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Konishi T, Kitahiro Y, Fujiwara N, Yamamoto K, Hashimoto M, Ito T, Itohara K, Fujioka K, Imafuku H, Otsuka I, Omura T, Yano I. Pharmacokinetics of Brexpiprazole, Quetiapine, Risperidone, and Its Active Metabolite Paliperidone in a Postpartum Woman and Her Baby. Ther Drug Monit 2024; 46:687-691. [PMID: 38648649 DOI: 10.1097/ftd.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/12/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Brexpiprazole is a second-generation antipsychotic approved in Japan in 2018; however, information on placental passage and breast milk transfer remains limited. In this report, the patient, a 30-year-old pregnant woman with schizophrenia, was medicated with brexpiprazole, risperidone, and quetiapine. METHODS The study used high-performance liquid chromatography-tandem mass spectrometry to determine the concentrations of brexpiprazole, quetiapine, risperidone, and its active metabolite (paliperidone) in maternal and neonatal plasma, cord venous plasma, and breast milk. Maternal plasma samples were obtained approximately 2 and 8 hours after the last administration of antipsychotics on the day of delivery and at the estimated drugs' trough time on days 1, 3, and 5 after delivery. RESULTS The maternal plasma concentrations of brexpiprazole, quetiapine, and paliperidone increased by approximately 3.5-fold on the fifth day compared with those on the day of delivery, whereas the risperidone concentration remained almost constant. Moreover, the neonatal plasma concentrations of the 4 drugs immediately after birth were indistinguishable from the umbilical cord concentrations and gradually decreased, except for risperidone. Relative infant doses of these compounds were below 1.1%. CONCLUSIONS Pregnancy status notably alters the pharmacokinetic properties of antipsychotics. Therefore, close and careful monitoring of clinical symptoms should be considered during pregnancy and after delivery. Although brexpiprazole is transferred to neonates through the placenta, breastfeeding is still possible because the relative infant dose value of this drug was much less than 10%.
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Affiliation(s)
- Toru Konishi
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Yumi Kitahiro
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Naoko Fujiwara
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | | | - Mari Hashimoto
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Takahiro Ito
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Kotaro Itohara
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Kazumichi Fujioka
- Division of Pediatrics, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Hitomi Imafuku
- Division of Obstetrics and Gynecology, Graduate School of Medicine, Kobe University, Kobe, Japan ; and
| | - Ikuo Otsuka
- Department of Psychiatry, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Tomohiro Omura
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
| | - Ikuko Yano
- Department of Pharmacy, Kobe University Hospital, Kobe, Japan
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Gursoy BK, Atay E, Bilir A, Firat F, Soylemez ESA, Kurt GA, Gozen M, Ertekin T. Effect of aripiprazole on neural tube development in early chick embryos. Toxicol Appl Pharmacol 2024; 489:117009. [PMID: 38906509 DOI: 10.1016/j.taap.2024.117009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/30/2024] [Accepted: 06/14/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Aripiprazole (ARI) is a recently developed antipsychotic medication that belongs to the second generation of antipsychotics. The literature has contradictory information regarding ARI, which has been classified as pregnant use category C by the FDA. METHODS 125 pathogen-free fertilized eggs were incubated for 28 h and divided into five groups of 25 eggs each (including the control group), and 18 eggs with intact integrity were selected from each group. After the experimental groups were divided, ARI was administered subblastodermally with a Hamilton micro-injector at 4 different doses (1 mg/kg, 5 mg/kg, 10 mg/kg, 20 mg/kg). At the 48th hour of incubation, all eggs were hatched and embryos were removed from the embryonic membranes. And then morphologic (position of the neural tube (open or closed), crown-rump length, number of somites, embryological development status), histopathologic (apoptosis (caspase 3), cell proliferation (PCNA), in situ recognition of DNA breaks (tunnel)), genetic (BRE gene expression) analyzes were performed. RESULTS According to the results of the morphological analysis, when the frequency of neural tube patency was evaluated among the experimental groups, a statistically significant difference was determined between the control group and all groups (p < 0.001). In addition, the mean crown-rump length and somite number of the embryos decreased in a dose-dependent manner compared to the control group. It was determined that mRNA levels of the BRE gene decreased in embryos exposed to ARI compared to the control group (p < 0.001). CONCLUSION Morphologically, histopathologically, and genetically, aripiprazole exposure delayed neurogenesis and development in early chick embryos. These findings suggest its use in pregnant women may be teratogenic. We note that these results are preliminary for pregnant women, but they should be expanded and studied with additional and other samples.
