1
|
Ismail O, Albdour K, Jaber Y, Jaber K, Alsaras A. Efficacy and safety of different pharmacological interventions in the treatment of tardive dyskinesia: a systematic review and network meta-analysis. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03722-5. [PMID: 38969949 DOI: 10.1007/s00228-024-03722-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 06/23/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVES The aim of this study is to indirectly compare and rank the different drugs that have been studied in randomized clinical trials (RCTs) in patients with tardive dyskinesia (TD) in terms of their efficacy in ameliorating the symptoms of TD and safety. DESIGN A network meta-analysis and a systematic review were registered prospectively on PROSPERO under the ID: CRD42023407823 and were conducted in accordance with the PRISMA-NMA guidelines. DATA SOURCES PubMed, Scopus, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Sciences, and Clinicaltrials.gov were searched to identify relevant records. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Any parallel randomized blinded controlled clinical trials that studied the use of any medications in treating TD and assessed the symptoms using a functional scale that has been previously validated. DATA EXTRACTION The standardized mean difference of improvement along with the reported adverse events for each drug was extracted from each trial, and a network meta-analysis was conducted using a random-effects model. RESULTS One thousand eight hundred seventeen patients in 33 RCTs were included in the analysis. Twenty-three different drugs were compared to placebo in terms of reduction in TD symptoms. Among these, valbenazine 80 mg (SMD = - 1.66, 95%CI = [- 2.55; - 0.78]), valbenazine 40 mg (- 1.00, [- 1.89; - 0.11]), and vitamin E (- 0.77, [- 1.45; - 0.1]) significantly reduced TD symptoms in comparison to placebo, while deutetrabenazine 36 mg (- 1.00, [- 2.12; 0.11]) and reserpine (- 0.54, [- 1.09; 0.02]) did not significantly reduce symptoms. Some serious adverse events were reported for valbenazine and deutetrabenazine, which included mainly psychiatric symptoms such as depression, worsening of schizophrenia, and suicidal ideation, while mild adverse events were reported for other drugs, and their incidence in the treatment arms was comparable to those in the placebo arm. CONCLUSIONS Valbenazine (80 and 40 mg) and vitamin E demonstrated efficacy in treating tardive dyskinesia. However, the significant side effects of valbenazine should prompt further investigation of alternative treatment modalities.
Collapse
Affiliation(s)
- Omar Ismail
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
| | - Karam Albdour
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942.
| | - Yazan Jaber
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
| | - Kamel Jaber
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
| | - Ameen Alsaras
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
| |
Collapse
|
2
|
Kraus L, Hetsch F, Schneider UC, Radbruch H, Holtkamp M, Meier JC, Fidzinski P. Dimethylethanolamine Decreases Epileptiform Activity in Acute Human Hippocampal Slices in vitro. Front Mol Neurosci 2019; 12:209. [PMID: 31551707 PMCID: PMC6743366 DOI: 10.3389/fnmol.2019.00209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 08/09/2019] [Indexed: 01/13/2023] Open
Abstract
Temporal lobe epilepsy (TLE) is the most common form of focal epilepsy with about 30% of patients developing pharmacoresistance. These patients continue to suffer from seizures despite polytherapy with antiepileptic drugs (AEDs) and have an increased risk for premature death, thus requiring further efforts for the development of new antiepileptic therapies. The molecule dimethylethanolamine (DMEA) has been tested as a potential treatment in various neurological diseases, albeit the functional mechanism of action was never fully understood. In this study, we investigated the effects of DMEA on neuronal activity in single-cell recordings of primary neuronal cultures. DMEA decreased the frequency of spontaneous synaptic events in a concentration-dependent manner with no apparent effect on resting membrane potential (RMP) or action potential (AP) threshold. We further tested whether DMEA can exert antiepileptic effects in human brain tissue ex vivo. We analyzed the effect of DMEA on epileptiform activity in the CA1 region of the resected hippocampus of TLE patients in vitro by recording extracellular field potentials in the pyramidal cell layer. Epileptiform burst activity in resected hippocampal tissue from TLE patients remained stable over several hours and was pharmacologically suppressed by lacosamide, demonstrating the applicability of our platform to test antiepileptic efficacy. Similar to lacosamide, DMEA also suppressed epileptiform activity in the majority of samples, albeit with variable interindividual effects. In conclusion, DMEA might present a new approach for treatment in pharmacoresistant TLE and further studies will be required to identify its exact mechanism of action and the involved molecular targets.
