernardo Dell'Osso
- Department of Biomedical and Clinical Sciences (DIBIC), Department of Psychiatry, ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
- Department of Psychiatry and Behavioral Sciences, Bipolar Disorders Clinic, Stanford Medical School, Stanford University, Stanford, CA, USA
- CRC "Aldo Ravelli" for Neurotechnology & Experimental Brain Therapeutics, University of Milan, Milan, Italy
- Centro per lo studio dei meccanismi molecolari alla base delle patologie neuro-psico-geriatriche, Università degli Studi di Milano, Milan, Italy
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3
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Tandon R, Nasrallah H, Akbarian S, Carpenter WT, DeLisi LE, Gaebel W, Green MF, Gur RE, Heckers S, Kane JM, Malaspina D, Meyer-Lindenberg A, Murray R, Owen M, Smoller JW, Yassin W, Keshavan M. The schizophrenia syndrome, circa 2024: What we know and how that informs its nature. Schizophr Res 2024; 264:1-28. [PMID: 38086109 DOI: 10.1016/j.schres.2023.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 03/01/2024]
Abstract
With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.
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Affiliation(s)
- Rajiv Tandon
- Department of Psychiatry, WMU Homer Stryker School of Medicine, Kalamazoo, MI 49008, United States of America.
| | - Henry Nasrallah
- Department of Psychiatry, University of Cincinnati College of Medicine Cincinnati, OH 45267, United States of America
| | - Schahram Akbarian
- Department of Psychiatry, Icahn School of Medicine at Mt. Sinai, New York, NY 10029, United States of America
| | - William T Carpenter
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Lynn E DeLisi
- Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA 02139, United States of America
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, LVR-Klinikum Dusseldorf, Heinrich-Heine University, Dusseldorf, Germany
| | - Michael F Green
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute of Neuroscience and Human Behavior, UCLA, Los Angeles, CA 90024, United States of America; Greater Los Angeles Veterans' Administration Healthcare System, United States of America
| | - Raquel E Gur
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States of America
| | - Stephan Heckers
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN 37232, United States of America
| | - John M Kane
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Glen Oaks, NY 11004, United States of America
| | - Dolores Malaspina
- Department of Psychiatry, Neuroscience, Genetics, and Genomics, Icahn School of Medicine at Mt. Sinai, New York, NY 10029, United States of America
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannhein/Heidelberg University, Mannheim, Germany
| | - Robin Murray
- Institute of Psychiatry, Psychology, and Neuroscience, Kings College, London, UK
| | - Michael Owen
- Centre for Neuropsychiatric Genetics and Genomics, and Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Jordan W Smoller
- Center for Precision Psychiatry, Department of Psychiatry, Psychiatric and Neurodevelopmental Unit, Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States of America
| | - Walid Yassin
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States of America
| | - Matcheri Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States of America
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Loonen AJ. Putative role of immune reactions in the mechanism of tardive dyskinesia. Brain Behav Immun Health 2023; 33:100687. [PMID: 37810262 PMCID: PMC10550815 DOI: 10.1016/j.bbih.2023.100687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023] Open
Abstract
The term extrapyramidal disorders is most often used for conditions such as Parkinson's disease or Huntington's disease, but also refers to a group of extrapyramidal side effects of antipsychotics (EPS), such as tardive dyskinesia (TD). After a brief description of some clinical features of TD, this article summarizes the relatively scarce results of research on a possible link between mainly cytokine levels and TD. This data was found by systematically searching Pubmed and Embase. The limitations of these types of studies are a major obstacle to interpretation. After describing relevant aspects of the neuroinflammatory response and the neuroanatomical backgrounds of EPS, a new hypothesis for the origin of TD is presented with emphasis on dysfunctions in the striosomal compartment of the striatum and the dorsal diencephalic connection system (DDCS). It is postulated that (partly immunologically-induced) increase in oxidative stress and the dopamine-dependent immune response in classic TD proceed primarily via the DDCS, which itself is activated from evolutionarily older parts of the forebrain. Neuroinflammatory responses in the choroid plexus of the third ventricle may contribute due to its proximity to the habenula. It is concluded that direct evidence for a possible role of inflammatory processes in the mechanism of TD is still lacking because research on this is still too much of a niche, but there are indications that warrant further investigation.
