Antipsychotic agents. Gradually improving treatment from the traditional oral neuroleptics to the first atypical depot

A critical appraisal of long acting injectable antipsychotics: Translating research to clinics

Long acting injections (LAI) are an effective alternative mode of administration of antipsychotics, less commonly used in clinical practice. Gap in knowledge base is an important source of attitudinal bias. Current article is focused on reviewing the literature for the principles underlying the choice, initiation, maintenance, switch and termination of an LAI; historical, pharmacological and clinical factors implicating the rationale of using LAI against oral agents and older against newer LAIs. Evidences available in clinical and basic psychopharmacological researches are critically appraised, highlighting the lacunae in our understanding. It is endeavored to open the window for the studies to be carried forward in the future answering critical questions which could lay a stronger base for clinical utility of different LAIs. Thus, this article tries to acquaint clinicians with the translatable knowledge imparted from the research and riposte queries for the researchers to explore in relation to LAI.

Naturalistic Impact of Second-Generation Antipsychotics on Weight Gain

Background:

While second-generation antipsychotics (SGAs) have had benefits over earlier antipsychotic treatments, their use has been associated with reports of weight gain. Body mass index (BMI) has been studied in clinical trials with limited comparison between drugs.

Objective:

To investigate the impact of each SGA on the risk of weight increase in an adult population.

Methods:

Using a national electronic medical records database, a naturalistic impact of SGAs on BMI was evaluated. Patients (aged ≥ 18 y) receiving a prescription for an antipsychotic drug between January 1995 and March 2004 were identified. An adverse event was defined as at least a 7% increase in BMI from baseline within one year of antipsychotic prescription and a post-increase BMI of at least 25 kg/m2.

Results:

A total of 9394 patients were identified, with 1514 cases of increased BMI after initial prescription. Risperidone (OR 1.39; 95% CI 1.16 to 1.66), quetiapine (OR 1.36; 95% CI 1.13 to 1.64), and olanzapine (OR 1.76; 95% CI 1.50 to 2.07)were significantly more likely to cause BMI increase compared with first-generation antipsychotics (FGAs). Aripiprazole (OR 0.72; 95% CI 0.36 to 1.46), ziprasidone (OR 0.68; 95% CI 0.39 to 1.18), and clozapine (OR 1.01; 95% CI 0.56 to 1.81) were less likely to induce weight gain compared with FGAs.

Conclusions:

This study provides a foundation for understanding how SGAs impact weight gain in a naturalistic, as opposed to a clinical trial, setting and provides evidence that there are differential risks of weight gain between SGAs. Because of negative long-term health effects of weight gain, physicians need to take all factors into consideration when recommending pharmaceutical therapy for patients with severe mental illness.

Problems and solutions to filling the drying drug pipeline for psychiatric disorders: a report from the inaugural 2012 CINP Think Tank

The inaugural Collegium Internationale Neuro-Psychopharmacologicum (CINP) Think Tank, a small open meeting sponsored by the CINP, discussed impediments to developing new drugs for psychiatric disorders and approaches to overcome these impediments. Whilst neuropsycharmacology has a rich pharmacopeia (current treatments benefiting many individuals), issues of treatment resistance, sub-optimal response and unwanted side effects remain problematic. Many scientific, economic and social issues are impeding the development of drugs (e.g. higher risk of failure, placebo effects, problematic regulatory environments, pressures imposed by patent protection, downward pressure on reimbursements and financial, legal and social risk aversion). A consensus of the meeting was that efforts to understanding the core pathophysiology of psychiatric disorders are fundamental to increasing the chance of developing new drugs. However, findings from disorders such as Huntington's chorea, have shown that knowing the cause of a disorder may not reveal new drug targets. By contrast, clinically useful biomarkers that define target populations for new drugs and models that allow findings to be accurately translated from animals to humans will increase the likelihood of developing new drugs. In addition, a greater accent on experimental medicine, creative clinical investigations and improved communication between preclinical neuropsychopharmacologists, clinicians committed to neuropsychopharmacological research, industry and the regulators would also be a driver to the development of new treatments. Finally, it was agreed that the CINP must continue its role as a conduit facilitating vibrant interactions between industry and academia as such communications are a central component in identifying new drug targets, developing new drugs and transitioning new drugs into the clinic.