Collapse
Affiliation(s)
- Larissa Kraus
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurology with Experimental Neurology, Berlin, Germany
- Berlin Institute of Health (BIH), Zoologisches Institut, Technische Universität Braunschweig, Braunschweig, Germany
| | - Florian Hetsch
- Zoologisches Institut, Technische Universität Braunschweig, Braunschweig, Germany
| | - Ulf C. Schneider
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Helena Radbruch
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neuropathology, Berlin, Germany
| | - Martin Holtkamp
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurology with Experimental Neurology, Berlin, Germany
- Berlin Institute of Health (BIH), Zoologisches Institut, Technische Universität Braunschweig, Braunschweig, Germany
| | - Jochen C. Meier
- Berlin Institute of Health (BIH), Zoologisches Institut, Technische Universität Braunschweig, Braunschweig, Germany
- Zoologisches Institut, Technische Universität Braunschweig, Braunschweig, Germany
| | - Pawel Fidzinski
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurology with Experimental Neurology, Berlin, Germany
| |
Collapse
|
3
|
Bergman H, Walker DM, Nikolakopoulou A, Soares-Weiser K, Adams CE. Systematic review of interventions for treating or preventing antipsychotic-induced tardive dyskinesia. Health Technol Assess 2018; 21:1-218. [PMID: 28812541 DOI: 10.3310/hta21430] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Antipsychotic medication can cause tardive dyskinesia (TD) - late-onset, involuntary, repetitive movements, often involving the face and tongue. TD occurs in > 20% of adults taking antipsychotic medication (first-generation antipsychotics for > 3 months), with this proportion increasing by 5% per year among those who continue to use these drugs. The incidence of TD among those taking newer antipsychotics is not different from the rate in people who have used older-generation drugs in moderate doses. Studies of TD have previously been found to be limited, with no treatment approach shown to be effective. OBJECTIVES To summarise the clinical effectiveness and safety of treatments for TD by updating past Cochrane reviews with new evidence and improved methods; to undertake public consultation to gauge the importance of the topic for people living with TD/the risk of TD; and to make available all data from relevant trials. DATA SOURCES All relevant randomised controlled trials (RCTs) and observational studies. REVIEW METHODS Cochrane review methods, network meta-analysis (NMA). DESIGN Systematic reviews, patient and public involvement consultation and NMA. SETTING Any setting, inpatient or outpatient. PARTICIPANTS For systematic reviews, adults with TD who have been taking a stable antipsychotic drug dose for > 3 months. INTERVENTIONS Any, with emphasis on those relevant to UK NHS practice. MAIN OUTCOME MEASURES Any measure of TD, global assessments and adverse effects/events. RESULTS We included 112 studies (nine Cochrane reviews). Overall, risk of bias showed little sign of improvement over two decades. Taking the outcome of 'TD symptoms improved to a clinically important extent', we identified two trials investigating reduction of antipsychotic dose [n = 17, risk ratio (RR) 0.42, 95% confidence interval (CI) 0.17 to 1.04; very low quality]. Switching was investigated twice in trials that could not be combined (switching to risperidone vs. antipsychotic withdrawal: one RCT, n = 42, RR 0.45, 95% CI 0.23 to 0.89; low quality; switching to quetiapine vs. haloperidol: one RCT, n = 45, RR 0.80, 95% CI 0.52 to 1.22; low quality). In addition to RCTs, six observational studies compared antipsychotic discontinuation with decreased or increased dosage, and there was no clear evidence that any of these strategies had a beneficial effect on TD symptoms (very low-quality evidence). We evaluated the addition to standard antipsychotic care of several treatments, but not anticholinergic treatments, for which we identified no trials. We found no clear effect of the addition of either benzodiazepines (two RCTs, n = 32, RR 1.12, 95% CI 0.6 to 2.09; very low