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Affiliation(s)
- Anton J.M. Loonen
- Unit of PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713AV, Groningen, the Netherlands
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5
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Mills J. More than a Half-Century with Haloperidol: Glories, Disparities, and Use Today. Issues Ment Health Nurs 2023; 44:83-87. [PMID: 36630647 DOI: 10.1080/01612840.2022.2158683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Jeremy Mills
- Peninsula, a Division of Parkwest Medical Center, Knoxville, Tennessee, USA
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6
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Caroff SN. A new era in the diagnosis and treatment of tardive dyskinesia. CNS Spectr 2022; 28:4-14. [PMID: 36278439 DOI: 10.1017/s1092852922000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tardive dyskinesia (TD) is a heterogeneous, hyperkinetic movement disorder induced by dopamine-receptor blocking agents that presents a unique challenge in the treatment of psychosis. Although acceptance of TD as a serious consequence of antipsychotic treatment was resisted initially, subsequent research by many investigators in psychopharmacology contributed to a rich store of knowledge on many aspects of the disorder. While basic neuroscience investigations continue to deepen our understanding of underlying motor circuitry, past trials of potential treatments of TD focusing on a range of theoretical targets were often inconclusive. Development of newer antipsychotics promised to reduce the risk of TD compared to older drugs, but their improved tolerability unexpectedly enabled an expanding market that paradoxically both increased the absolute number of patients at risk and diminished attention to TD which was relegated to legacy status. Fortunately, development and approval of novel vesicular monoamine transporter inhibitors offered evidence-based symptomatic treatment of TD for the first time and rekindled interest in the disorder. Despite recent progress, many questions remain for future research including the mechanisms underlying TD, genetic predisposition, phenomenological diversity, whether new cases are reversible, how to implement best practices to prevent and treat TD, and whether the development of novel antipsychotics free of the risk of TD is attainable. We owe our patients the aspirational goal of striving for zero prevalence of persistent symptoms of TD in anyone treated for psychosis.
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Affiliation(s)
- Stanley N Caroff
- Behavioral Health Service, Corporal Michael J. Crescenz VA Medical Center and the Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Pai N, Acar M, Juneja P, Kouhkamari MH, Siva S, Mullan J. Antipsychotic prescribing patterns in Australia: a retrospective analysis. BMC Psychiatry 2022; 22:110. [PMID: 35148707 PMCID: PMC8840322 DOI: 10.1186/s12888-022-03755-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/28/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND To examine real-world patterns of antipsychotic use in patients with schizophrenia Australia. METHODS This retrospective cohort analysis was conducted using the Australian Commonwealth Department of Human Services Pharmaceutical Benefits Scheme (PBS) 10% sample data. Included data were for patients aged 16-years or older who initiated treatment for the first time with a PBS-reimbursed antipsychotic medication for schizophrenia between July 2013 and September 2017. Patterns of treatment usage were summarised descriptively. Differences in prescribing patterns by age and prescribing year were reported. Treatment persistence was estimated using Kaplan-Meier methods, with differences explored using log-rank tests. Values of p < 0.05 were considered statistically significant. RESULTS 6,740 patients, representing 8,249 non-unique patients, received prescriptions for antipsychotic medications. Patients were aged 16 years to over 85 years (54.5% were < 55 years) and two-thirds of patients were male (61%). The majority of treatment episodes (62%, n = 5,139/8,249) were prescribed an atypical oral antipsychotic. Typical long-acting antipsychotic therapies (LATs) were prescribed 19% of the treatment episodes (n = 1,608/8,249. There was a small increase in prescribing of atypical LAT and typical LAT and a small decrease in atypical oral and clozapine prescribing over the study period. Treatment persistence was greatest in patients treated with clozapine, than in those treated with atypical LATs. CONCLUSIONS While the majority of patients receive atypical antipsychotic medications, one in five continue to use older typical LAT therapies. Patient age and time on therapy may be associated with choice of therapy. Persistence to atypical LAT therapy is better than for other treatment modalities in this real-world cohort.
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Affiliation(s)
- Nagesh Pai
- School of Medicine, University of Wollongong (UOW), Wollongong, Australia. .,Illawarra Shoalhaven Local Health District (ISLHD), Wollongong, Australia.
| | - Mustafa Acar
- Janssen-Cilag Pty Ltd, North Ryde, NSW Australia
| | | | | | | | - Judy Mullan
- grid.1007.60000 0004 0486 528XSchool of Medicine, University of Wollongong (UOW), Wollongong, Australia
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Krause P, Kroneberg D, Gruber D, Koch K, Schneider GH, Kühn AA. Long-term effects of pallidal deep brain stimulation in tardive dystonia: a follow-up of 5-14 years. J Neurol 2022; 269:3563-3568. [PMID: 35083518 PMCID: PMC9217904 DOI: 10.1007/s00415-022-10965-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/28/2022]
Abstract
Introduction Pallidal DBS is an established treatment for severe isolated dystonia. However, its use in disabling and treatment-refractory tardive syndromes (TS) including tardive dyskinesia and tardive dystonia (TD) is less well investigated and long-term data remain sparse. This observational study evaluates long-term effects of deep brain stimulation (DBS) of the globus pallidus internus (GPi) in patients with medically refractory TS. Methods We retrospectively analyzed a cohort of seven TD patients with bilateral GPi-DBS. Involuntary movements, dystonia and disability were rated at long-term follow-up (LT-FU) after a mean of 122 ± 33.2 SD months (range 63–171 months) and compared to baseline (BL), short-term (ST-FU; mean 6 ± 2.0 SD months) and 4-year follow-up (4y-FU; mean 45 ± 12.3 SD months) using the Abnormal Involuntary Movement Scale (AIMS) and the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS), respectively. Quality of life and mood were evaluated using the SF36 and Beck Depression Index (BDI) questionnaires, respectively. Results At LT-FU patients had improved by 73% ± 14.2 SD in involuntary movements and 90% ± 1.0 SD in dystonia. Mood had improved significantly whereas quality of life remained unchanged compared to baseline. No serious long-lasting stimulation-related adverse events (AEs) were observed. Three patients of this cohort presented without active stimulation and ongoing symptom relief at long-term follow-up after 3–10 years of continuous DBS. Conclusion Pallidal DBS is a safe and effective long-term TD treatment. Even more interesting, three of our patients could stop stimulation after several years of DBS without serious relapse. Larger studies need to explore the phenomenon of ongoing symptom relief after DBS cessation. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-10965-8.