Barriers to, and strategies for, starting a long acting injection clinic in a community mental health center

As many as 50% of patients with schizophrenia do not take oral antipsychotic medications as prescribed, yet long acting injections are rarely utilized. Community agencies that serve this population are often over-burdened and poorly funded. There are negative attitudes on the part of both physicians and consumers about injections. Transportation and logistics are often problematic. We describe the unique opportunity provided by the need for bi-weekly or monthly injections to establish a recovery-oriented group around injection visits. Our approach discusses methods and resources to help overcome some of the common barriers by establishing advocates within the agency, establishing necessary infrastructure, providing education for consumers, providers, and staff, sharing information about successful outcomes with clinic staff and working through billing issues. We also recommend public advocacy on the part of the clinic and consumers to work with state funding sources to change regulations that may limit appropriate clinical care.

A 52-week open-label study of the safety and tolerability of paliperidone palmitate in patients with schizophrenia

The safety and tolerability of paliperidone palmitate, an injectable atypical antipsychotic agent, were assessed in a 1-year open-label extension of a double-blind study in patients with schizophrenia. Patients from the double-blind study who experienced a recurrence, remained recurrence free until study end, or who were in the transition, maintenance or double-blind phases and had received at least one injection of paliperidone palmitate when enrollment was stopped, were eligible for the open-label extension. Patients received gluteal injections of paliperidone palmitate once every 4 weeks: starting dose 50 mg eq. followed by 25, 50, 75, or 100 mg eq. flexible dosing. Of the 388 patients enrolled, 288 completed the open-label extension. During the open-label extension, the median (range) duration of exposure to paliperidone palmitate was 338 days (10; 390), and 74% of patients received all 12 open-label injections of paliperidone palmitate. The most frequent (≥ 5% in total group) adverse events were insomnia (7%); worsening of schizophrenia; nasopharyngitis; headache; and weight increase (6% each). Potentially prolactin-related adverse events occurred in 13 (3%) patients, mostly women, and none resulted in study discontinuation. Extrapyramidal treatment-emergent adverse events were reported in 25 (6%) patients; tremor was the most frequently reported (n = 8, 2%). At open-label extension endpoint, investigator-rated redness at the injection site was observed in ≤ 4% of patients in each group. Injection-site pain was rated by investigators as absent in 82-87% of patients. Schizophrenia symptoms measured by Positive and Negative Syndrome Scale and personal and social performance changes improved during the open-label extension.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: efficacy, quality of life and functional outcome

OBJECTIVE

This international, non-randomised study evaluated maintained efficacy and safety of Risperidone Long-Acting Injectable (RLAI) compared to previous medications. To investigate the possible effect of differences in national health care systems across Europe, the UK subset efficacy, health-related quality of life (HRQoL) and functioning data are reported here.

METHODS

Patients with schizophrenia or other psychotic disorders, symptomatically stable on antipsychotic medication, received intramuscular injections of RLAI 25 mg (to a maximum of 50 mg) every 2 weeks for 6 months.

RESULTS

Of 182 UK patients recruited; 79% had schizophrenia (87% paranoid), 21% other psychotic disorders; 96% had been hospitalised at sometime. Improvement in mean Positive and Negative Syndrome Scale (PANSS) total score was significant at 1 month through to endpoint (p = 0.0001). There were significant improvements in PANSS subscales (p <or= 0.001), PANSS-Marder subscores (p <or= 0.0391), and in Clinical Global Impression-Severity (p = 0.0001) at endpoint. Patients reported improvements in: HRQoL (p < 0.05), Global Assessment of Functioning (p = 0.0001) and patient satisfaction (p = 0.0001) at endpoint. The proportion of patients rating RLAI treatment as 'very good' increased from 10% to 40%. 55% (22/40) of patients hospitalised at baseline were discharged by endpoint.

