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Abdolizadeh A, Hosseini Kupaei M, Kambari Y, Amaev A, Korann V, Torres-Carmona E, Song J, Ueno F, Koizumi MT, Nakajima S, Agarwal SM, Gerretsen P, Graff-Guerrero A. The effect of second-generation antipsychotics on anxiety/depression in patients with schizophrenia: A systematic review and meta-analysis. Schizophr Res 2024; 270:11-36. [PMID: 38843584 DOI: 10.1016/j.schres.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 05/06/2024] [Accepted: 05/26/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVE Despite the high prevalence of anxiety in schizophrenia, no established guideline exists for the management of these symptoms. We aimed to synthesize evidence on the effect of second-generation antipsychotics (SGAs) on anxiety in patients with schizophrenia. METHODS We systematically searched Medline, Embase, PsycInfo, Web of Science, PubMed, and Cochrane library to identify randomized controlled trials of SGAs that reporting anxiety measures in schizophrenia. The search was limited to English-language articles published before February 2024. Data were pooled using a random-effects model. RESULTS Among 48 eligible studies, 29 (n = 7712) were included in the meta-analyses comparing SGAs to placebo, haloperidol, or another SGAs for their effect on anxiety/depression. SGAs had a small effect on anxiety/depression versus placebo (SMD = -0.28 (95 % CI [-0.34, -0.21], p < .00001, I2 = 47 %, n = 5576)) associated with efficacy for positive (z = 5.679, p < .001) and negative symptoms (z = 4.490, p < .001). Furthermore, SGAs were superior to haloperidol (SMD = -0.44, 95 % CI [-0.75, -0.13], p = .005, n = 1068) with substantial study-level heterogeneity (I2 = 85 %). Excluding one study of quetiapine in first-episode patients (SMD = -3.05, n = 73), SGAs showed a small effect on anxiety/depression versus haloperidol without heterogeneity (SMD = -0.23, 95 % CI [-0.35, -0.12], p = 01; I2 = %0). Risperidone's effect on anxiety/depression was comparable to olanzapine (SMD = -0.02, 95 % CI [-0.24,0.20], p = .87, I2 = 45 %, n = 753) and amisulpride (SMD = 0.27, 95 % CI [-1.08,0.61], p = .13, I2 = 50 %, n = 315). CONCLUSION While SGAs showed a small effect on anxiety/depression, the findings are inconclusive due to scarcity of research on comorbid anxiety in schizophrenia, heterogeneity of anxiety symptoms, and the scales used to measure anxiety. Further studies employing specific anxiety scales are required to explore antipsychotics, considering their receptor affinity and augmentation with serotonin/norepinephrine reuptake inhibitors or benzodiazepines for managing anxiety in schizophrenia.
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Affiliation(s)
- Ali Abdolizadeh
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Yasaman Kambari
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aron Amaev
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vittal Korann
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Edgardo Torres-Carmona
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jianmeng Song
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Fumihiko Ueno
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Michel-Teruki Koizumi
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, National Hospital Organization Shimofusa Psychiatric Medical Center, Chiba, Japan
| | - Shinichiro Nakajima
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Sri Mahavir Agarwal
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, CAMH, Toronto, ON, Canada
| | - Philip Gerretsen
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, CAMH, Toronto, ON, Canada
| | - Ariel Graff-Guerrero
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, CAMH, Toronto, ON, Canada.
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Ibragimov K, Keane GP, Carreño Glaría C, Cheng J, Llosa AE. Haloperidol (oral) versus olanzapine (oral) for people with schizophrenia and schizophrenia-spectrum disorders. Cochrane Database Syst Rev 2024; 7:CD013425. [PMID: 38958149 PMCID: PMC11220909 DOI: 10.1002/14651858.cd013425.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
BACKGROUND Schizophrenia is often a severe and disabling psychiatric disorder. Antipsychotics remain the mainstay of psychotropic treatment for people with psychosis. In limited resource and humanitarian contexts, it is key to have several options for beneficial, low-cost antipsychotics, which require minimal monitoring. We wanted to compare oral haloperidol, as one of the most available antipsychotics in these settings, with a second-generation antipsychotic, olanzapine. OBJECTIVES To assess the clinical benefits and harms of haloperidol compared to olanzapine for people with schizophrenia and schizophrenia-spectrum disorders. SEARCH METHODS We searched the Cochrane Schizophrenia study-based register of trials, which is based on monthly searches of CENTRAL, CINAHL, ClinicalTrials.gov, Embase, ISRCTN, MEDLINE, PsycINFO, PubMed and WHO ICTRP. We screened the references of all included studies. We contacted relevant authors of trials for additional information where clarification was required or where data were incomplete. The register was last searched on 14 January 2023. SELECTION CRITERIA Randomised clinical trials comparing haloperidol with olanzapine for people with schizophrenia and schizophrenia-spectrum disorders. Our main outcomes of interest were clinically important change in global state, relapse, clinically important change in mental state, extrapyramidal side effects, weight increase, clinically important change in quality of life and leaving the study early due to adverse effects. DATA COLLECTION AND ANALYSIS We independently evaluated and extracted data. For dichotomous outcomes, we calculated risk ratios (RR) and their 95% confidence intervals (CI) and the number needed to treat for an additional beneficial or harmful outcome (NNTB or NNTH) with 95% CI. For continuous data, we estimated mean differences (MD) or standardised mean differences (SMD) with 95% CIs. For all included studies, we assessed risk of bias (RoB 1) and we used the GRADE approach to create a summary of findings table. MAIN RESULTS We included 68 studies randomising 9132 participants. We are very uncertain whether there is a difference between haloperidol and olanzapine in clinically important change in global state (RR 0.84, 95% CI 0.69 to 1.02; 6 studies, 3078 participants; very low-certainty evidence). We are very uncertain whether there is a difference between haloperidol and olanzapine in relapse (RR 1.42, 95% CI 1.00 to 2.02; 7 studies, 1499 participants; very low-certainty evidence). Haloperidol may reduce the incidence of clinically important change in overall mental state compared to olanzapine (RR 0.70, 95% CI 0.60 to 0.81; 13 studies, 1210 participants; low-certainty evidence). For every eight people treated with haloperidol instead of olanzapine, one fewer person would experience this improvement. The evidence suggests that haloperidol may result in a large increase in extrapyramidal side effects compared to olanzapine (RR 3.38, 95% CI 2.28 to 5.02; 14 studies, 3290 participants; low-certainty evidence). For every three people treated with haloperidol instead of olanzapine, one additional person would experience extrapyramidal side effects. For weight gain, the evidence suggests that there may be a large reduction in the risk with haloperidol compared to olanzapine (RR 0.47, 95% CI 0.35 to 0.61; 18 studies, 4302 participants; low-certainty evidence). For every 10 people treated with haloperidol instead of olanzapine, one fewer person would experience weight increase. A single study suggests that haloperidol may reduce the incidence of clinically important change in quality of life compared to olanzapine (RR 0.72, 95% CI 0.57 to 0.91; 828 participants; low-certainty evidence). For every nine people treated with haloperidol instead of olanzapine, one fewer person would experience clinically important improvement in quality of life. Haloperidol may result in an increase in the incidence of leaving the study early due to adverse effects compared to olanzapine (RR 1.99, 95% CI 1.60 to 2.47; 21 studies, 5047 participants; low-certainty evidence). For every 22 people treated with haloperidol instead of olanzapine, one fewer person would experience this outcome. Thirty otherwise relevant studies and several endpoints from 14 included studies could not be evaluated due to inconsistencies and poor transparency of several parameters. Furthermore, even within studies that were included, it was often not possible to use data for the same reasons. Risk of bias differed substantially for different outcomes and the certainty of the evidence ranged from very low to low. The most common risks of bias leading to downgrading of the evidence were blinding (performance bias) and selective reporting (reporting bias). AUTHORS' CONCLUSIONS Overall, the certainty of the evidence was low to very low for the main outcomes in this review, making it difficult to draw reliable conclusions. We are very uncertain whether there is a difference between haloperidol and olanzapine in terms of clinically important global state and relapse. Olanzapine may result in a slightly greater overall clinically important change in mental state and in a clinically important change in quality of life. Different side effect profiles were noted: haloperidol may result in a large increase in extrapyramidal side effects and olanzapine in a large increase in weight gain. The drug of choice needs to take into account side effect profiles and the preferences of the individual. These findings and the recent inclusion of olanzapine alongside haloperidol in the WHO Model List of Essential Medicines should increase the likelihood of it becoming more easily available in low- and middle- income countries, thereby improving choice and providing a greater ability to respond to side effects for people with lived experience of schizophrenia. There is a need for additional research using appropriate and equivalent dosages of these drugs. Some of this research needs to be done in low- and middle-income settings and should actively seek to account for factors relevant to these. Research on antipsychotics needs to be person-centred and prioritise factors that are of interest to people with lived experience of schizophrenia.