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Affiliation(s)
- Patricia Krause
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité, University Medicine Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Daniel Kroneberg
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité, University Medicine Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Doreen Gruber
- Department of Neurology and Stereotactic Surgery, University Medicine of Magdeburg, Magdeburg, Germany
| | - Kristin Koch
- Department of Psychiatry and Psychotherapy, Charité, University Medicine Berlin, Campus Mitte, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité, University Medicine Berlin, University Medicine Berlin, Campus Mitte, Berlin, Germany
| | - Andrea A Kühn
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité, University Medicine Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany.
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Mori Y, Takeuchi H, Tsutsumi Y. Current perspectives on the epidemiology and burden of tardive dyskinesia: a focused review of the clinical situation in Japan. Ther Adv Psychopharmacol 2022; 12:20451253221139608. [PMID: 36601351 PMCID: PMC9806439 DOI: 10.1177/20451253221139608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/28/2022] [Indexed: 12/28/2022] Open
Abstract
UNLABELLED Tardive dyskinesia (TD) is a movement disorder that can develop with the use of dopamine receptor-blocking agents and is most commonly caused by antipsychotics. The use of antipsychotics is expanding, which may lead to an increased number of patients experiencing TD. To summarise the current knowledge of the epidemiology and risk factors for TD in Japan, we reviewed articles related to the current state of knowledge around TD identified through a PubMed search, and held a roundtable discussion of experts in Japan on 9 September 2021 to form the basis of the opinion presented within this review. The true prevalence of TD among patients treated with antipsychotics is not well characterised; it is reported to be between 15% and 50% globally and between 6.5% and 7.7% in Japan. Potential barriers to timely treatment of TD include the stigma surrounding mental health issues and the lack of data regarding TD in Asian patients. This review summarises the current knowledge of the epidemiology, challenges to TD diagnosis and risk factors for TD in Japan. Recent strategies for symptom monitoring and early diagnosis, as well as consensus recommendations are included. Achieving a high level of awareness of TD among physicians who treat patients with psychiatric disorders is of great importance and physicians should ensure that patients with psychiatric disorders receiving antipsychotics are proactively monitored for signs of TD. PLAIN LANGUAGE SUMMARY Plain Language Summary (In Japanese). VISUAL SUMMARY Visual Summary (In Japanese).
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Affiliation(s)
- Yasuhiro Mori
- Department of Psychiatry, Aichi Medical University, 1-1 Yazako-karimata, Nagakute 480-1195, Aichi, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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The effect of rs1076560 (DRD2) and rs4680 (COMT) on tardive dyskinesia and cognition in schizophrenia subjects. Psychiatr Genet 2020; 30:125-135. [PMID: 32931693 PMCID: PMC10111058 DOI: 10.1097/ypg.0000000000000258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of the study is to test the association of a functional variant each in DRD2 and COMT genes with schizophrenia and its endophenotypes. BASIC METHODS Effect of two functional variants rs1076560 in DRD2 and rs4680 in COMT on (1) schizophrenia (502 cases, 448 controls) diagnosed by Diagnostic and Statistical Manual of Mental Disorders-IV criteria and in subsets with (2) tardive dyskinesia (80 positive, 103 negative), assessed by Abnormal Involuntary Movement Scale (AIMS), positive and negative symptoms assessed by Positive and Negative Syndrome Scale (PANSS) and (3) cognition (299 cases, 245 controls), estimated by Penn Computerized Neurocognitive Battery, were analysed either using analysis of variance (ANOVA) or regression analysis. MAIN RESULTS No association of two SNPs with schizophrenia, but association of rs4680 (P < 0.05) with tardive dyskinesia was observed. On ANOVA, main effect of smoking [F(2,148) = 16.3; P = 3.9 × 10]; rs4680 [F(2,148) = 3.3; P = 0.04] and interaction effect of tardive dyskinesia-status*Smoking [F(2,148) = 5.4, P = 0.006]; Smoking*rs1076560 [F(3,148) = 3.6; P = 0.01]; Smoking*rs4680 [F(4,148) = 5.3; P = 4.7 × 10] were significant with AIMS tardive dyskinesia score. The main effect of rs1076560 [F(2,148) = 4.5; P = 0.013] and rs4680 [F(2,148) = 4.0; P = 0.02] were significant with limb truncal tardive dyskinesia. Allelic/genotypic (P = 0.004/P = 0.01) association of rs1076560 with negative scale of PANSS in tardive dyskinesia-negative; diminished expression factor of PANSS in tardive dyskinesia-negative subcohort (allelic/genotypic P = 3.3 × 10/6.6 × 10) and tardive dyskinesia cohorts (P = 0.003/0.002); genotypic association (P = 0.05) with disorganised/concrete factor in tardive dyskinesia-positive subcohorts were observed by regression analysis using gPLINKv2.050. Further allelic/genotypic (P = 0.02) association of rs4680 with depressed factor of PANSS in tardive dyskinesia cohort was observed. Allelic/genotypic association of rs1076560 with abstraction and mental flexibilityaccuracy (P = 0.03/0.04), abstraction and mental flexibilityefficiency (P = 0.01/0.02); allelic association with spatial abilityprocessing speed (P = 0.03), emotionefficiency (P = 0.05); and with spatial abilityefficiency (genotypic, P = 0.05) in healthy controls and allelic association of rs4680 with emotionefficiency in cases with schizophrenia (P = 0.04) were notable. PRINCIPAL CONCLUSION Dopaminergic genes seem to contribute to tardive dyskinesia and cognition warranting replication.