CONCLUSION

Sustained, significant improvement in symptom control, HRQoL and functioning was seen in stable patients treated with RLAI over 6 months following a switch from previous antipsychotic medications.

Perceptions on efficacy and side effects of conventional depot antipsychotics (CDA) and atypical depot antipsychotics (ADA): Psychiatrists versus patients in Hong Kong

Abstract Objectives. We compared the satisfaction level of psychiatrists and psychiatric patients towards conventional (CDA) and atypical (ADA) depot antipsychotics on symptom management, role functioning, and side effects. Method. Patients from an out-patient clinic of a public hospital and psychiatrists from public hospitals participated in the survey in 2007-2008. A total of 153 patients were interviewed by a tailor-made questionnaire and 72 psychiatrists self-administered a similar questionnaire. Results. Both groups shared similar attitudes towards clinical effectiveness and treatment efficacy of ADA and CDA. More patients were ambivalent towards relapse prevention of CDA than psychiatrists (30.7 vs. 16.7%, P<0.044) and three quarters of psychiatrists believed that ADA are associated with less side effects. More than half of the patients showed negative attitudes towards the effectiveness of CDA on improving quality of life (52.40%), work (57.50%), and recreation (55.50%). Psychiatrists were more aware of the limitation of CDA and severity of side effects of CDA. They did not, however, seem to incorporate patients' opinions and research findings into their clinical practice. Conclusion. Evidence-based practice and shared decision-making model between clinicians and mental patients should be advocated. More investigations should be devoted to examine the efficacy of ADA as the alternative to CDA.

Experience with injectable long-acting risperidone in long-term therapy after an acute episode of schizophrenia: the SPHERE Study

BACKGROUND

Risperidone long-acting injectable (RLAI) is the first long-acting formulation of an atypical antipsychotic introduced into clinical practice. RLAI combines the benefits of atypical antipsychotic agents with an extended duration of activity and is intended for long-term management of schizophrenia. This study evaluated the use of RLAI as part of a long-term management strategy in patients with an acute episode of schizophrenia.

OBJECTIVES

The primary objective was to determine clinicians' approaches to the use of RLAI in patients with an acute exacerbation of schizophrenia by examining the prescribing patterns of antipsychotic and other psychotropic medications. Other objectives were to evaluate the overall safety of switching patients to RLAI from previous antipsychotic therapy and to determine patients', caregivers' and relatives' attitudes towards RLAI treatment.

METHODS

The Safety and Profile of Handling and Employing of Risperdal Consta in Emergency/Acute Care Settings (SPHERE) study was an observational, non-interventional, multicenter, retrospective study involving a large cohort of patients with acute psychotic exacerbation who attended Spanish emergency/acute care facilities (between August and December 2003) and were treated with RLAI during hospitalization.

RESULTS

A total of 1232 patients (70% men; mean age 37 years; median of 8 months since most recent admission) were included in the analyses; 79% had been receiving antipsychotic therapy prior to admission. All patients received RLAI post-stabilization. The main reasons for initiating RLAI were the need for long-term treatment (76%) and a low adherence to previous treatment (71%). RLAI doses administered during hospitalization were: 25 (26%), 37.5 (29%), 50 (42%) and 75-100 mg (3%). The mean number of injections per patient (2 +/- 1) and mean hospitalization time (25 +/- 16 days) indicated that RLAI was administered every 2 weeks as per the manufacturer's recommendations. All patients were discharged on RLAI treatment; 62% were prescribed concomitant therapy, mainly oral risperidone (39%), anxiolytics (25%), antiparkinsonians (15%), hypnotics (11%) and anticonvulsants (11%). Only 5.7% of patients reported adverse events, most commonly extrapyramidal symptoms (1.1%) and somnolence (0.9%).

CONCLUSIONS

As part of a long-term management strategy aimed at improving treatment adherence in schizophrenic patients, RLAI was prescribed to a wide spectrum of patients with an acute episode of schizophrenia during hospitalization and at the time of discharge from emergency/acute care facilities. RLAI was well tolerated in the study population and the overall impression of patients, primary caregivers and relatives to RLAI therapy was positive.

Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia

This study examined the medication compliance of people with schizophrenia in relation to their self-stigma, insight, attitude towards medication, and socio-demographic status via a cross-sectional observational design. Eighty-six Chinese adults with schizophrenia were recruited from the psychiatric hospitals and community settings for this study. The findings suggested that stereotype agreement of self-stigmatization and attitude towards medication were moderately correlated with medication compliance. Poor insight and living alone were found to be significant predictors of medication compliance based on regression analysis. Insight was identified to be the strongest predictor on compliance which accounted for 68.35% of the total variance. Although self-stigma is only moderately linked with medication compliance, its effects on medication-induced stigma cannot be ignored.

Long-acting risperidone improves negative symptoms in stable psychotic patients

The aim of this paper was to evaluate the efficacy of risperidone long-acting injectable (RLAI) for reducing negative symptoms of schizophrenia in patients with predominantly negative symptoms at baseline. A subanalysis was performed on data from the 6-month, open-label Switch to Risperidone Microspheres trial. Patients with Positive and Negative Syndrome Scale (PANSS) negative subscale score > or = 21, which was higher than their PANSS positive subscale score, were included in this subanalysis. Improvement in negative symptoms was measured by assessing change in the PANSS negative subscale and a negative factor score. Additional outcome variables included measures in general functioning, quality of life and patient satisfaction. A total of 842 patients were eligible for inclusion in this subanalysis. Six months of treatment was completed by 631 (74.9%) patients. Forty-three (5.1%) patients discontinued treatment due to an adverse event. Negative symptoms were significantly reduced by 6.1 +/- 6.3 points for the PANSS negative score and 6.1 +/- 6.4 points for the negative factor score (P < 0.0001 for both). Significant improvements were also noted for total PANSS and other PANSS subscale scores, general functioning, quality of life and patient satisfaction (P < 0.0001). The most common treatment-emergent adverse events (>5%) were: anxiety (6.8% of patients), exacerbation of disease (6.2%) and insomnia (5.7%). Overall, RLAI was well tolerated and associated with significant reductions in movement disorder severity. The treatment resulted in a significant improvement in negative symptom severity and was well tolerated in patients with predominantly negative symptoms, who switched from a stable antipsychotic regimen

Long-acting formulations of atypical antipsychotics: time to reconsider when to introduce depot antipsychotics

The current availability of a long-acting injectable formulation of risperidone and the potential future availability of long-acting formulations of other atypical antipsychotics (such as paliperidone) should prompt a reconsideration of at what stage in the treatment of schizophrenia such long-acting agents should be introduced. At present, long-acting formulations, particularly of conventional antipsychotics (depots), are usually reserved for patients with chronic schizophrenia who are at high-risk of noncompliance. Recent and increasing data from other patient groups, such as those with first-episode psychosis, suggest that long-acting risperidone is associated with good efficacy and tolerability leading to high patient acceptance, and treatment continuation rates that are greater than with oral antipsychotics. The benefits of an atypical antipsychotic coupled with the assurance of medication delivery in the form of a long-acting injection imply that these novel formulations should be considered in first-episode patients, for whom optimal outcome is frequently compromised by early treatment discontinuation and poor adherence.