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Affiliation(s)
- Khasan Ibragimov
- Ecole des Hautes Etudes en Sante Publique (EHESP), Hautes Etudes en Sante Publique (EHESP), Paris, France
- Epicentre, Paris, France
| | | | | | - Jie Cheng
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Augusto Eduardo Llosa
- Epicentre, Paris, France
- Operational Centre Barcelona, Médecins Sans Frontières, Barcelona, Spain
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Kooij KL, Luijendijk MCM, Drost L, Platenburg G, van Elburg A, Adan RAH. Intranasal administration of olanzapine has beneficial outcome in a rat activity-based anorexia model. Eur Neuropsychopharmacol 2023; 71:65-74. [PMID: 37031523 DOI: 10.1016/j.euroneuro.2023.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/15/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023]
Abstract
The atypical antipsychotic drug olanzapine is prescribed despite clinical studies on olanzapine treatment showing mixed results on treatment efficacy in anorexia nervosa. We investigated the effect of systemic and intranasal administration of olanzapine in the activity-based anorexia (ABA) model. Rats were habituated to a running wheel and exposed to the ABA model while treated with olanzapine. During ABA rats had 1.5 h of daily access to food and ad libitum access to a running wheel for seven consecutive days. Olanzapine was administered via an osmotic minipump (1, 2.75, and 7.5 mg/kg) or intranasally 2 h before dark onset (1 and 2.75 mg/kg). We monitored body weight, food intake, wheel revolutions, body temperature, and adipose tissue. We found 2.75 and 7.5 mg/kg systemic olanzapine decreased wheel revolutions during ABA. Relative adipose tissue mass was increased in the 7.5 mg/kg olanzapine-treated group while body weight, food intake, and body temperature were unaltered by the systemic olanzapine. 1 and 2.75 mg/kg intranasal olanzapine diminished wheel revolutions and body temperature during the first 2 h after administration. The intranasal olanzapine-treated rats had a higher body weight at the end of ABA. We find that olanzapine has beneficial outcomes in the ABA via two administration routes by acting mainly on running wheel activity. Intranasal olanzapine showed a rapid effect in the first hours after administration in reducing locomotor activity. We recommend further exploring intranasal administration of olanzapine in anorectic patients to assist them in coping with restlessness.
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Affiliation(s)
- Karlijn L Kooij
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Altrecht Eating Disorders Rintveld, Zeist, the Netherlands.
| | - Mieneke C M Luijendijk
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Lisa Drost
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
| | | | - Annemarie van Elburg
- Altrecht Eating Disorders Rintveld, Zeist, the Netherlands; Department of Clinical Psychology, Utrecht University, the Netherlands.
| | - Roger A H Adan
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Altrecht Eating Disorders Rintveld, Zeist, the Netherlands; Dept of Neuroscience and Physiology, Sahlgrenska academy, Univ of Gothenborg, Sweden.
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4
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Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Ponsford M, Ponsford JL. Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials. J Neurotrauma 2023; 40:33-51. [PMID: 35833454 DOI: 10.1089/neu.2022.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are frequently used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety, and impact upon patient outcomes. The sedating and cognitive side effects of these agents are theorized to exacerbate confusion during PTA, leading to prolonged PTA duration and increased agitation. This study, conducted in a subacute inpatient rehabilitation setting, describes the results of a double-blind, randomized, placebo-controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group comparisons were additionally conducted, examining level of agitation; number of agitated days; agitation at discharge, duration, and depth of PTA; length of hospitalization; cognitive outcome; adverse events; and rescue medication use. Eleven agitated participants in PTA (mean [M] age = 39.82 years, standard deviation [SD] = 20.06; mean time post-injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every 3 to 4 days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37-0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5-20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. In group analyses, participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine, mean = 9.32, SD = 0.69; placebo, M = 10.68, SD = 0.30; p = .009, d = -2.16), and a trend toward longer PTA duration with large effect size (olanzapine, M = 71.96 days, SD = 20.31; placebo, M = 47.50 days, SD = 11.27; p = 0.072, d = 1.26). No further group comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so. Importantly, administration of olanzapine during PTA may lead to increased patient confusion, possibly prolonging PTA. When utilizing olanzapine, physicians must therefore balance the possible advantages of agitation management with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings and the efficacy and outcomes associated with the use of any pharmacological agent for the management of agitation during the PTA period.
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
| | - Adam McKay
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia.,Division of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
| | - John Olver
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, Melbourne, Australia
| | - Michael Ponsford
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
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Miller J. Managing acute agitation and aggression in the world of drug shortages. Ment Health Clin 2021; 11:334-346. [PMID: 34824958 PMCID: PMC8582771 DOI: 10.9740/mhc.2021.11.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
Abstract
Acute agitation and aggression create safety risks for both patients and staff, often leading to psychiatric emergencies. Quick and appropriate treatment is necessary to achieve safe and effective outcomes. Unfortunately, there are several factors that hinder timely interventions, such as medication shortages and delay in staff preparedness. Ultimately, the goal of managing acute agitation and aggression in the clinical setting is to de-escalate the situation and prevent harm to patients and staff. This article will explore useful interventions in realizing treatment goals for the management of agitation and aggression in adults while navigating limitations faced in practice.
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Japanese Society of Neuropsychopharmacology: "Guideline for Pharmacological Therapy of Schizophrenia". Neuropsychopharmacol Rep 2021; 41:266-324. [PMID: 34390232 PMCID: PMC8411321 DOI: 10.1002/npr2.12193] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022] Open
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Muir-Cochrane E, Oster C, Grimmer K. Interrogating systematic review recommendations for effective chemical restraint. J Eval Clin Pract 2020; 26:1768-1779. [PMID: 32059065 DOI: 10.1111/jep.13363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/12/2020] [Accepted: 01/16/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Baldaçara L, Diaz AP, Leite V, Pereira LA, Dos Santos RM, Gomes Júnior VDP, Calfat ELB, Ismael F, Périco CAM, Porto DM, Zacharias CEK, Cordeiro Q, da Silva AG, Tung TC. Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach. ACTA ACUST UNITED AC 2019; 41:324-335. [PMID: 30843960 PMCID: PMC6804299 DOI: 10.1590/1516-4446-2018-0177] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/18/2018] [Indexed: 01/07/2023]
Abstract
Objective: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. Methods: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. Conclusion: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. Systematic review registry number: CRD42017054440.