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Lu JY, Tiwari AK, Freeman N, Zai GC, Luca VD, Müller DJ, Tampakeras M, Herbert D, Emmerson H, Cheema SY, King N, Voineskos AN, Potkin SG, Lieberman JA, Meltzer HY, Remington G, Kennedy JL, Zai CC. Liver enzyme CYP2D6 gene and tardive dyskinesia. Pharmacogenomics 2020; 21:1065-1072. [PMID: 32969762 DOI: 10.2217/pgs-2020-0065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Tardive dyskinesia (TD) is an iatrogenic involuntary movement disorder occurring after extended antipsychotic use with unclear pathogenesis. CYP2D6 is a liver enzyme involved in antipsychotic metabolism and a well-studied gene candidate for TD. Materials & methods: We tested predicted CYP2D6 metabolizer phenotype with TD occurrence and severity in our two samples of European chronic schizophrenia patients (total n = 198, of which 82 had TD). Results: TD occurrence were associated with extreme metabolizer phenotype, controlling for age and sex (p = 0.012). In other words, individuals with either increased and no CYP2D6 activity were at higher risk of having TD. Conclusion: Unlike most previous findings, TD occurrence may be associated with both extremes of CYP2D6 metabolic activity rather than solely for poor metabolizers.
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Affiliation(s)
- Justin Y Lu
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada
| | - Arun K Tiwari
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada
| | - Natalie Freeman
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada
| | - Gwyneth C Zai
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Vincenzo de Luca
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Daniel J Müller
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Maria Tampakeras
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada
| | - Deanna Herbert
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada
| | - Heather Emmerson
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada
| | - Sheraz Y Cheema
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada
| | - Nicole King
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada
| | - Aristotle N Voineskos
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Steven G Potkin
- Department of Psychiatry & Human Behavior, Long Beach Veterans Administration Health Care System, University of California, Irvine, Irvine, CA 92617, USA
| | - Jeffrey A Lieberman
- Department of Psychiatry, Columbia University College of Physicians & Surgeons, New York City, NY 10032, USA
| | - Herbert Y Meltzer
- Psychiatry & Behavioral Sciences, Pharmacology & Physiology, Chemistry of Life Processes Institute, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Gary Remington
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - James L Kennedy
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Clement C Zai
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction & Mental Health, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada.,Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, M5S 1A8, Canada
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12
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Treatment of Tardive Dyskinesia: A General Overview with Focus on the Vesicular Monoamine Transporter 2 Inhibitors. Drugs 2019; 78:525-541. [PMID: 29484607 DOI: 10.1007/s40265-018-0874-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Tardive dyskinesia (TD) encompasses the spectrum of iatrogenic hyperkinetic movement disorders following exposure to dopamine receptor-blocking agents (DRBAs). Despite the advent of atypical or second- and third-generation antipsychotics with a presumably lower risk of complications, TD remains a persistent and challenging problem. Prevention is the first step in mitigating the risk of TD, but early recognition, gradual withdrawal of offending medications, and appropriate treatment are also critical. As TD is often a persistent and troublesome disorder, specific antidyskinetic therapies are often needed for symptomatic relief. The vesicular monoamine transporter 2 (VMAT2) inhibitors, which include tetrabenazine, deutetrabenazine, and valbenazine, are considered the treatment of choice for most patients with TD. Deutetrabenazine-a deuterated version of tetrabenazine-and valbenazine, the purified parent product of one of the main tetrabenazine metabolites, are novel VMAT2 inhibitors and the only drugs to receive approval from the US FDA for the treatment of TD. VMAT2 inhibitors deplete presynaptic dopamine and reduce involuntary movements in many hyperkinetic movement disorders, particularly TD, Huntington disease, and Tourette syndrome. The active metabolites of the VMAT2 inhibitors have high affinity for VMAT2 and minimal off-target binding. Compared with tetrabenazine, deutetrabenazine and valbenazine have pharmacokinetic advantages that translate into less frequent dosing and better tolerability. However, no head-to-head studies have compared the various VMAT2 inhibitors. One of the major advantages of VMAT2 inhibitors over DRBAs, which are still being used by some clinicians in the treatment of some hyperkinetic disorders, including TD, is that they are not associated with the development of TD. We also briefly discuss other treatment options for TD, including amantadine, clonazepam, Gingko biloba, zolpidem, botulinum toxin, and deep brain stimulation. Treatment of TD and other drug-induced movement disorders must be individualized and based on the severity, phenomenology, potential side effects, and other factors discussed in this review.