Long-Acting Injectable Risperidone for the Treatment of Schizophrenia

Schizophrenia remains a severe disorder that is associated with a poor outcome in a large subgroup of patients. Major efforts should be made to improve treatment for all patients who have this debilitating disease. Second-generation antipsychotics were a major step forward in this respect; however, important unmet needs remain, such as a better solution for frequent noncompliance problems. Depot formulations are known to have advantages in this respect. However, for a long time, only depot formulations of conventional antipsychotics were available, with their high risk of extrapyramidal adverse effects. Therefore, there has been only very restricted use of depot antipsychotics, which mainly focused on patients with chronic disease who were difficult to treat and had a high risk of noncompliance. The situation may change with the advent of a depot formulation of an atypical antipsychotic. The first depot formulation of an atypical antipsychotic to be introduced to the market is long-acting injectable risperidone. On the basis of the pharmacokinetic properties of the depot formulation, a 2-week interval between administrations is recommended. The antipsychotic efficacy of long-acting risperidone was demonstrated in two 12-week, double-blind, randomised, phase III studies, one versus placebo and the other versus oral risperidone. These two studies, together with one open-label, long-term study over 12 months, belong to the core group of trials that were relevant for the licensing of long-acting risperidone. A relapse-prevention, control group study comparing the long-acting formulation versus oral risperidone was not performed because of the known principal methodological problems of such a comparison. Instead, as much clinical data as possible was collected from observational studies that investigated questions relevant for clinical practice, such as efficacy, safety and tolerability in different subgroups, and transition from pre-treatment with different kinds of antipsychotics to long-acting risperidone. On the basis of these data, it can be stated that the efficacy of the long-term formulation of risperidone is proven, and that the safety and tolerability are more or less comparable to those of oral risperidone. The local tolerability at the injection site is good. Because it is well known that noncompliance is a frequent feature of the treatment of schizophrenia, and considering the advantages of atypical antipsychotics, consideration of whether long-acting atypical antipsychotics should have a broader indication than is the case with the depot formulations of the classical antipsychotics is warranted.

The endocannabinoid system as an emerging target of pharmacotherapy

The recent identification of cannabinoid receptors and their endogenous lipid ligands has triggered an exponential growth of studies exploring the endocannabinoid system and its regulatory functions in health and disease. Such studies have been greatly facilitated by the introduction of selective cannabinoid receptor antagonists and inhibitors of endocannabinoid metabolism and transport, as well as mice deficient in cannabinoid receptors or the endocannabinoid-degrading enzyme fatty acid amidohydrolase. In the past decade, the endocannabinoid system has been implicated in a growing number of physiological functions, both in the central and peripheral nervous systems and in peripheral organs. More importantly, modulating the activity of the endocannabinoid system turned out to hold therapeutic promise in a wide range of disparate diseases and pathological conditions, ranging from mood and anxiety disorders, movement disorders such as Parkinson's and Huntington's disease, neuropathic pain, multiple sclerosis and spinal cord injury, to cancer, atherosclerosis, myocardial infarction, stroke, hypertension, glaucoma, obesity/metabolic syndrome, and osteoporosis, to name just a few. An impediment to the development of cannabinoid medications has been the socially unacceptable psychoactive properties of plant-derived or synthetic agonists, mediated by CB(1) receptors. However, this problem does not arise when the therapeutic aim is achieved by treatment with a CB(1) receptor antagonist, such as in obesity, and may also be absent when the action of endocannabinoids is enhanced indirectly through blocking their metabolism or transport. The use of selective CB(2) receptor agonists, which lack psychoactive properties, could represent another promising avenue for certain conditions. The abuse potential of plant-derived cannabinoids may also be limited through the use of preparations with controlled composition and the careful selection of dose and route of administration. The growing number of preclinical studies and clinical trials with compounds that modulate the endocannabinoid system will probably result in novel therapeutic approaches in a number of diseases for which current treatments do not fully address the patients' need. Here, we provide a comprehensive overview on the current state of knowledge of the endocannabinoid system as a target of pharmacotherapy.

Use of magnetic resonance imaging in tracking the course and treatment of schizophrenia

Confirming the early conceptualization of Bleuler (1911) and Kraepelin (1919), magnetic resonance imaging (MRI) studies have demonstrated structural and functional brain abnormalities, predominantly involving the frontal and temporal lobes, in schizophrenia. Most of the abnormalities are already present at illness onset. However, there is, growing evidence for treatment-related neural changes in schizophrenia, such as enlargement of the caudate nucleus (neurotoxic effect) with the use of typical antipsychotics and increases in cortical volumes and improved functional responses (neurotrophic effect) with the use of atypical antipsychotics. More recently, brain changes during the prodrome and transition-to-illness stages of schizophrenia have begun to be characterized. Another area of importance is the use of MRI, as a biological marker, to monitor and define partial or full resistance to medication. Understanding the trait- and state-related influences of brain abnormalities during the course of the illness is critical for developing effective treatment and possibly prevention strategies in schizophrenia.