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Affiliation(s)
- Leonardo Baldaçara
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Universidade Federal do Tocantins (UFT), Palmas, TO, Brazil.,Secretaria de Estado de Saúde do Tocantins, Palmas, TO, Brazil
| | - Alexandre P Diaz
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina (UNISUL), Palhoça, SC, Brazil
| | - Verônica Leite
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Secretaria de Estado de Saúde do Tocantins, Palmas, TO, Brazil.,Secretaria de Saúde do Município de Palmas, Palmas, TO, Brazil
| | - Lucas A Pereira
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Universidade Salvador (UNIFACS), Salvador, BA, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, BA, Brazil.,Faculdade de Tecnologia e Ciências (FTC), Salvador, BA, Brazil
| | - Roberto M Dos Santos
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brazil.,Pronto Atendimento em Saúde Mental, João Pessoa, PB, Brazil
| | - Vicente de P Gomes Júnior
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Associação Psiquiátrica do Piauí (APPI), Teresina, PI, Brazil
| | - Elie L B Calfat
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil.,Centro de Atenção Integrada à Saúde Mental, Franco da Rocha, SP, Brazil
| | - Flávia Ismael
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina do ABC, Santo André, SP, Brazil.,Coordenadoria de Saúde Mental, São Caetano do Sul, SP, Brazil.,Universidade de São Caetano do Sul, São Caetano do Sul, SP, Brazil
| | - Cintia A M Périco
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina do ABC, Santo André, SP, Brazil.,Coordenadoria de Saúde Mental, São Bernardo do Campo, SP, Brazil
| | - Deisy M Porto
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Instituto de Psiquiatria de Santa Catarina, São José, SC, Brazil.,Coordenação Estadual de Saúde Mental, Florianópolis, SC, Brazil
| | - Carlos E K Zacharias
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Secretaria de Estado da Saúde de São Paulo, São Paulo, SP, Brazil.,Secretaria de Saúde do Município de Sorocaba, São Paulo, SP, Brazil
| | - Quirino Cordeiro
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil.,Coordenação-Geral de Saúde Mental, Álcool e Outras Drogas, Ministério da Saúde, Brazil
| | - Antônio Geraldo da Silva
- Asociación Psiquiátrica de América Latina (APAL)Asociación Psiquiátrica de América Latina (APAL).,ABP, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina, Universidade do Porto/Conselho Federal de Medicina (CFM), Porto, Portugal
| | - Teng C Tung
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
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10
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Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy. J Emerg Med 2018; 54:364-374. [DOI: 10.1016/j.jemermed.2017.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 11/22/2022]
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Gottlieb M, Long B, Koyfman A. Approach to the Agitated Emergency Department Patient. J Emerg Med 2018; 54:447-457. [PMID: 29395692 DOI: 10.1016/j.jemermed.2017.12.049] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/17/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management. OBJECTIVE This review provides an evidence-based summary of the current ED evaluation and management of acute agitation. DISCUSSION Acute agitation is an increasingly common presentation to the ED and has a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies. Missed diagnosis of a dangerous etiology of the patient's agitation may result in severe morbidity and mortality. Assessment and management of the agitated patient should occur concurrently. Focused history and physical examination are recommended, though control of the patient's agitation may be required. All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration. CONCLUSION Acute agitation is an important presentation that requires prompt recognition and treatment. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians to safely and effectively manage these patients.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Katagiri H, Taketsuna M, Kondo S, Kajimoto K, Aoi E, Tanji Y. Safety and effectiveness of rapid-acting intra-muscular olanzapine for agitation associated with schizophrenia - Japan postmarketing surveillance study. Neuropsychiatr Dis Treat 2018; 14:265-272. [PMID: 29391799 PMCID: PMC5769586 DOI: 10.2147/ndt.s147124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the safety and effectiveness of rapid-acting intramuscular (IM) olanzapine in the treatment of acute agitation associated with schizophrenia in real-world clinical settings in Japan. METHODS In this multicenter, postmarketing surveillance (PMS) study, patients with acute agitation associated with schizophrenia were treated with IM olanzapine daily in a daily clinical setting. The observational period ranged from 1 to 7 days, including the day of initial administration. Safety was assessed by reporting treatment-emergent adverse events (TEAEs) and adverse drug reactions (ADRs). The Positive and Negative Syndrome Scale - Excited Component (PANSS-EC) score was used to evaluate effectiveness at baseline and at 2 hours (after each administration), 2 days, and 3 days (end of the observational period) from the last administration of the IM olanzapine injection. RESULTS The safety analysis set included 999 patients, and the initial dose of 10 mg was administered to 955 patients. TEAEs were reported in 28 patients (36 events), the most common of which were dyslalia (5 patients), akathisia and somno lence (4 patients each), hepatic function abnormal (3 patients), and constipation and dehydration (2 patients each). One serious adverse event of akathisia occurred during the observation period. The PANSS-EC score (mean ± standard deviation) was 23.3±6.4 (n=625) at baseline, 16.9±7.0 (n=522) at 2 hours after initial injection, and 14.9±6.5 (n=650) at the last observation carried forward. CONCLUSION The results of this Japanese PMS study demonstrated that IM olanzapine is safe and has a favorable effectiveness profile in the treatment of schizophrenia patients with acute agitation.
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Affiliation(s)
| | | | | | - Kenta Kajimoto
- Scientific Communications, Medicines Development Unit Japan
| | - Etsuko Aoi
- Global Patient Safety Japan, Quality and Patient Safety, Eli Lilly Japan K.K., Kobe, Japan
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Zaman H, Sampson SJ, Beck AL, Sharma T, Clay FJ, Spyridi S, Zhao S, Gillies D. Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database Syst Rev 2017; 12:CD003079. [PMID: 29219171 PMCID: PMC6486117 DOI: 10.1002/14651858.cd003079.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acute psychotic illness, especially when associated with agitated or violent behaviour, can require urgent pharmacological tranquillisation or sedation. In several countries, clinicians often use benzodiazepines (either alone or in combination with antipsychotics) for this outcome. OBJECTIVES To examine whether benzodiazepines, alone or in combination with other pharmacological agents, is an effective treatment for psychosis-induced aggression or agitation when compared with placebo, other pharmacological agents (alone or in combination) or non-pharmacological approaches. SEARCH METHODS We searched the Cochrane Schizophrenia Group's register (January 2012, 20 August 2015 and 3 August 2016), inspected reference lists of included and excluded studies, and contacted authors of relevant studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing benzodiazepines alone or in combination with any antipsychotics, versus antipsychotics alone or in combination with any other antipsychotics, benzodiazepines or antihistamines, for people who were aggressive or agitated due to psychosis. DATA COLLECTION AND ANALYSIS We reliably selected studies, quality assessed them and extracted data. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CI) using a fixed-effect model. For continuous outcomes, we calculated the mean difference (MD) between groups. If there was heterogeneity, this was explored using a random-effects model. We assessed risk of bias and created a 'Summary of findings' table using GRADE. MAIN RESULTS Twenty trials including 695 participants are now included in the review. The trials compared benzodiazepines or benzodiazepines plus an antipsychotic with placebo, antipsychotics, antihistamines, or a combination of these. The quality of evidence for the main outcomes was low or very low due to very small sample size of included studies and serious risk of bias (randomisation, allocation concealment and blinding were not well conducted in the included trials, 30% of trials (six out of 20) were supported by pharmaceutical institutes). There was no clear effect for most outcomes.Benzodiazepines versus placeboOne trial compared benzodiazepines with placebo. There was no difference in the number of participants sedated at 24 hours (very low quality evidence). However, for the outcome of global state, clearly more people receiving placebo showed no improvement in the medium term (one to 48 hours) (n = 102, 1 RCT, RR 0.62, 95% CI 0.40 to 0.97, very low quality evidence). Benzodiazepines versus antipsychoticsWhen compared with haloperidol, there was no observed effect for benzodiazepines for sedation by 16 hours (n = 434, 8 RCTs, RR 1.13, 95% CI 0.83 to 1.54, low quality evidence). There was no difference in the number of participants who had not improved in the medium term (n = 188, 5 RCTs, RR 0.89, 95% CI 0.71 to 1.11, low quality evidence). However, one small study found fewer participants improved when receiving benzodiazepines compared with olanzapine (n = 150, 1 RCT, RR 1.84, 95% CI 1.06 to 3.18, very low quality evidence). People receiving benzodiazepines were less likely to experience extrapyramidal effects in the medium term compared to people receiving haloperidol (n = 233, 6 RCTs, RR 0.13, 95% CI 0.04 to 0.41, low quality evidence).Benzodiazepines versus combined antipsychotics/antihistaminesWhen benzodiazepine was compared with combined antipsychotics/antihistamines (haloperidol plus promethazine), there was a higher risk of no improvement in people receiving benzodiazepines in the medium term (n = 200, 1 RCT, RR 2.17, 95% CI 1.16 to 4.05, low quality evidence). However, for sedation, the results were controversial between two groups: lorazepam may lead to lower risk of sedation than combined antipsychotics/antihistamines (n = 200, 1 RCT, RR 0.91, 95% CI 0.84 to 0.98, low quality evidence); while, midazolam may lead to higher risk of sedation than combined antipsychotics/antihistamines (n = 200, 1 RCT, RR 1.13, 95% CI 1.04 to 1.23, low quality evidence).Other combinationsData comparing benzodiazepines plus antipsychotics versus benzodiazepines alone did not yield any results with clear differences; all were very low quality evidence. When comparing combined benzodiazepines/antipsychotics (all studies compared haloperidol) with the same antipsychotics alone (haloperidol), there was no difference between groups in improvement in the medium term (n = 185, 4 RCTs, RR 1.17, 95% CI 0.93 to 1.46, low quality evidence), but sedation was more likely in people who received the combination therapy (n = 172, 3 RCTs, RR 1.75, 95% CI 1.14 to 2.67,very low quality evidence). Only one study compared combined benzodiazepine/antipsychotics with antipsychotics; however, this study did not report our primary outcomes. One small study compared combined benzodiazepines/antipsychotics with combined antihistamines/antipsychotics. Results showed a higher risk of no clinical improvement (n = 60, 1 RCT, RR 25.00, 95% CI 1.55 to 403.99, very low quality evidence) and sedation status (n = 60, 1 RCT, RR 12.00, 95% CI 1.66 to 86.59, very low quality evidence) in the combined benzodiazepines/antipsychotics group. AUTHORS' CONCLUSIONS The evidence from RCTs for the use of benzodiazepines alone is not good. There were relatively few good data. Most trials were too small to highlight differences in either positive or negative effects. Adding a benzodiazepine to other drugs does not seem to confer clear advantage and has potential for adding unnecessary adverse effects. Sole use of older antipsychotics unaccompanied by anticholinergic drugs seems difficult to justify. Much more high-quality research is still needed in this area.