quality) or vitamin E (six RCTs, n = 264, RR 0.95, 95% CI 0.89 to 1.01; low quality). Buspirone as an adjunctive treatment did have some effect in one small study (n = 42, RR 0.53, 95% CI 0.33 to 0.84; low quality), as did hypnosis and relaxation (one RCT, n = 15, RR 0.45, 95% CI 0.21 to 0.94; very low quality). We identified no studies focusing on TD in people with dementia. The NMA model found indirect estimates to be imprecise and failed to produce useful summaries on relative effects of interventions or interpretable results for decision-making. Consultation with people with/at risk of TD highlighted that management of TD remains a concern, and found that people are deeply disappointed at the length of time it has taken researchers to address the issue. LIMITATIONS Most studies remain small and poorly reported. CONCLUSIONS Clinicians, policy-makers and people with/at risk of TD are little better informed than they were decades ago. Underpowered trials of limited quality repeatedly fail to provide answers. FUTURE WORK TD reviews have data from current trials extracted, tabulated and traceable to source. The NMA highlights one context in which support for this technique is ill advised. All relevant trials, even if not primarily addressing the issue of TD, should report appropriate binary outcomes on groups of people with this problem. Randomised trials of treatments for people with established TD are indicated. These should be large (> 800 participants), necessitating accrual through accurate local/national registers, including an intervention with acceptable treatments and recording outcomes used in clinical practice. STUDY REGISTRATION This study is registered as PROSPERO CRD4201502045. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
| | - Dawn-Marie Walker
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | | | | | - Clive E Adams
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| |
Collapse
|
4
|
Chouinard G, Samaha AN, Chouinard VA, Peretti CS, Kanahara N, Takase M, Iyo M. Antipsychotic-Induced Dopamine Supersensitivity Psychosis: Pharmacology, Criteria, and Therapy. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018. [PMID: 28647739 DOI: 10.1159/000477313] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The first-line treatment for psychotic disorders remains antipsychotic drugs with receptor antagonist properties at D2-like dopamine receptors. However, long-term administration of antipsychotics can upregulate D2 receptors and produce receptor supersensitivity manifested by behavioral supersensitivity to dopamine stimulation in animals, and movement disorders and supersensitivity psychosis (SP) in patients. Antipsychotic-induced SP was first described as the emergence of psychotic symptoms with tardive dyskinesia (TD) and a fall in prolactin levels following drug discontinuation. In the era of first-generation antipsychotics, 4 clinical features characterized drug-induced SP: rapid relapse after drug discontinuation/dose reduction/switch of antipsychotics, tolerance to previously observed therapeutic effects, co-occurring TD, and psychotic exacerbation by life stressors. We review 3 recent studies on the prevalence rates of SP, and the link to treatment resistance and psychotic relapse in the era of second-generation antipsychotics (risperidone, paliperidone, perospirone, and long-acting injectable risperidone, olanzapine, quetiapine, and aripiprazole). These studies show that the prevalence rates of SP remain high in schizophrenia (30%) and higher (70%) in treatment-resistant schizophrenia. We then present neurobehavioral findings on antipsychotic-induced supersensitivity to dopamine from animal studies. Next, we propose criteria for SP, which describe psychotic symptoms and co-occurring movement disorders more precisely. Detection of mild/borderline drug-induced movement disorders permits early recognition of overblockade of D2 receptors, responsible for SP and TD. Finally, we describe 3 antipsychotic withdrawal syndromes, similar to those seen with other CNS drugs, and we propose approaches to treat, potentially prevent, or temporarily manage SP.