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Affiliation(s)
- Betul Kurtses Gursoy
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Psychiatry, Afyonkarahisar, Turkey.
| | - Emre Atay
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Anatomy, Afyonkarahisar, Turkey
| | - Abdulkadir Bilir
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Anatomy, Afyonkarahisar, Turkey
| | - Fatma Firat
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Histology and Embryology, Afyonkarahisar, Turkey
| | - Evrim Suna Arikan Soylemez
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Medical Biology, Afyonkarahisar, Turkey
| | - Gulan Albas Kurt
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Anatomy, Afyonkarahisar, Turkey
| | - Mert Gozen
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Psychiatry, Afyonkarahisar, Turkey
| | - Tolga Ertekin
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Anatomy, Afyonkarahisar, Turkey
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Othman MA, Husni M, El-Din WAN, Salem AH, Sarwani N, Rashid A, Fadel R. Prenatal aripiprazole induces alterations of rat placenta: a histological, immunohistochemical and ultrastructural study. J Mol Histol 2024; 55:415-426. [PMID: 38713244 DOI: 10.1007/s10735-024-10199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 05/01/2024] [Indexed: 05/08/2024]
Abstract
Antipsychotic drugs (APDs) are used to treat many psychiatric illnesses as schizophrenia. Typical antipsychotic drugs (TAPDs) are being used; however, they have many side effects. Atypical antipsychotic drugs (AAPDs) are newer medications with known fewer side effects. Aripiprazole (ARI) is an AAPD, recommended by healthcare providers, even during pregnancy. It can cross the placental barrier and enter fetal circulation, so it might be possible that ARI can adversely impair normal placental development and growth, if it is given prenatally. ARI was applied orally to pregnant female rats in two doses (3& 6 mg/kg body weight). On gestation day 20, the mothers were sacrificed, and the placentas were removed and processed for general histological and electron microscopic evaluations. Immunohistochemistry was done using anti-PCNA (proliferating cell nuclear antigen), anti-Bax (for apoptosis) and anti-vascular endothelial growth factor alpha (VEGFA). Morphological evaluation revealed degenerative changes in the placenta as dark nuclei, vacuolization, and cyst formation. Ultra-structurally, there was degeneration of cellular components including organelles and nuclei. These changes were found in different cells of the basal and labyrinth zones and were dose dependent. Immunohistochemistry revealed upregulation of Bax and VEGFA and downregulation of PCNA. Prenatal administration of the AAPD, ARI to pregnant female rats resulted in histological changes in the placenta. Additionally, there was a decrease in cellular proliferation and increase in apoptosis, and vascular impairment. This indicates placental atrophy and dysgenesis and might suggest possible teratogenic effects to ARI, which needs further evaluation.
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Affiliation(s)
- Manal A Othman
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, P.O Box: 26671, Manama, Bahrain.
- Department of Histology and Cell Biology, Faculty of Medicine, Assiut University, Assuit, Egypt.
| | - Mariwan Husni
- Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
- Department of Psychiatry, Northern Ontario School of Medicine University, Ontario, Canada
| | - Wael Amin Nasr El-Din
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, P.O Box: 26671, Manama, Bahrain
- Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Abdel-Halim Salem
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, P.O Box: 26671, Manama, Bahrain
- Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Nasir Sarwani
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, P.O Box: 26671, Manama, Bahrain
| | - Aisha Rashid
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, P.O Box: 26671, Manama, Bahrain
| | - Raouf Fadel
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, P.O Box: 26671, Manama, Bahrain
- Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Brissos S, Balanzá-Martínez V. Long-acting antipsychotic treatments: focus on women with schizophrenia. Ther Adv Psychopharmacol 2024; 14:20451253241263715. [PMID: 39091697 PMCID: PMC11292690 DOI: 10.1177/20451253241263715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 06/05/2024] [Indexed: 08/04/2024] Open
Abstract
Effective management of schizophrenia (SZ) requires long-term treatment with antipsychotics (APs) to prevent clinical relapse, attain remission and improve patients' personal and social functioning, and quality of life. Although APs remain the cornerstone treatment for patients with SZ, despite their potential benefits, long-acting injectable APs (LAI-APs) remain underused, most notably in women with SZ. The efficacy and tolerability of APs differ significantly between men and women, and some of these differences are more noticeable depending on the patient's age and the stage of the disorder. Although sex differences may influence treatment outcomes in SZ, their pertinence has been insufficiently addressed, especially regarding the use of LAI-APs. Some biological and social experiences, such as pregnancy, lactation, contraception and menopause, are specific to women, but these remain under-researched issues. Implications of this disorder in parenting are also of special pertinence regarding women; therefore, taking sex differences into account when treating SZ patients is now recommended, and improving personalized approaches has been proposed as a priority in the management of psychosis. In this narrative, critical review, we address some aspects specific to sex and their implications for the clinical management of women with SZ, with a special focus on the potential role of LAI-AP treatments.