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Affiliation(s)
- Hadar Zaman
- Bradford School of Pharmacy & Medical Sciences, Faculty of Life Sciences, University of Bradford, Horton Road, Bradford, UK, BD7 1DP
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Ostinelli EG, Brooke‐Powney MJ, Li X, Adams CE. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2017; 7:CD009377. [PMID: 28758203 PMCID: PMC6483410 DOI: 10.1002/14651858.cd009377.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Haloperidol used alone is recommended to help calm situations of aggression or agitation for people with psychosis. It is widely accessible and may be the only antipsychotic medication available in limited-resource areas. OBJECTIVES To examine whether haloperidol alone is an effective treatment for psychosis-induced aggression or agitation, wherein clinicians are required to intervene to prevent harm to self and others. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (26th May 2016). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register. SELECTION CRITERIA Randomised controlled trials (RCTs) involving people exhibiting aggression and/or agitation thought to be due to psychosis, allocated rapid use of haloperidol alone (by any route), compared with any other treatment. Outcomes of interest included tranquillisation or asleep by 30 minutes, repeated need for rapid tranquillisation within 24 hours, specific behaviours (threat or injury to others/self), adverse effects. We included trials meeting our selection criteria and providing useable data. DATA COLLECTION AND ANALYSIS We independently inspected all citations from searches, identified relevant abstracts, and independently extracted data from all included studies. For binary data we calculated risk ratio (RR), for continuous data we calculated mean difference (MD), and for cognitive outcomes we derived standardised mean difference (SMD) effect sizes, all with 95% confidence intervals (CI) and using a fixed-effect model. We assessed risk of bias for the included studies and used the GRADE approach to produce 'Summary of findings' tables which included our pre-specified main outcomes of interest. MAIN RESULTS We found nine new RCTs from the 2016 update search, giving a total of 41 included studies and 24 comparisons. Few studies were undertaken in circumstances that reflect real-world practice, and, with notable exceptions, most were small and carried considerable risk of bias. Due to the large number of comparisons, we can only present a summary of main results.Compared with placebo, more people in the haloperidol group were asleep at two hours (2 RCTs, n=220, RR 0.88, 95%CI 0.82 to 0.95, very low-quality evidence) and experienced dystonia (2 RCTs, n=207, RR 7.49, 95%CI 0.93 to 60.21, very low-quality evidence).Compared with aripiprazole, people in the haloperidol group required fewer injections than those in the aripiprazole group (2 RCTs, n=473, RR 0.78, 95%CI 0.62 to 0.99, low-quality evidence). More people in the haloperidol group experienced dystonia (2 RCTs, n=477, RR 6.63, 95%CI 1.52 to 28.86, very low-quality evidence).Four trials (n=207) compared haloperidol with lorazepam with no significant differences with regard to number of participants asleep at one hour (1 RCT, n=60, RR 1.05, 95%CI 0.76 to 1.44, very low-quality of evidence) or those requiring additional injections (1 RCT, n=66, RR 1.14, 95%CI 0.91 to 1.43, very low-quality of evidence).Haloperidol's adverse effects were not offset by addition of lorazepam (e.g. dystonia 1 RCT, n=67, RR 8.25, 95%CI 0.46 to 147.45, very low-quality of evidence).Addition of promethazine was investigated in two trials (n=376). More people in the haloperidol group were not tranquil or asleep by 20 minutes (1 RCT, n=316, RR 1.60, 95%CI 1.18 to 2.16, moderate-quality evidence). Acute dystonia was too common in the haloperidol alone group for the trial to continue beyond the interim analysis (1 RCT, n=316, RR 19.48, 95%CI 1.14 to 331.92, low-quality evidence). AUTHORS' CONCLUSIONS Additional data from new studies does not alter previous conclusions of this review. If no other alternative exists, sole use of intramuscular haloperidol could be life-saving. Where additional drugs are available, sole use of haloperidol for extreme emergency could be considered unethical. Addition of the sedating promethazine has support from better-grade evidence from within randomised trials. Use of an alternative antipsychotic drug is only partially supported by fragmented and poor-grade evidence. Adding a benzodiazepine to haloperidol does not have strong evidence of benefit and carries risk of additional harm.After six decades of use for emergency rapid tranquillisation, this is still an area in need of good independent trials relevant to real-world practice.
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Affiliation(s)
- Edoardo G Ostinelli
- Università degli Studi di MilanoDepartment of Health SciencesVia Antonio di Rudinì 8MilanItaly20142
| | - Melanie J Brooke‐Powney
- The University of ManchesterDepartment of Clinical Psychology2nd Floor, Zochonis BuildingBrunswick StreetManchesterUKM13 9PL
| | - Xue Li
- Systematic Review Solutions LtdNottinghamUK
| | - Clive E Adams
- The University of NottinghamCochrane Schizophrenia GroupInstitute of Mental HealthInnovation Park, Triumph Road,NottinghamUKNG7 2TU
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Serum high-sensitivity C-reactive protein: A delicate sentinel elevated in drug-free acutely agitated patients with schizophrenia. Psychiatry Res 2016; 246:89-94. [PMID: 27669496 DOI: 10.1016/j.psychres.2016.09.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 09/04/2016] [Accepted: 09/20/2016] [Indexed: 12/28/2022]
Abstract
Increased levels of high-sensitivity C reactive protein (hsCRP) have been reported in schizophrenia, but to date, no study is designed to examine serum hsCRP in acutely agitated patients with schizophrenia, an extreme state that requires immediate diagnosis and medical treatment. Serum hsCRP levels were assessed in 32 clinically acutely agitated patients and 42 healthy control subjects matched for demographic properties. Further, serum hsCRP levels in acutely agitated patients were compared with control subjects and with the levels after the patients were treated with anti-psychiatric medications. Meanwhile, the influence of clinical subtypes, family history, and gender, as well as the levels of white blood cell (WBC) counts were also considered. In results, serum hsCRP levels were significantly higher in acutely agitated patients with schizophrenia than in healthy subjects. The elevation of serum hsCRP in patients was not affected by gender, family history (P>0.05), and clinical classification of schizophrenia (P>0.05). However, the elevation of hsCRP was suppressed by the medical treatment for schizophrenia with acute agitation (P<0.05). In addition, WBC counts, another inflammation-related indicator, were also increased significantly in acutely agitated patients compared with healthy subjects, consistent with the elevation of serum hsCRP. In conclusion, hsCRP is an important indicator of immune alterations in the pathogenesis of schizophrenia and has potential to be developed into a sensitive marker for the acute agitation in schizophrenia.
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Dundar Y, Greenhalgh J, Richardson M, Dwan K. Pharmacological treatment of acute agitation associated with psychotic and bipolar disorder: a systematic review and meta-analysis. Hum Psychopharmacol 2016; 31:268-85. [PMID: 27151529 DOI: 10.1002/hup.2535] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/22/2016] [Accepted: 03/16/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We used systematic review methodology to identify and evaluate short-term pharmacological interventions for agitation associated with schizophrenia or bipolar disorder. METHOD We searched electronic databases for randomised controlled trials involving comparisons between current treatments for agitation, benzodiazepines, antipsychotics and placebo. The patient population was adults with agitation associated with psychotic or bipolar disorder treated in specialist mental health services. The outcome of interest was change in agitation measured by accepted standard scales. Paired meta-analyses and network meta-analyses are presented. RESULTS Seventeen randomised controlled trials were identified (n = 3841). Treatments included haloperidol, olanzapine, aripiprazole, risperidone and lorazepam. The primary outcome was change in Positive and Negative Syndrome Scale Excited Component scores. Pair-wise comparisons suggest that after 60 min, olanzapine is superior to haloperidol; no other treatment was more effective than any other. At 120 min, loxapine 10 mg is more effective than loxapine 5 mg, and olanzapine is more effective than lorazepam. In the network meta-analyses, no treatment was superior to any other. CONCLUSION Because of limitations of available research, firm conclusions could not be drawn regarding the efficacy and safety of any identified intervention. Based on our results, there is no evidence that one drug is more effective or preferred over any other and treatment decisions could be made based on individual patient needs or costs. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Yenal Dundar
- Liverpool Reviews and Implementation Group, University of Liverpool, UK.,Mersey Care NHS Trust, Liverpool, UK
| | | | - Marty Richardson
- Liverpool Reviews and Implementation Group, University of Liverpool, UK
| | - Kerry Dwan
- Liverpool Reviews and Implementation Group, University of Liverpool, UK
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Garriga M, Pacchiarotti I, Kasper S, Zeller SL, Allen MH, Vázquez G, Baldaçara L, San L, McAllister-Williams RH, Fountoulakis KN, Courtet P, Naber D, Chan EW, Fagiolini A, Möller HJ, Grunze H, Llorca PM, Jaffe RL, Yatham LN, Hidalgo-Mazzei D, Passamar M, Messer T, Bernardo M, Vieta E. Assessment and management of agitation in psychiatry: Expert consensus. World J Biol Psychiatry 2016; 17:86-128. [PMID: 26912127 DOI: 10.3109/15622975.2015.1132007] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.