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13
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Maximizing response to first-line antipsychotics in schizophrenia: a review focused on finding from meta-analysis. Psychopharmacology (Berl) 2019; 236:545-559. [PMID: 30506237 DOI: 10.1007/s00213-018-5133-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/22/2018] [Indexed: 12/12/2022]
Abstract
RATIONALE There are many psychotropic drugs available for treatment of schizophrenia. The clinician's choice of the most effective first-line antipsychotic treatment for patients with schizophrenia should balance considerations of differential efficacy of antipsychotics against the relative risk of different side effects. METHOD We reviewed recent studies using meta-analytic techniques and additional studies of new antipsychotics which quantitatively evaluate the efficacy of side effects of first- and second-generation antipsychotics and studies of the efficacy on add-on secondary medications. We present an integrated summary of these results to guide a clinician's decision-making. RESULTS Recent meta-analyses have suggested that antipsychotics are not equivalent in efficacy. Clozapine (effect size [SMD] 0.88 vs. placebo), amisulpride (effect size 0.6 vs placebo), olanzapine (effect size 0.59 vs. placebo), and risperidone (effect size 0.56 vs placebo) show small but statistically significant differences compared to a number of other antipsychotics on measures of overall efficacy (effect sizes 0.33-0.50). However, increasing placebo response remains a concern in interpreting these data. Amisulpride (effect size 0.47 vs placebo) and cariprazine (effect size in one trial compared to risperidone 0.29) have the strongest evidence indicating greater efficacy for treating primary negative symptoms relative to other antipsychotics. In terms of side effects, clozapine and olanzapine have among the highest weight gain potential and sertindole and amisulpride have more effects on QTc prolongation than other commonly used antipsychotics. Prolactin elevation is highest with paliperidone, risperidone, and amisulpride. Adjunctive treatment with an antidepressant drug may improve response in patients with schizophrenia who also have severe depressive or negative symptoms. For multi-episode patients with an inadequate response to an adequate dose and duration of the initial antipsychotic choice, switching to another antipsychotic, with a different receptor profile, may improve response, although evidence is very limited. In first-episode patients, a recent study on switching to another antipsychotic, with a different receptor profile after 4 weeks demonstrated no beneficial effects. There is little evidence to support using doses above the therapeutic range other than in exceptional circumstances. CONCLUSIONS Our review of recent studies using meta-analytic techniques has provided evidence that all antipsychotics are not equal in the severity of different side effects and in some measures of clinical efficacy. Comparative analysis and rankings from network meta-analyses can provide guidance to clinicians in choosing the most appropriate antipsychotic for first-line treatment, if used in conjunction with available information of the patient's history of previous clinical response or higher risks for specific side effects.
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14
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Frei K. Tardive dyskinesia: Who gets it and why. Parkinsonism Relat Disord 2019; 59:151-154. [DOI: 10.1016/j.parkreldis.2018.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 01/13/2023]
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15
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Sienaert P, van Harten P, Rhebergen D. The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:415-428. [PMID: 31727227 DOI: 10.1016/b978-0-444-64012-3.00025-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Although highly prevalent, motor syndromes in psychiatry and motor side effects of psychopharmacologic agents remain understudied. Catatonia is a syndrome with specific motor abnormalities that can be seen in the context of a variety of psychiatric and somatic conditions. The neuroleptic malignant syndrome is a lethal variant, induced by antipsychotic drugs. Therefore, antipsychotics should be used with caution in the presence of catatonic signs. Antipsychotics and other dopamine-antagonist drugs can also cause motor side effects such as akathisia, (tardive) dyskinesia, and dystonia. These syndromes share a debilitating impact on the functioning and well-being of patients. To reduce the risk of inducing these side effects, a balanced and well-advised prescription of antipsychotics is of utmost importance. Clinicians should be able to recognize motor side effects and be knowledgeable of the different treatment modalities.
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Affiliation(s)
- Pascal Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven, Kortenberg, Belgium.
| | - Peter van Harten
- Research Department, GGz Centraal Innova, Amersfoort, and Department of Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - Didi Rhebergen
- Department of Psychiatry and Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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16
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Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry 2018; 17:341-356. [PMID: 30192094 PMCID: PMC6127750 DOI: 10.1002/wps.20567] [Citation(s) in RCA: 263] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 12/16/2022] Open
Abstract
The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.