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Affiliation(s)
- Sofia Brissos
- Centro Hospitalar Psiquiátrico de Lisboa, Av. Brasil 53, Lisbon 1700, Portugal
| | - Vicent Balanzá-Martínez
- Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine, CIBERSAM, INCLIVA, University of Valencia, Valencia, Spain
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Dono F, Consoli S, Tappatà M, Evangelista G, Russo M, Lanzone J, Pozzilli V, Nucera B, Rinaldi F, Di Pietro M, Tinti L, Troisi S, Calisi D, D'Apolito M, Narducci F, Assenza G, Anzellotti F, Brigo F, Vollono C, Onofrj M, Sensi SL, Michelucci R. Autoimmune encephalitis during pregnancy: A diagnostic and therapeutic challenge-A systematic review with individual patients' analysis and clinical recommendations. Epilepsia Open 2023; 8:1221-1240. [PMID: 37562964 PMCID: PMC10690706 DOI: 10.1002/epi4.12806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/06/2023] [Indexed: 08/12/2023] Open
Abstract
Several reports have described the autoimmune encephalitis' (AE) possible onset during pregnancy. In this systematic review, we summarize the available data on the diagnostic and therapeutic approach to AE during pregnancy, highlighting the associated maternal and fetal clinical outcomes. A systematic search of the literature was performed. The following databases were used: PubMed, Google Scholar, EMBASE, and CrossRef. The revision was registered on the PROSPERO platform (CRD42022336357). Forty-nine patients were included. AE onset was mainly observed during the first and the second trimester of pregnancy with psychiatric manifestations and seizures as main onset symptoms. CSF analysis showed AE-specific autoantibody positivity in 33 patients (anti-NMDA receptor as the most frequent). EEG generally showed normal findings. MRI revealed pathological findings in less than half of patients. Tumor screening was positive in 14 cases. First-line immunotherapy (single or combined) was generally employed while second line was administered in a minority of patients. Levetiracetam was the most used antiseizure medication. Cesarean section was performed in 18 women. Most of the women had an excellent early outcome after delivery but 22 showed persistent neurological deficits in long-term follow-up. Fetal outcome was positive in 33 cases, whereas 12 cases of fetal death were reported. A logistic regression showed that no variable significantly influenced the odds of good/bad maternal and fetal clinical outcome. Diagnosis and treatment of AE during pregnancy is challenging. The rate of miscarriage in women with AE seems to be higher than the general population. In addition, mothers may show long-term neurological deficits.
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Affiliation(s)
- Fedele Dono
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies, and Technology – CAST‐University G. d'Annunzio of Chieti‐PescaraChietiItaly
| | - Stefano Consoli
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies, and Technology – CAST‐University G. d'Annunzio of Chieti‐PescaraChietiItaly
| | - Maria Tappatà
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Giacomo Evangelista
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies, and Technology – CAST‐University G. d'Annunzio of Chieti‐PescaraChietiItaly
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies, and Technology – CAST‐University G. d'Annunzio of Chieti‐PescaraChietiItaly
| | - Jacopo Lanzone
- Neurorehabilitation Department, IRCCS Salvatore Maugeri FoundationInstitute of MilanMilanItaly
- Department of Systems Medicine, NeuroscienceUniversity of Rome Tor VergataRomeItaly
| | - Valeria Pozzilli
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Bruna Nucera
- Department of NeurologyHospital of Merano (SABES‐ASDAA)MeranoItaly
| | - Fabrizio Rinaldi
- Department of NeurologyHospital of Merano (SABES‐ASDAA)MeranoItaly
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Lorenzo Tinti
- Department of NeurologySan Gerardo Hospital ASST MonzaMonzaItaly
| | - Serena Troisi
- Pediatric Neurology, Department of NeuroscienceSantobono‐Pausilipon Children's HospitalNaplesItaly
| | - Dario Calisi
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Maria D'Apolito
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Flavia Narducci
- Unit of Neurology, Neurophysiology, Neurobiology, Department of MedicineUniversity Campus Bio‐Medico of RomeRomeItaly
| | - Giovanni Assenza
- Unit of Neurology, Neurophysiology, Neurobiology, Department of MedicineUniversity Campus Bio‐Medico of RomeRomeItaly
| | - Francesca Anzellotti
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Francesco Brigo
- Department of NeurologyHospital of Merano (SABES‐ASDAA)MeranoItaly
| | - Catello Vollono
- Unit of Neurophysiopathology and Sleep Medicine, Department of Geriatrics, Neurosciences and OrthopedicsIRCCS Policlinico Universitario Agostino Gemelli, Catholic UniversityRomeItaly
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Stefano L. Sensi
- Department of Neuroscience, Imaging and Clinical Science“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies, and Technology – CAST‐University G. d'Annunzio of Chieti‐PescaraChietiItaly
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Uguz F, Sharma V, Boyce P, Clark CT, Galbally M, Koukopoulos A, Marsh W, Stevens A, Viguera A. Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors. J Clin Psychopharmacol 2023; 43:434-452. [PMID: 37683233 DOI: 10.1097/jcp.0000000000001740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
ABSTRACT Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.