Collapse
Affiliation(s)
- Guy Chouinard
- Clinical Pharmacology and Toxicology Program, McGill University Montreal, Montreal, QC, Canada
| | | | | | | | | | | | | |
Collapse
|
5
|
Tammenmaa‐Aho I, Asher R, Soares‐Weiser K, Bergman H. Cholinergic medication for antipsychotic-induced tardive dyskinesia. Cochrane Database Syst Rev 2018; 3:CD000207. [PMID: 29553158 PMCID: PMC6494194 DOI: 10.1002/14651858.cd000207.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tardive dyskinesia (TD) remains a troublesome adverse effect of conventional antipsychotic (neuroleptic) medication. It has been proposed that TD could have a component of central cholinergic deficiency. Cholinergic drugs have been used to treat TD. OBJECTIVES To determine the effects of cholinergic drugs (arecoline, choline, deanol, lecithin, meclofenoxate, physostigmine, RS 86, tacrine, metoxytacrine, galantamine, ipidacrine, donepezil, rivastigmine, eptastigmine, metrifonate, xanomeline, cevimeline) for treating antipsychotic-induced TD in people with schizophrenia or other chronic mental illness. SEARCH METHODS An electronic search of the Cochrane Schizophrenia Group's Study-Based Register of Trials (16 July 2015 and April 2017) was undertaken. This register is assembled by extensive searches for randomised controlled trials in many electronic databases, registers of trials, conference proceedings and dissertations. References of all identified studies were searched for further trial citations. SELECTION CRITERIA We included reports identified by the search if they were of controlled trials involving people with antipsychotic-induced TD and chronic mental illness, who had been randomly allocated to either a cholinergic agent or to a placebo or no intervention. Two review authors independently assessed the methodological quality of the trials. DATA COLLECTION AND ANALYSIS Two review authors extracted data and, where possible, estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We analysed data on an intention-to-treat basis, with the assumption that people who left early had no improvement. We assessed risk of bias and created a 'Summary of findings' table using GRADE. MAIN RESULTS We included 14 studies investigating the use of cholinergic drugs compared with placebo published between 1976 and 2014. All studies involved small numbers of participants (five to 60 people). Three studies that investigated the new cholinergic Alzheimer drugs for the treatment of TD are new to this update. Overall, the risk of bias in the included studies was unclear, mainly due to poor reporting; allocation concealment was not described, generation of the sequence was not explicit, studies were not clearly blinded, we are unsure if data are incomplete, and data were often poorly or selectively reported.We are uncertain about the effect of new or old cholinergic drugs on no clinically important improvement in TD symptoms when compared with placebo; the quality of evidence was very low (RR 0.89, 95% CI 0.65 to 1.23; 27 people, 4 RCTs). Eight trials found that cholinergic drugs may make little or no difference to deterioration of TD symptoms (low-quality evidence, RR 1.11, 95% CI 0.55 to 2.24; 147 people). Again, due to very low-quality evidence, we are uncertain about the effects on mental state (RR 0.50, 95% CI 0.10 to 2.61; 77 people, 5 RCTs), adverse events (RR 0.56, 95% CI 0.15 to 2.14; 106 people, 4 RCTs), and leaving the study early (RR 1.09,95% CI 0.56 to 2.10; 288 people 12 RCTs). No study reported on social confidence, social inclusion, social networks, or personalised quality of life. AUTHORS' CONCLUSIONS TD remains a major public health problem. The clinical effects of both older cholinergic drugs and new cholinergic agents, now used for treating Alzheimer's disease, are unclear, as too few, too small studies leave many questions unanswered. Cholinergic drugs should remain of interest to researchers and currently have little place in routine clinical work. However, with the advent of new cholinergic agents now used for treating Alzheimer's disease, scope exists for more informative trials. If these new cholinergic agents are to be investigated for treating people with TD, their effects should be demonstrated in large well-designed, conducted and reported randomised trials.