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Affiliation(s)
- Marina Garriga
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Isabella Pacchiarotti
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Siegfried Kasper
- c Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | | - Michael H Allen
- e University of Colorado Depression Center , Denver , CO 80045 , USA
| | - Gustavo Vázquez
- f Research Center for Neuroscience and Neuropsychology, Department of Neuroscience , University of Palermo , Buenos Aires , Argentina
| | | | - Luis San
- h CIBERSAM, Parc Sanitari Sant Joan De Déu , Barcelona , Catalonia , Spain
| | - R Hamish McAllister-Williams
- i Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Northumberland Tyne and Wear NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Konstantinos N Fountoulakis
- j 3rd Department of Psychiatry, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Philippe Courtet
- k Department of Emergency Psychiatry and Post Acute Care , Hôpital Lapeyronie , CHU Montpellier , France
| | - Dieter Naber
- l Department for Psychiatry and Psychotherapy , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Esther W Chan
- m Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine , the University of Hong Kong , Hong Kong , China
| | - Andrea Fagiolini
- n School of Medicine, Department of Molecular Medicine , University of Siena , Siena , Italy
| | - Hans Jürgen Möller
- o Department of Psychiatry and Psychotherapy , Ludwig Maximilian University , Munich , Germany
| | - Heinz Grunze
- p Paracelsus Medical University , Salzburg , Austria
| | - Pierre Michel Llorca
- q Service De Psychiatrie B , CHU De Clermont-Ferrand , Clermont-Ferrand , France
| | | | - Lakshmi N Yatham
- s Mood Disorders Centre, Department of Psychiatry , University of British Columbia , Vancouver , British Columbia , Canada
| | - Diego Hidalgo-Mazzei
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Marc Passamar
- t Centre Hospitalier Pierre-Jamet, SAUS , Albi , France
| | - Thomas Messer
- u Danuvius Klinik GmbH, Pfaffenhofen an Der Ilm , Germany
| | - Miquel Bernardo
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Eduard Vieta
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
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Douglas‐Hall P, Whicher EV. 'As required' medication regimens for seriously mentally ill people in hospital. Cochrane Database Syst Rev 2015; 2015:CD003441. [PMID: 26689942 PMCID: PMC7052742 DOI: 10.1002/14651858.cd003441.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Drugs used to treat psychotic illnesses may take weeks to be effective. In the interim, additional 'as required' doses of medication can be used to calm patients in psychiatric wards. The practice is widespread, with 20% to 50% of people on acute psychiatric wards receiving at least one 'as required' dose of psychotropic medication during their admission. OBJECTIVES To compare the effects of 'as required' medication regimens with regular patterns of medication for the treatment of psychotic symptoms or behavioural disturbance, thought to be secondary to psychotic illness. These regimens may be given alone or in addition to any regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register, which is based on regular searches of MEDLINE, EMBASE, PubMed, CINAHL, BIOSIS, AMED, PsycINFO and registries of clinical trials, in November 2001, March 2006, July 2012 andOctober 2013. SELECTION CRITERIA We aimed to include all relevant randomised controlled trials involving hospital inpatients with schizophrenia or schizophrenia-like illnesses, comparing any regimen of medication administered for the short-term relief of behavioural disturbance, or psychotic symptoms, to be given at the discretion of ward staff ('as required', 'prn') with fixed non-discretionary patterns of drug administration of the same drug(s). This was in addition to regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses where prescribed. DATA COLLECTION AND ANALYSIS We independently inspected abstracts and papers for inclusion. If trials had been found, we would have extracted data from the papers and quality assessed the data. For dichotomous data we would have calculated the risk ratios (RR), with the 95% confidence intervals (CI). We would have conducted analyses on an intention-to-treat basis. If data were available we would have completed a 'Summary of findings' table using GRADE. MAIN RESULTS We have not been able to identify any randomised trials comparing 'as required' medication regimens to regular regimens of the same drug. Our main outcomes of interest were important changes in (i) mental state, (ii) behaviour, (iii) dose of medication used, (iv) adverse events, (v) satisfaction with care and (iv) cost of care. AUTHORS' CONCLUSIONS There is currently no evidence from within randomised trials to support this common practice. Current practice is based on clinical experience and habit rather than high quality evidence.
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Affiliation(s)
- Petrina Douglas‐Hall
- South London and Maudsley NHS TrustPharmacy DepartmentMaudsley HospitalDenmark HillLondonUKSE5 8AZ
| | - Emma V Whicher
- Richmond Royal HospitalRichmond CDATKew Foot RoadRichmondUK
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Pan PY, Lee MS, Yeh CB. The efficacy and safety of once-daily quetiapine extended release in patients with schizophrenia switched from other antipsychotics: an open-label study in Chinese population. BMC Psychiatry 2015; 15:1. [PMID: 25609320 PMCID: PMC4308905 DOI: 10.1186/s12888-014-0378-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 12/20/2014] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Non-adherence to antipsychotic medication in schizophrenic patients is common and associated with symptom relapse and poorer long-term outcomes. The risk factors for treatment non-adherence include dosing frequency and complexity. Besides, slower dose titration in an acute schizophrenic episode may lead to attenuated efficacy. Therefore, the convenient dosage regimen and rapid initiation scheme of quetiapine extended release (XR) were expected to provide better effectiveness and promote adherence in patients with schizophrenia. This study was implemented to assess the efficacy and safety of once-daily quetiapine XR in schizophrenic patients with switched from other antipsychotics which were suboptimal due to insufficient efficacy or tolerability. METHODS This was a 12-week, open-label study conducted in the Chinese population in Taiwan. Patients who had a score of 4 (moderate) or greater on any of the 7 items of the Positive and Negative Syndrome Scale (PANSS) Positive Symptom Subscale and needed to switch from previous antipsychotics were recruited. Quetiapine XR was administered at 300 mg on day 1, 600 mg on day 2 and up to 800 mg after day 2. From day 8 until the end of the study, the dose of quetiapine XR was adjusted within 400-800 mg per day, depending on the clinical response and tolerance of the patients. The variable of the primary outcome was the change from baseline to Week 12 in PANSS total and subscale scores. Secondary outcome was the baseline-to-endpoint difference in the Clinical Global Impression-Severity (CGI-S) scores of the participants. RESULTS Sixty-one patients were recruited and 55.7% of them completed the study. The mean changes in the PANSS total score and CGI-S score showed significant improvement (-18.4, p < .001 and -1.0, p < .001, respectively). Four patients (6.7%) experienced adverse events including headache, exacerbation of psychosis and dysuria. The use of concomitant anticholinergics decreased from 15.0% to 8.3%. CONCLUSIONS The results of our investigation implicated that quetiapine XR was an effective and well tolerated alternative for Chinese schizophrenic patients with previous suboptimal treatment. Future large-scale studies are warranted to validate our results. TRIAL REGISTRATION ClinicalTrials.gov ID NCT02142556 . Registered 15 May 2014.
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Affiliation(s)
- Pei-Yin Pan
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, No.325, Sec.2,Chenggong Rd., Neihu Dist., Taipei City, 114, Taiwan.
| | - Meei-Shyuan Lee
- School of Public Health, National Defense Medical Center, No.161, Sec. 6, Minquan E. Rd., Neihu Dist., Taipei City, 114, Taiwan.
| | - Chin-Bin Yeh
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, No.325, Sec.2,Chenggong Rd., Neihu Dist., Taipei City, 114, Taiwan.