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Affiliation(s)
- T Scott Stroup
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gray
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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17
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Stegmayer K, Walther S, van Harten P. Tardive Dyskinesia Associated with Atypical Antipsychotics: Prevalence, Mechanisms and Management Strategies. CNS Drugs 2018; 32:135-147. [PMID: 29427000 DOI: 10.1007/s40263-018-0494-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
All antipsychotics, including the atypical antipsychotics (AAPs), may cause tardive dyskinesia (TD), a potentially irreversible movement disorder, the pathophysiology of which is currently unknown. The prevention and treatment of TD remain major challenges for clinicians. We conducted a PubMed search to review the prevalence and etiology of and management strategies for TD associated with AAPs. TD prevalence rates varied substantially between studies, with an estimated prevalence of around 20% in patients using AAPs. The risk of TD is lower with AAPs than with typical antipsychotics (TAPs) but remains a problem because AAPs are increasingly being prescribed. Important risk factors associated with TD include the duration of antipsychotic use, age, and ethnicity other than Caucasian. Theories about the etiology of TD include supersensitivity of the dopamine receptors and oxidative stress, but other neurotransmitters and factors are probably involved. Studies concerning the management of TD have considerable methodological limitations. Thus, recommendations for the management of TD are based on a few trials and clinical experience, and no general guidelines for the management of TD can be established. The best management strategy remains prevention. Caution is required when prescribing antipsychotics, and regular screening is needed for early detection of TD. Other strategies may include reducing the AAP dosage, switching to clozapine, or administering vesicular monoamine transporter (VMAT)-2 inhibitors. In severe cases, local injections of botulinum toxin or deep brain stimulation may be considered. More clinical trials in larger samples are needed to gather valid information on the effect of interventions targeting TD.
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Affiliation(s)
- Katharina Stegmayer
- University Hospital of Psychiatry, Bolligenstrasse 111, 3060, Bern, Switzerland.
| | - Sebastian Walther
- University Hospital of Psychiatry, Bolligenstrasse 111, 3060, Bern, Switzerland
| | - Peter van Harten
- Psychiatric Centre GGz Centraal, Innova, Amersfoort, The Netherlands.,School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
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18
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Abstract
BACKGROUND Tardive dyskinesia (TD) is a disfiguring movement disorder, often of the orofacial region, frequently caused by using antipsychotic drugs. A wide range of strategies have been used to help manage TD, and for those who are unable to have their antipsychotic medication stopped or substantially changed, the benzodiazepine group of drugs have been suggested as a useful adjunctive treatment. However, benzodiazepines are very addictive. OBJECTIVES To determine the effects of benzodiazepines for antipsychotic-induced tardive dyskinesia in people with schizophrenia, schizoaffective disorder, or other chronic mental illnesses. SEARCH METHODS On 17 July 2015 and 26 April 2017, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (including trial registers), inspected references of all identified studies for further trials and contacted authors of each included trial for additional information. SELECTION CRITERIA We included all randomised controlled trials (RCTs) focusing on people with schizophrenia (or other chronic mental illnesses) and antipsychotic-induced TD that compared benzodiazepines with placebo, no intervention, or any other intervention for the treatment of TD. DATA COLLECTION AND ANALYSIS We independently extracted data from the included studies and ensured that they were reliably selected, and quality assessed. For homogenous dichotomous data, we calculated random effects, risk ratio (RR), and 95% confidence intervals (CI). We synthesised continuous data from valid scales using mean differences (MD). For continuous outcomes, we preferred endpoint data to change data. We assumed that people who left early had no improvement. MAIN RESULTS The review now includes four trials (total 75 people, one additional trial since 2006, 21 people) randomising inpatients and outpatients in China and the USA. Risk of bias was mostly unclear as reporting was poor. We are uncertain about all the effects as all evidence was graded at very low quality. We found no significant difference between benzodiazepines and placebo for the outcome of 'no clinically important improvement in TD' (2 RCTs, 32 people, RR 1.12, 95% CI 0.60 to 2.09, very low quality evidence). Significantly fewer participants allocated to clonazepam compared with phenobarbital (as active placebo) experienced no clinically important improvement (RR 0.44, 95% CI 0.20 to 0.96, 1 RCT, 21 people, very low quality evidence). For the outcome 'deterioration of TD symptoms,' we found no clear difference between benzodiazepines and placebo (2 RCTs, 30 people, RR 1.48, 95% CI 0.22 to 9.82, very low quality evidence). All 10 participants allocated to benzodiazepines experienced any adverse event compared with 7/11 allocated to phenobarbital (RR 1.53, 95% CI 0.97 to 2.41, 1 RCT, 21 people, very low quality evidence). There was no clear difference in the incidence of participants leaving the study early for benzodiazepines compared with placebo (3 RCTs, 56 people, RR 2.73, 95% CI 0.15 to 48.04, very low quality evidence) or compared with phenobarbital (as active placebo) (no events, 1 RCT, 21 people, very low quality evidence). No trials reported on social confidence, social inclusion, social networks, or personalised quality of life, which are outcomes designated important by patients. No trials comparing benzodiazepines with placebo or treatment as usual reported on adverse effects. AUTHORS' CONCLUSIONS There is only evidence of very low quality from a few small and poorly reported trials on the effect of benzodiazepines as an adjunctive treatment for antipsychotic-induced TD. These inconclusive results mean routine clinical use is not indicated and these treatments remain experimental. New and better trials are indicated in this under-researched area; however, as benzodiazepines are addictive, we feel that other techniques or medications should be adequately evaluated before benzodiazepines are chosen.