Collapse
Affiliation(s)
- Irina Tammenmaa‐Aho
- Helsinki City HospitalPalliative Care (Home Hospital Services)HelsinkiFinland
| | | | - Karla Soares‐Weiser
- CochraneCochrane Editorial UnitSt Albans House, 57 ‐ 59 HaymarketLondonUKSW1Y 4QX
| | - Hanna Bergman
- CochraneCochrane ResponseSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | | |
Collapse
|
6
|
Lin CC, Ondo WG. Non-VMAT2 inhibitor treatments for the treatment of tardive dyskinesia. J Neurol Sci 2018; 389:48-54. [PMID: 29433806 DOI: 10.1016/j.jns.2018.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/02/2018] [Indexed: 02/05/2023]
Abstract
Although VMAT2-inhibitors are now established as first-line treatment for tardive dyskinesia, not all patients respond to, or tolerate them. Numerous other agents have been adopted to treat tardive dyskinesia, but with variable results and generally lower quality methodologic reports. Amantadine is the most promising but benzodiazepines, branched chain neutral amino acids, Vitamin B6, several nutraceuticals, and botulinum toxin injections might help some patients. In all cases, better placebo controlled trials are needed before definitive recommendations can be made.
Collapse
Affiliation(s)
| | - William G Ondo
- Methodist Neurological Institute, Houston, TX, USA; Weill Cornell Medical School, New York, NY, USA.
| |
Collapse
|
7
|
Chouinard G, Margolese HC. Manual for the Extrapyramidal Symptom Rating Scale (ESRS). Schizophr Res 2005; 76:247-65. [PMID: 15949657 DOI: 10.1016/j.schres.2005.02.013] [Citation(s) in RCA: 291] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 02/18/2005] [Accepted: 02/21/2005] [Indexed: 10/25/2022]
Abstract
The Extrapyramidal Symptom Rating Scale (ESRS) was developed to assess four types of drug-induced movement disorders (DIMD): Parkinsonism, akathisia, dystonia, and tardive dyskinesia (TD). Comprehensive ESRS definitions and basic instructions are given. Factor analysis provided six ESRS factors: 1) hypokinetic Parkinsonism; 2) orofacial dyskinesia; 3) trunk/limb dyskinesia; 4) akathisia; 5) tremor; and 6) tardive dystonia. Two pivotal studies found high inter-rater reliability correlations in both antipsychotic-induced movement disorders and idiopathic Parkinson disease. For inter-rater reliability and certification of raters, >or=80% of item ratings of the complete scale should be +/-1 point of expert ratings and >or=70% of ratings on individual items of each ESRS subscale should be +/-1 point of expert ratings. During a cross-scale comparison, AIMS and ESRS were found to have a 96% (359/374) agreement between TD-defined cases by DSM-IV TD criteria. Two recent international studies using the ESRS included over 3000 patients worldwide and showed an incidence of TD ranging from 10.2% (2000) to 12% (1998). ESRS specificity was investigated through two different approaches, path analyses and ANCOVA PANSS factors changes, which found that ESRS measurement of drug-induced EPS is valid and discriminative from psychiatric symptoms.
Collapse
Affiliation(s)
- Guy Chouinard
- Clinical Psychopharmacology Unit, Allan Memorial Institute, McGill University Health Centre, and Department of Psychiatry, McGill University, Montreal, QC, Canada, H3A 1A1.