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Despite Expert Recommendations, Second-generation Antipsychotics Are Not Often Prescribed in the Emergency Department. J Emerg Med 2014; 46:808-13. [DOI: 10.1016/j.jemermed.2014.01.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/21/2013] [Accepted: 01/28/2014] [Indexed: 11/19/2022]
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Powney MJ, Adams CE, Jones H. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2012; 11:CD009377. [PMID: 23152276 DOI: 10.1002/14651858.cd009377.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Haloperidol, used alone is recommended to help calm situations of aggression with people with psychosis. This drug is widely accessible and may be the only antipsychotic medication available in areas where resources are limited. OBJECTIVES To investigate whether haloperidol alone, administered orally, intramuscularly or intravenously, is effective treatment for psychosis-induced agitation or aggression. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (1st June 2011). SELECTION CRITERIA Randomised controlled trials (RCTs) involving people exhibiting agitation or aggression (or both) thought to be due to psychosis, allocated rapid use of haloperidol alone (by any route), compared with any other treatment. Outcomes included tranquillisation or asleep by 30 minutes, repeated need for rapid tranquillisation within 24 hours, specific behaviours (threat or injury to others/self), adverse effects. DATA COLLECTION AND ANALYSIS We independently selected and assessed studies for methodological quality and extracted data. 'Summary of findings' tables were produced for each comparison grading the evidence and calculating, where possible and appropriate, a range of absolute effects. MAIN RESULTS We included 32 studies comparing haloperidol with 18 other treatments. Few studies were undertaken in circumstances that reflect real world practice, and, with notable exceptions, most were small and carried considerable risk of bias.Compared with placebo, more people in the haloperidol group were asleep at two hours (2 RCTs, n = 220, risk ratio (RR) 0.88, 95% confidence interval (CI) 0.82 to 0.95). Dystonia was common (2 RCTs, n = 207, RR 7.49, CI 0.93 to 60.21). Compared with aripiprazole, people in the haloperidol group required fewer injections than those in the aripiprazole group (2 RCTs, n = 473, RR 0.78, CI 0.62 to 0.99). More people in the haloperidol group experienced dystonia (2 RCTs, n = 477, RR 6.63, CI 1.52 to 28.86).Despite three larger trials with ziprasidone (total n = 739), data remain patchy, largely because of poor design and reporting. Compared with zuclopenthixol acetate, more people who received haloperidol required more than three injections (1 RCT, n = 70, RR 2.54, CI 1.19 to 5.46).Three trials (n = 205) compared haloperidol with lorazepam. There were no significant differences between the groups with regard to the number of participants asleep at one hour (1 RCT, n = 60, RR 1.05, CI 0.76 to 1.44). However, by three hours, significantly more people were asleep in the lorazepam group compared with the haloperidol group (1 RCT, n = 66, RR 1.93, CI 1.14 to 3.27). There were no differences in numbers requiring more than one injection (1 RCT, n = 66, RR 1.14, CI 0.91 to 1.43).Haloperidol's adverse effects were not offset by addition of lorazepam (e.g. dystonia 1 RCT, n = 67, RR 8.25, CI 0.46 to 147.45; required antiparkinson medication RR 2.74, CI 0.81 to 9.25). Addition of promethazine was investigated in one larger and better graded trial (n = 316). More people in the haloperidol group were not tranquil or asleep by 20 minutes (RR 1.60, CI 1.18 to 2.16). Significantly more people in the haloperidol alone group experienced one or more adverse effects (RR 11.28, CI 1.47 to 86.35). Acute dystonia for those allocated haloperidol alone was too common for the trial to continue beyond the interim analysis (RR 19.48, CI 1.14 to 331.92). AUTHORS' CONCLUSIONS If no other alternative exists, sole use of intramuscular haloperidol could be life-saving. Where additional drugs to offset the adverse effects are available, sole use of haloperidol for the extreme emergency, in situations of coercion, could be considered unethical. Addition of the sedating promethazine has support from better-grade evidence from within randomised trials. Use of an alternative antipsychotic drug is only partially supported by fragmented and poor-grade evidence. Evidence for use of newer generation antipsychotic alternatives is no stronger than that for older drugs. Adding a benzodiazepine to haloperidol does not have strong evidence of benefit and carries a risk of additional harm.After six decades of use for emergency rapid tranquillisation, this is still an area in need of good independent trials relevant to real world practice.
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Affiliation(s)
- Melanie J Powney
- Department of Clinical Psychology, The University ofManchester,Manchester, UK.
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Gault TI, Gray SM, Vilke GM, Wilson MP. Are Oral Medications Effective in the Management of Acute Agitation? J Emerg Med 2012; 43:854-9. [DOI: 10.1016/j.jemermed.2012.01.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 01/16/2012] [Indexed: 11/24/2022]
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Liu-Seifert H, Osuntokun OO, Godfrey JL, Feldman PD. Patient perspectives on antipsychotic treatments and their association with clinical outcomes. Patient Prefer Adherence 2010; 4:369-77. [PMID: 21049089 PMCID: PMC2962402 DOI: 10.2147/ppa.s12461] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Indexed: 01/29/2023] Open
Abstract
This analysis examined patient-reported attitudes toward antipsychotic medication and the relationship of these attitudes with clinical outcomes and pharmacotherapy adherence. The analysis included three randomized, double-blind studies in patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders 4th Edition and randomly assigned to treatment with olanzapine 5-20 mg/day or another antipsychotic (haloperidol 2-20 mg/day, risperidone 2-10 mg/day, or ziprasidone 80-160 mg/day). Patient-reported improvements were significantly greater for olanzapine (n = 488) versus other treatments (haloperidol n = 145, risperidone n = 158, or ziprasidone n = 271) on multiple Drug Attitude Inventory items. A positive attitude toward medication reported by patients was significantly associated with greater clinical improvement on the Positive and Negative Syndrome Scale and lower discontinuation rates. These results suggest that patients' perceptions of treatment benefits are associated with objective clinical measures, including reduction of symptom severity and lower discontinuation rates. Furthermore, olanzapine may be associated with more positive treatment attitudes. These findings may contribute to a better understanding of reasons for treatment adherence from patients' own perspectives.
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Affiliation(s)
- Hong Liu-Seifert
- Lilly Research Laboratories, Indianapolis, IN, USA
- Correspondence: Hong Liu-Seifert, Lilly Research Laboratories, Lilly Corporate Center, Drop code 6152, Indianapolis, IN 46285, USA, Tel +1 317 433 0662, Fax +1 317 276 6026, Email
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Airoldi G. Efficacia e tossicità della terapia farmacologica per il controllo del paziente acutamente agitato (II parte). ITALIAN JOURNAL OF MEDICINE 2010. [DOI: 10.1016/j.itjm.2010.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Systematic reviews of assessment measures and pharmacologic treatments for agitation. Clin Ther 2010; 32:403-25. [DOI: 10.1016/j.clinthera.2010.03.006] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2010] [Indexed: 11/21/2022]
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Buchanan RW, Kreyenbuhl J, Kelly DL, Noel JM, Boggs DL, Fischer BA, Himelhoch S, Fang B, Peterson E, Aquino PR, Keller W. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36:71-93. [PMID: 19955390 PMCID: PMC2800144 DOI: 10.1093/schbul/sbp116] [Citation(s) in RCA: 618] [Impact Index Per Article: 44.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In light of the large number of studies published since the 2004 update of Schizophrenia Patient Outcomes Research Team psychopharmacological treatment recommendations, we conducted an extensive literature review to determine whether the current psychopharmacological treatment recommendations required revision and whether there was sufficient evidence to warrant new treatment recommendations for prespecified outcomes of interest. We reviewed over 400 articles, which resulted in 16 treatment recommendations: the revision of 11 previous treatment recommendations and 5 new treatment recommendations. Three previous treatment recommendations were eliminated. There were 13 interventions and/or outcomes for which there was insufficient evidence for a treatment recommendation, and a statement was written to summarize the current level of evidence and identify important gaps in our knowledge that need to be addressed. In general, there was considerable consensus among the Psychopharmacology Evidence Review Group and the expert consultants. Two major areas of contention concerned whether there was sufficient evidence to recommend specific dosage ranges for the acute and maintenance treatment of first-episode and multi-episode schizophrenia and to endorse the practice of switching antipsychotics for the treatment of antipsychotic-related weight gain. Finally, there continue to be major gaps in our knowledge, including limited information on (1) the use of adjunctive pharmacological agents for the treatment of persistent positive symptoms or other symptom domains of psychopathology, including anxiety, cognitive impairments, depressive symptoms, and persistent negative symptoms and (2) the treatment of co-occurring substance or medical disorders that occur frequently in individuals with schizophrenia.