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Affiliation(s)
- Hanna Bergman
- CochraneCochrane ResponseSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Paranthaman S Bhoopathi
- Royal Care Super Speciality HospitalDepartment of PsychiatryNeelamburCoimbatoreTamil NaduIndia641062
| | - Karla Soares‐Weiser
- CochraneCochrane Editorial UnitSt Albans House, 57 ‐ 59 HaymarketLondonUKSW1Y 4QX
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19
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Caroff SN, Campbell EC, Carroll B. Pharmacological treatment of tardive dyskinesia: recent developments. Expert Rev Neurother 2017; 17:871-881. [DOI: 10.1080/14737175.2017.1358616] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Stanley N. Caroff
- Corporal Michael J. Crescenz Veterans Affairs Medical Center and the Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - E. Cabrina Campbell
- Corporal Michael J. Crescenz Veterans Affairs Medical Center and the Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA
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20
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Solmi M, Murru A, Pacchiarotti I, Undurraga J, Veronese N, Fornaro M, Stubbs B, Monaco F, Vieta E, Seeman MV, Correll CU, Carvalho AF. Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review. Ther Clin Risk Manag 2017; 13:757-777. [PMID: 28721057 PMCID: PMC5499790 DOI: 10.2147/tcrm.s117321] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Since the discovery of chlorpromazine (CPZ) in 1952, first-generation antipsychotics (FGAs) have revolutionized psychiatric care in terms of facilitating discharge from hospital and enabling large numbers of patients with severe mental illness (SMI) to be treated in the community. Second-generation antipsychotics (SGAs) ushered in a progressive shift from the paternalistic management of SMI symptoms to a patient-centered approach, which emphasized targets important to patients - psychosocial functioning, quality of life, and recovery. These drugs are no longer limited to specific Diagnostic and Statistical Manual of Mental Disorders (DSM) categories. Evidence indicates that SGAs show an improved safety and tolerability profile compared with FGAs. The incidence of treatment-emergent extrapyramidal side effects is lower, and there is less impairment of cognitive function and treatment-related negative symptoms. However, treatment with SGAs has been associated with a wide range of untoward effects, among which treatment-emergent weight gain and metabolic abnormalities are of notable concern. The present clinical review aims to summarize the safety and tolerability profile of selected FGAs and SGAs and to link treatment-related adverse effects to the pharmacodynamic profile of each drug. Evidence, predominantly derived from systematic reviews, meta-analyses, and clinical trials of the drugs amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, ziprasidone, CPZ, haloperidol, loxapine, and perphenazine, is summarized. In addition, the safety and tolerability profiles of antipsychotics are discussed in the context of the "behavioral toxicity" conceptual framework, which considers the longitudinal course and the clinical and therapeutic consequences of treatment-emergent side effects. In SMI, SGAs with safer metabolic profiles should ideally be prescribed first. However, alongside with safety, efficacy should also be considered on a patient-tailored basis.
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Affiliation(s)
- Marco Solmi
- Neuroscience Department, University of Padua
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Andrea Murru
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Juan Undurraga
- Department of Psychiatry, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo
- Early Intervention Program, J. Horwitz Psychiatric Institute, Santiago, Chile
| | - Nicola Veronese
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- National Research Council, Ageing Section, Padua
| | - Michele Fornaro
- Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, School of Medicine, University “Federico II”, Naples, Italy
- New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Brendon Stubbs
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London
- Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Francesco Monaco
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Eduard Vieta
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | | | - Christoph U Correll
- Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks
- Department of Psychiatry and Molecular Medicine Hempstead, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - André F Carvalho
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Translational Psychiatry Research Group and Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
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21
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Abstract
Dyskinesias encompass a variety of different hyperkinetic phenomenologies, particularly chorea, dystonia, stereotypies, and akathisia. The main types of drug-induced dyskinesias include levodopa-induced dyskinesia (LID) in patients with Parkinson's disease and tardive syndrome (TS), typically present in patients with psychiatric or gastrointenstinal disorders treated with dopamine receptor blocking drugs, also referred to as neuroleptics. Besides preventive measures (i.e., avoiding the use of the offending drugs), general treatment strategies include slow taper of the offending agent and use of dopamine-depleting agents like tetrabenazine. Botulinum toxin may be helpful for wearing off focal dystonia and some forms of tardive dystonia. Deep brain stimulation is usually reserved for patients with disabling motor fluctuations, LID, and for severe TS that cannot be managed medically.
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Affiliation(s)
- Dhanya Vijayakumar
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX, 77030-4202, USA
| | - Joseph Jankovic
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, 7200 Cambridge, Suite 9A, Houston, TX, 77030-4202, USA.