| | | |
Collapse
|
8
|
Tammenmaa IA, Sailas E, McGrath JJ, Soares-Weiser K, Wahlbeck K. Systematic review of cholinergic drugs for neuroleptic-induced tardive dyskinesia: a meta-analysis of randomized controlled trials. Prog Neuropsychopharmacol Biol Psychiatry 2004; 28:1099-107. [PMID: 15610922 DOI: 10.1016/j.pnpbp.2004.05.045] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2004] [Indexed: 11/17/2022]
Abstract
The authors evaluated the efficacy of cholinergic drugs in the treatment of neuroleptic-induced tardive dyskinesia (TD) by a systematic review of the literature on the following agents: choline, lecithin, physostigmine, tacrine, 7-methoxyacridine, ipidacrine, galantamine, donepezil, rivastigmine, eptastigmine, metrifonate, arecoline, RS 86, xanomeline, cevimeline, deanol, and meclofenoxate. All relevant randomized controlled trials, without any language or year limitations, were obtained from the Cochrane Schizophrenia Group's Register of Trials. Trials were classified according to their methodological quality. For binary and continuous data, relative risks (RR) and weighted or standardized mean differences (SMD) were calculated, respectively. Eleven trials with a total of 261 randomized patients were included in the meta-analysis. Cholinergic drugs showed a minor trend for improvement of tardive dyskinesia symptoms, but results were not statistically significant (RR 0.84, 95% confidence interval (CI) 0.68 to 1.04, p=0.11). Despite an extensive search of the literature, eligible data for the meta-analysis were few and no results reached statistical significance. In conclusion, we found no evidence to support administration of the old cholinergic agents lecithin, deanol, and meclofenoxate to patients with tardive dyskinesia. In addition, two trials were found on novel cholinergic Alzheimer drugs in tardive dyskinesia, one of which was ongoing. Further investigation of the clinical effects of novel cholinergic agents in tardive dyskinesia is warranted.
Collapse
Affiliation(s)
- Irina A Tammenmaa
- Department of Psychiatry, University of Helsinki, Helsinki University Central Hospital, P.O. Box 320, FIN-00029, Finland
| | | | | | | | | |
Collapse
|
9
|
Tammenmaa IA, McGrath JJ, Sailas E, Soares-Weiser K. Cholinergic medication for neuroleptic-induced tardive dyskinesia. Cochrane Database Syst Rev 2002:CD000207. [PMID: 12137608 DOI: 10.1002/14651858.cd000207] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Tardive dyskinesia remains a troublesome adverse effect of conventional antipsychotic (neuroleptic) medication. It has been proposed that tardive dyskinesia could have a component of central cholinergic deficiency. Cholinergic drugs have been used to treat tardive dyskinesia. OBJECTIVES To determine the effects of cholinergic drugs (arecoline, choline, deanol, lecithin, meclofenoxate, physostigmine, RS 86, tacrine, metoxytacrine, galantamine, ipidacrine, donepezil, rivastigmine, eptastigmine, metrifonate, xanomeline, cevimeline) for treating neuroleptic-induced tardive dyskinesia in people with schizophrenia or other chronic mental illness. SEARCH STRATEGY An electronic search of the Cochrane Schizophrenia Group's register (October 2001) was undertaken. This register is assembled by extensive searches for randomised controlled trials in many electronic databases, registers of conference proceedings and dissertations. References of all identified studies were searched for further trial citations. Principal authors of trials were contacted. SELECTION CRITERIA Reports identified by the search were included if they were of controlled trials dealing with people with neuroleptic-induced tardive dyskinesia and chronic mental illness, who had been randomly allocated to either a cholinergic agent or to a placebo or no intervention. Two reviewers independently assessed methodological quality of trials. DATA COLLECTION AND ANALYSIS Two researchers extracted data and, where possible, estimated relative risks (RR) or weighted mean differences (WMD), with 95% confidence intervals (CI). Data were analysed on an intention-to-treat basis, with the assumption that people who dropped out had no improvement. MAIN RESULTS We included eleven studies investigating the use of older cholinergic drugs compared with placebo. Most studies involved small numbers of participants (5-20 people). We found no completed trials of the new cholinergic Alzheimer drugs for the treatment of tardive dyskinesia. Cholinergic drugs did not result in any substantial improvement in tardive dyskinesia symptoms when compared with placebo (8 RCTs, 170 people, RR no important improvement 0.84 CI 0.68 to 1.04). Neither did tardive dyskinesia symptoms increase (7 RCTs, 137 people, RR deterioration in tardive dyskinesia 1.17 CI 0.55 to 2.50). Pooled results for endpoint AIMS scores were equivocal (4 RCTs, 86 people, WMD -0.19 CI -0.53 to 0.14). Deanol may cause gastric adverse effects (5 RCTs, 61 people, RR 9.00 CI 0.55-148) and other adverse effects such as sedation and peripheral cholinergic effects (6 RCTs, 94 people, RR 6.83 CI 0.99-47). One study reported on global outcome. Meclofenoxate was neither clearly helpful nor harmful when compared with placebo (1 RCT, 60 people, RR not of global benefit 0.89 CI 0.59 to 1.32). We found no difference between people allocated cholinergics and those given placebo for the outcome of leaving the study before completion (10 RCTs, 240 people, RR 0.52 CI 0.21 to 1.33). REVIEWER'S CONCLUSIONS Tardive dyskinesia remains a major public health problem. The clinical effects of older cholinergic drugs are unclear, as too few, too small studies leave many questions unanswered. Cholinergic drugs should remain of interest to researchers and currently have little place in routine clinical work. However, with the advent of new cholinergic agents now used for treating Alzheimer's disease, scope exists for more informative trials. If these new cholinergic agents are to be investigated for treating people with tardive dyskinesia, their effects should be demonstrated in well-designed, conducted and reported randomised trials.
Collapse
Affiliation(s)
- I A Tammenmaa
- Department of Psychiatry, University of Helsinki, Lapinlahti Hospital, P.O.Box 320, FIN-00029 Helsinki University Central Hospital, Finland.
| | | | | | | |
Collapse
|
10
|
Abstract
This systematic review aimed to collate randomized controlled trials (RCTs) of various interventions used to treat tardive dyskinesia (TD) and, where appropriate, to combine the data for meta-analysis. Clinical trials were identified by electronic searches, handsearches and contact with principal investigators. Data were extracted independently by two reviewers, for outcomes related to improvement, deterioration, side-effects and drop out rates. Data were pooled using the Mantel-Haenzel Odds Ratio (fixed effect model). For treatments that had significant effects, the number needed to treat (NNT) was calculated. From 296 controlled clinical trials, data were extracted from 47 trials. For most interventions, we could identify no RCT-derived evidence of efficacy. A meta-analysis showed that baclofen, deanol and diazepam were no more effective than a placebo. Single RCTs demonstrated a lack of evidence of any effect for bromocriptine, ceruletide, clonidine, estrogen, gamma linolenic acid, hydergine, lecithin, lithium, progabide, seligiline and tetrahydroisoxazolopyridinol. The meta-analysis found that five interventions were effective: L-dopa, oxypertine, sodium valproate, tiapride and vitamin E; neuroleptic reduction was marginally significant. Data from single RCTs revealed that insulin, alpha methyl dopa and reserpine were more effective than a placebo. There was a significantly increased risk of adverse events associated with baclofen, deanol, L-dopa, oxypertine and reserpine. Meta-analysis of the impact of placebo (n=485) showed that 37.3% of participants showed an improvement. Interpretation of this systematic review requires caution as the individual trials identified tended to have small sample sizes. For many compounds, data from only one trial were available, and where meta-analyses were possible, these were based on a small number of trials. Despite these concerns, the review facilitated the interpretation of the large and diverse range of treatments used for TD. Clinical recommendations for the treatment of TD are made, based on the availability of RCT-derived evidence, the strength of that evidence and the presence of adverse effects.
Collapse
Affiliation(s)
- K V Soares
- Medical Health Unit for Research, Gertner Institute, C Sheba Medical Center, Tel Hashomer, Israel
| | | |
Collapse
|