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Affiliation(s)
- Robert W. Buchanan
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228,To whom correspondence should be addressed; tel: 410-402-7876, fax: 410-402-7198, e-mail:
| | - Julie Kreyenbuhl
- Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD,VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center, Baltimore, MD
| | - Deanna L. Kelly
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228
| | - Jason M. Noel
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
| | - Douglas L. Boggs
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228
| | - Bernard A. Fischer
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228
| | - Seth Himelhoch
- Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - Beverly Fang
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - Eunice Peterson
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - Patrick R. Aquino
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - William Keller
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
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Olanzapine versus aripiprazole for the treatment of agitation in acutely ill patients with schizophrenia. J Clin Psychopharmacol 2008; 28:601-7. [PMID: 19011427 DOI: 10.1097/jcp.0b013e31818aaf6c] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Rapid control of agitation is of critical importance in the treatment of acutely ill patients with schizophrenia. Both olanzapine and aripiprazole have been shown to be safe and effective in this setting, with each having somewhat different receptor binding affinity profiles. This 5-day, randomized, double-blind trial evaluated relative improvements in agitation in hospitalized patients who received orally dosed olanzapine (n = 306, 20 mg/d) or aripiprazole (n = 298, 15 mg/d, increasing to 30 mg/d as needed). Lorazepam was also given as needed (total dose, < or =4 mg/d) but not in place of a study drug dose increase. The primary efficacy measure was daily mean change from baseline in Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) score. Secondary measures of positive symptoms and safety were also assessed. Significant improvements from baseline in PANSS-EC and secondary efficacy measures were seen for both olanzapine and aripiprazole (P < 0.001),with no between-group differences. A greater proportion of aripiprazole-treated patients received lorazepam at each visit compared with olanzapine-treated patients, but this difference was significant only at visit 5 (41.2% vs 31.0%, P = 0.033). Fasting glucose and triglycerides increased more significantly in olanzapine-treated patients (P = 0.030 and P < 0.001, respectively). Prolactin increased in the olanzapine group and decreased in the aripiprazole group with a significant between-group difference (P < 0.001). During the first 5 days of randomized treatment, olanzapine and aripiprazole displayed similar efficacy profiles for treating agitation associated with schizophrenia. Aripiprazole-treated patients had smaller increases in glucose and lipids, but no difference was observed between treatments in the proportion of patients experiencing categorical shifts in these measures.
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Villari V, Rocca P, Fonzo V, Montemagni C, Pandullo P, Bogetto F. Oral risperidone, olanzapine and quetiapine versus haloperidol in psychotic agitation. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:405-13. [PMID: 17900775 DOI: 10.1016/j.pnpbp.2007.09.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 09/10/2007] [Accepted: 09/10/2007] [Indexed: 11/19/2022]
Abstract
PURPOSE Acute agitation is a common presentation in emergency departments and is often secondary to an underlying psychotic condition. The aim of this study was to compare the effectiveness of three second generation antipsychotics (risperidone, olanzapine, quetiapine) versus haloperidol in the treatment of psychotic agitation for up to 72 h. GENERAL METHODS We recruited 101 patients with acute psychosis who were admitted at the Mental Health Department 1 South of Turin, Psychiatric Emergency Service of San Giovanni Battista Hospital, from June 2004 to June 2005. FINDINGS Aggressive behavior, as measured by Modified Overt Aggression Scale and Hostility-suspiciousness factor derived from the Brief Psychiatric Rating Scale, significantly improved in all groups, with no significant between-group differences. Extrapyramidal symptoms were more common in haloperidol treated patients compared with patients receiving risperidone, olanzapine or quetiapine. CONCLUSIONS Our results show that in the clinical practice setting of emergency psychiatry olanzapine, risperidone, quetiapine are as effective as haloperidol and better tolerated.
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Affiliation(s)
- Vincenzo Villari
- Emergency Department, Psychiatric Emergency Service, S. Giovanni Hospital, Corso Bramante 88, 10126 Turin, Italy
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Chakrabarti A, Whicher E, Morrison M, Douglas-Hall P. 'As required' medication regimens for seriously mentally ill people in hospital. Cochrane Database Syst Rev 2007:CD003441. [PMID: 17636723 DOI: 10.1002/14651858.cd003441.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Drugs used to treat psychotic illnesses may take weeks to be effective. In the interim, additional 'as required' doses of medication can be used to calm patients in psychiatric wards. The practice is widespread with 20% - 50% of people on acute psychiatric wards receiving at least one 'as required' dose of psychotropic medication during their admission. OBJECTIVES To compare the effects of 'as required' medication regimens with regular regimens of medication for the treatment of psychotic symptoms or behavioural disturbance, thought to be secondary to psychotic illness. SEARCH STRATEGY For this 2006 update, we searched The Cochrane Schizophrenia Group's register of trials (March 2006). SELECTION CRITERIA We included all relevant randomised control trials involving hospital inpatients with schizophrenia or schizophrenia-like illnesses, comparing any regimen of medication administered for the short term relief of behavioural disturbance, or psychotic symptoms, to be given at the discretion of ward staff ('as required', 'prn') with fixed non-discretionary patterns of drug administration of the same drug(s). This was in addition to regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses where prescribed. DATA COLLECTION AND ANALYSIS We independently inspected abstracts, extracted data from the papers and quality assessed the data. For dichotomous data we would have calculated the relative risks (RR), with the 95% confidence intervals (CI) and the number needed to treat statistic (NNT). Analyses would have been conducted on an intention-to-treat basis. MAIN RESULTS We didn't identify any randomised trials comparing 'as required' medication regimens to regular regimens of the same drug. AUTHORS' CONCLUSIONS There is no evidence from within randomised trials to support this common current practices. Current practice is based on clinical experience and habit rather than high quality evidence.
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Boidi G, Ferro M. Rapid dose initiation of quetiapine for the treatment of acute schizophrenia and schizoaffective disorder: a randomised, multicentre, parallel-group, open study. Hum Psychopharmacol 2007; 22:299-306. [PMID: 17487936 DOI: 10.1002/hup.844] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Rapid resolution of symptoms is a priority for clinicians treating acute psychosis, and rapid initiation of pharmacotherapy may prove beneficial. This study examined rapid dose initiation of quetiapine in acutely ill patients. METHODS A 2-week, multicentre, randomised, parallel-group, open study. Inpatients (n = 269) diagnosed with schizophrenia or schizoaffective disorder received rapid (n = 139) or conventional (n = 130) initiation of quetiapine, followed by flexible dosing (maximum 800 mg/day). Primary outcome included proportion of patients experiencing > or =1 episode of selected AEs (somnolence, dizziness, orthostatic hypotension) during Week 1. Secondary outcomes included discontinuations due to AEs, and efficacy assessed by BPRS and CGI-S scores. RESULTS The proportion of patients with > or =1 selected AE during Week 1 was 5.4% and 10.1% in the conventional and rapid initiation groups, respectively. Most common AEs (>5% patients) were hypotension, tachycardia, somnolence and sedation. Overall, four (3.1%) and three (2.1%) patients from the conventional and rapid initiation group, respectively, withdrew due to AEs. BPRS and CGI-S scores decreased significantly (p < 0.001) from baseline in both groups. CONCLUSION A higher proportion of patients experienced AEs with rapid initiation of quetiapine (800 mg/day by Day 4), although withdrawals due to AEs were comparable. Rapid initiation of quetiapine was generally well tolerated and effective in this setting.
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Affiliation(s)
- Giuseppina Boidi
- SPDC Dipartimento di Salute Mentale ASL 3, Genovese, Genoa, Italy
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Turan S, Emul M, Duran A, Mert A, Ugur M. Effectiveness of olanzapine in neurosyphilis related organic psychosis: a case report. J Psychopharmacol 2007; 21:556-8. [PMID: 17092977 DOI: 10.1177/0269881106071033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The clinicians usually do not consider syphilis in the differential diagnosis for patients with acute and chronic psychiatric symptoms. To familiarize clinicians particularly with neurosyphilis (NS) and to discuss the atypical antipsychotic alternatives, we wish to present a case with agitated, resistant psychotic symptoms related to neurosyphilis. The case was a 55-year-old male who has had anxiety, irritability, auditory hallucinations, ataxia, dysarthric speech, paranoid and persecutory delusions and agitated behaviour. Parenteral ziprasidone 20 mg/bid was initialized at the first day of admission to reduce agitation. Then it was switched to olanzapine velotab 10 mg/bid because of inefficacy. Parenteral cephtriaxon 1 g/daily was administered because of seropositive VDRl and TPHA and positive cerebrospinal fluid VDRl. Olanzapine velotab may be a good alternative antipsychotic and should be considered in reducing agitation and psychotic symptoms in NS.
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Affiliation(s)
- Senol Turan
- Department of Psychiatry, Medical Faculty of Istanbul University, Turkey.