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22
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Reduce the risk of drug-induced tardive syndromes by minimizing exposure to dopamine receptor blocking agents whenever possible. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Goodwin GM, Haddad PM, Ferrier IN, Aronson JK, Barnes T, Cipriani A, Coghill DR, Fazel S, Geddes JR, Grunze H, Holmes EA, Howes O, Hudson S, Hunt N, Jones I, Macmillan IC, McAllister-Williams H, Miklowitz DR, Morriss R, Munafò M, Paton C, Saharkian BJ, Saunders K, Sinclair J, Taylor D, Vieta E, Young AH. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2016; 30:495-553. [PMID: 26979387 PMCID: PMC4922419 DOI: 10.1177/0269881116636545] [Citation(s) in RCA: 473] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.
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Affiliation(s)
- G M Goodwin
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - P M Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Eccles, Manchester, UK
| | - I N Ferrier
- Institute of Neuroscience, Newcastle University, UK and Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK
| | - J K Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Trh Barnes
- The Centre for Mental Health, Imperial College London, Du Cane Road, London, UK
| | - A Cipriani
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - D R Coghill
- MACHS 2, Ninewells' Hospital and Medical School, Dundee, UK; now Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia
| | - S Fazel
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - J R Geddes
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - H Grunze
- Univ. Klinik f. Psychiatrie u. Psychotherapie, Christian Doppler Klinik, Universitätsklinik der Paracelsus Medizinischen Privatuniversität (PMU), Salzburg, Christian Doppler Klinik Salzburg, Austria
| | - E A Holmes
- MRC Cognition & Brain Sciences Unit, Cambridge, UK
| | - O Howes
- Institute of Psychiatry (Box 67), London, UK
| | | | - N Hunt
- Fulbourn Hospital, Cambridge, UK
| | - I Jones
- MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff, UK
| | - I C Macmillan
- Northumberland, Tyne and Wear NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead, Tyne and Wear, UK
| | - H McAllister-Williams
- Institute of Neuroscience, Newcastle University, UK and Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK
| | - D R Miklowitz
- UCLA Semel Institute for Neuroscience and Human Behavior, Division of Child and Adolescent Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - R Morriss
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Nottingham, UK
| | - M Munafò
- MRC Integrative Epidemiology Unit, UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, Bristol, UK
| | - C Paton
- Oxleas NHS Foundation Trust, Dartford, UK
| | - B J Saharkian
- Department of Psychiatry (Box 189), University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Kea Saunders
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Jma Sinclair
- University Department of Psychiatry, Southampton, UK
| | - D Taylor
- South London and Maudsley NHS Foundation Trust, Pharmacy Department, Maudsley Hospital, London, UK
| | - E Vieta
- Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - A H Young
- Centre for Affective Disorders, King's College London, London, UK
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Morigaki R, Mure H, Kaji R, Nagahiro S, Goto S. Therapeutic Perspective on Tardive Syndrome with Special Reference to Deep Brain Stimulation. Front Psychiatry 2016; 7:207. [PMID: 28082923 PMCID: PMC5183634 DOI: 10.3389/fpsyt.2016.00207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/15/2016] [Indexed: 12/28/2022] Open
Abstract
Tardive syndrome (TDS) is a potentially permanent and irreversible hyperkinetic movement disorder caused by exposure to dopamine receptor blocking agents. Guidelines published by the American Academy of Neurology recommend pharmacological first-line treatment for TDS with clonazepam (level B), ginkgo biloba (level B), amantadine (level C), and tetrabenazine (level C). Recently, a class II study provided level C evidence for use of deep brain stimulation (DBS) of the globus pallidus internus (GPi) in patients with TDS. Although the precise pathogenesis of TDS remains to be elucidated, the beneficial effects of GPi-DBS in patients with TDS suggest that the disease may be a basal ganglia disorder. In addition to recent advances in understanding the pathophysiology of TDS, this article introduces the current use of DBS in the treatment of medically intractable TDS.
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Affiliation(s)
- Ryoma Morigaki
- Parkinson's Disease and Dystonia Research Center, Tokushima University Hospital, Tokushima University, Tokushima, Japan; Department of Neurodegenerative Disorders Research, Graduate School of Medical Sciences, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan; Department of Neurosurgery, Graduate School of Medical Sciences, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Hideo Mure
- Parkinson's Disease and Dystonia Research Center, Tokushima University Hospital, Tokushima University, Tokushima, Japan; Department of Neurosurgery, Graduate School of Medical Sciences, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Ryuji Kaji
- Parkinson's Disease and Dystonia Research Center, Tokushima University Hospital, Tokushima University, Tokushima, Japan; Department of Clinical Neuroscience, Graduate School of Medical Sciences, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Shinji Nagahiro
- Parkinson's Disease and Dystonia Research Center, Tokushima University Hospital, Tokushima University, Tokushima, Japan; Department of Neurosurgery, Graduate School of Medical Sciences, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Satoshi Goto
- Parkinson's Disease and Dystonia Research Center, Tokushima University Hospital, Tokushima University, Tokushima, Japan; Department of Neurodegenerative Disorders Research, Graduate School of Medical Sciences, Institute of Biomedical Sciences, Tokushima University, Tokushima, Japan
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