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Peuskens J, Kasper S, Arango C, Luca Bandinelli P, Gastpar M, Keks N, Mitchell S, Oral T, Timdahl K, Vieta E. Management of acutely ill patients in the hospital setting: focus on quetiapine. Int J Psychiatry Clin Pract 2007; 11:61-72. [PMID: 24941277 DOI: 10.1080/13651500601168291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We have considered published work and clinical experience focusing on the atypical antipsychotic quetiapine in order to form a consensus on the most appropriate treatment strategies for hospitalised patients with acute schizophrenia or bipolar disorder. It is important to consider the specific treatment needs of these patients and these are discussed in the context of current treatment guidelines. We will review the efficacy and tolerability of atypical antipsychotics versus conventional antipsychotics and/or benzodiazepines as a first-line treatment, and examine the suitability of oral versus intramuscular formulations in the acute setting. The potentially beneficial properties of specific atypical agents are also considered. Appropriate dosing is particularly important in acutely ill patients as it can help achieve rapid improvement. We will discuss emerging data which show that rapid initiation of quetiapine in patients with acute psychosis or mania is not only as effective as standard initiation, but is also well tolerated. This may be important for treatment in the long term as a positive initial treatment experience can determine patient compliance and treatment adherence. In conclusion, this review recommends that oral atypical antipsychotics should be a first-choice medication for acutely ill cooperative patients in the hospital setting.
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Affiliation(s)
- Joseph Peuskens
- University Psychiatric Centre KU Leuven, Campus St.-Jozef Kortenberg, Leuven, Belgium
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Abstract
The purpose of this review is to critically review the current literature on olanzapine with an emphasis on emergent themes and key findings in the use of this agent for the treatment of mood disorders and schizophrenia. New information continues to emerge on the impact of olanzapine on schizophrenia and on aspects of the course of mood disorders. There are also continued efforts to understand, predict and manage the side-effect risk with olanzapine.
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Affiliation(s)
- Peter F Buckley
- Department of Psychiatry and Health Behavior, Medical College of Georgia, 1515 Pope Avenue, Augusta, GA 30912-3800, USA.
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Marco CA, Vaughan J. Emergency management of agitation in schizophrenia. Am J Emerg Med 2005; 23:767-76. [PMID: 16182986 DOI: 10.1016/j.ajem.2005.02.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2005] [Revised: 02/20/2005] [Accepted: 02/25/2005] [Indexed: 10/25/2022] Open
Abstract
Schizophrenia is a common psychiatric condition, affecting approximately 1% of the population. Acute emergent presentations often include hallucinations, delusions, thought, and speech disorders. Agitation is common among emergency patients with schizophrenia. Decisional capacity should be assessed in all patients. Reversible causes of agitation should be ruled out, including infection, metabolic disorders, endocrine disorders, trauma, pain, noncompliance, toxicological disorders, and structural brain abnormalities. Agitation may be managed acutely using a combination of pharmacological agents and nonpharmacological interventions. Effective pharmacological agents include several classes of antipsychotic agents and benzodiazepines. Potential life-threatening complications of pharmacological therapy should be anticipated, which may include neuroleptic malignant syndrome (NMS), prolonged QT syndrome, and respiratory depression. Nonpharmacological interventions may include a quiet environment, physical restraints, and behavioral interventions. Disposition decisions should be made based on the etiology of agitation, effective management, decisional capacity, and presence of suicidal or homicidal intentions. Many patients who have required nonpharmacological or pharmacological management of agitation require inpatient psychiatric treatment, either voluntarily or involuntarily. Psychiatric consultation should be sought for patients with schizophrenia and uncertain disposition determinations, or those requiring other complex management decisions.
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Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, St Vincent Mercy Medical Center, Toledo, OH 43608-2691, USA.
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Battaglia J, Houston JP, Ahl J, Meyers AL, Kaiser CJ. A post hoc analysis of transitioning to oral treatment with olanzapine or haloperidol after 24-hour intramuscular treatment in acutely agitated adult patients with schizophrenia. Clin Ther 2005; 27:1612-8. [PMID: 16330297 DOI: 10.1016/j.clinthera.2005.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Acutely agitated patients with schizophrenia might require treatment with IM antipsychotics, followed by a transition to oral medication. OBJECTIVE The aim of this study was to assess the relationship between 24-hour IM and transitional oral dosages of 2 antipsychotic medications, olanzapine and haloperidol. METHODS This post hoc analysis used data from a multinational, double-blind, randomized, placebo-controlled study comparing the efficacy of olanzapine, haloperidol, and placebo in acutely agitated inpatients aged > or =18 years with schizophrenia conducted at hospitals in 13 countries. Patients received 1 to 3 IM injections of olanzapine 10 mg or haloperidol 7.5 mg over 24 hours (IM phase), followed by 4 days of oral treatment with 5 to 20 mg/d of either antipsychotic (oral phase). Study patients were grouped according to which drug they received, and subgrouped based on whether they received a single or multiple IM injections. Rates of transition to lower (5-10 mg/d) versus higher (15-20 mg/d) dosages were compared within and between treatments. RESULTS Data from 236 patients were analyzed (olanzapine, 121 patients [76 men, 45 women; mean (SD) age, 38.4 (12.2) years; mean (SD) weight, 74.9 (18.5) kg]; haloperidol, 115 patients [80 men, 35 women; mean (SD) age, 38.0 (10.2) years; mean (SD) weight, 75.4 (18.7) kg]). At the end of the IM phase, the rate of haloperidol patients who were transitioned to lower oral doses was significantly higher in the single-injection subgroup compared with the multiple-injection subgroup (P = 0.03); this difference was not found in the group receiving olanzapine. At day 4 of oral treatment, the rates of patients in the olanzapine and haloperidol groups who were transitioned to higher oral doses were significantly higher in the single-injection subgroups compared with the multiple-injection subgroups (P = 0.002 and =0.003, respectively). CONCLUSION In this study, the proportion of agitated patients with schizophrenia who transitioned to higher dosages (15-20 mg) of olanzapine or haloperidol by day 4 of the oral switch was significantly greater in patients who were previously treated with a single IM injection of olanzapine (10 mg) or haloperidol (7.5 mg).right.
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Affiliation(s)
- John Battaglia
- Program of Assertive Community Treatment, Madison, WI 53703, USA.
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Riker RR, Fraser GL. Adverse Events Associated with Sedatives, Analgesics, and Other Drugs That Provide Patient Comfort in the Intensive Care Unit. Pharmacotherapy 2005; 25:8S-18S. [PMID: 15899744 DOI: 10.1592/phco.2005.25.5_part_2.8s] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the 2002 publication of multidisciplinary clinical practice guidelines for intensive care unit (ICU) sedation and analgesia, additional information regarding adverse drug events has been reported. Our understanding of the risks associated with these sedative and analgesic agents promises to improve outcomes by helping clinicians identify and respond to therapeutic misadventures sooner. This review focuses on many issues, including the potentially fatal consequences associated with the propofol infusion syndrome, the evolving understanding of propylene glycol intoxication associated with parenteral lorazepam, new data involving high-dose and long-term dexmedetomidine therapy, haloperidol- and methadone-related prolongation of QTc intervals on the electrocardiogram, adverse events associated with atypical antipsychotics, and the potential for nonsteroidal antiinflammatory drugs to interfere with bone healing.
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Affiliation(s)
- Richard R Riker
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Maine Medical Center, Portland, Maine 04102, USA
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Abstract
Based on information from clinical trials, both the efficacy and adverse effects of conventional antipsychotics in the treatment of schizophrenia are dose related. The overlapping nature of these dose-response profiles limits the use of these agents. Atypical antipsychotics provide greater relief across the comorbid symptom domains of schizophrenia, but dose-response studies and clinical experience have revealed that some of these drugs also have dose limitations. This article reviews the dose-response relationships of the atypical antipsychotics as presented predominantly in pivotal, randomised studies (double-blind and otherwise). Limited data indicate that clozapine shows dose-related efficacy up to 600 mg/day in patients with treatment-resistant schizophrenia. However, higher dosages of clozapine may be associated with the risk of seizures. Risperidone demonstrates dose-related adverse events that compromise efficacy. The dose-response relationships for ziprasidone, quetiapine and aripiprazole are less well established. The efficacy of olanzapine appears to be dose related within the recommended dosage range of 10-20 mg/day, but clinical trials that have explored higher dosages suggest improved efficacy. Furthermore, the higher doses are not associated with a significantly increased incidence of adverse events. Further studies are clearly needed to fully characterise the dose-response relationships of atypical antipsychotics.
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Affiliation(s)
- Bruce J Kinon
- Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Drop Code 4133, Indianapolis, IN 46285, USA
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