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Affiliation(s)
- Faruk Uguz
- From the Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Verinder Sharma
- Schulich School of Medicine and Dentistry, The University of Western Ontario; Lawson Health Research Institute; Parkwood Institute Mental Health, Perinatal Mental Health Clinic, London Health Sciences Center, London, Ontario, Canada
| | - Philip Boyce
- Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Crystal T Clark
- Department of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Megan Galbally
- Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Alexia Koukopoulos
- University Hospital Policlinico Umberto I, La Sapienza University of Rome; Centro Lucio Bini, Rome, Italy
| | - Wendy Marsh
- Department of Psychiatry, University of Massachusetts Medical School/UMass Memorial Medical Center, Worcester, MA.
| | - Anja Stevens
- Centre for Bipolar Disorders, Dimence Group, Deventer, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Psychiatry, the Netherlands
| | - Adele Viguera
- Cleveland Clinic, Cleveland Clinic Neurological Institute, Cleveland, OH
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7
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Powell J, Taylor D, Manoharan M. The pharmacological management of acute behavioural disturbance in pregnancy. BJPSYCH ADVANCES 2023. [DOI: 10.1192/bja.2023.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
SUMMARY
Acute behavioural disturbance is relatively common during the perinatal period. The management of agitation in pregnant women is similar to that in the general population, although with some additional considerations, such as modifications to restraint techniques, careful medication selection, monitoring of maternal and fetal well-being and the importance of a debrief. There are benefits of agreeing a pre-determined care plan for women who are at risk.
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Huybrechts KF, Straub L, Karlsson P, Pazzagli L, Furu K, Gissler M, Hernandez-Diaz S, Nørgaard M, Zoega H, Bateman BT, Cesta CE, Cohen JM, Leinonen MK, Reutfors J, Selmer RM, Suarez EA, Ulrichsen SP, Kieler H. Association of In Utero Antipsychotic Medication Exposure With Risk of Congenital Malformations in Nordic Countries and the US. JAMA Psychiatry 2023; 80:156-166. [PMID: 36477338 PMCID: PMC9856848 DOI: 10.1001/jamapsychiatry.2022.4109] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Psychiatric disorders are common among female individuals of reproductive age. While antipsychotic medication use is increasing, the safety of such medications in pregnancy is an area with large evidence gaps. Objective To evaluate the risk of first-trimester antipsychotic exposure with respect to congenital malformations, focusing on individual drugs and specific malformation subtypes. Design, Setting, and Participants This cohort study used data from nationwide health registers from the 5 Nordic countries and the US and spanned 1996 to 2018. The Nordic cohort included all pregnancies resulting in singleton live-born infants, and the US cohort consisted of publicly insured mothers linked to their live-born infants nested in the nationwide Medicaid Analytic eXtract. Data were analyzed from November 2020 to April 2022. Exposures One or more first-trimester dispensing of any atypical, any typical, and individual antipsychotic drugs. Main Outcomes and Measures Any major congenital malformation and specific malformation subtypes previously suggested to be associated with antipsychotic exposure in utero: cardiovascular malformations, oral clefts, neural tube defects, hip dysplasia, limb reduction defects, anorectal atresia/stenosis, gastroschisis, hydrocephalus, other specific brain anomalies, and esophageal disorders. Propensity score stratification was used to control for potential confounders. Pooled adjusted estimates were calculated using indirect standardization. Results A total of 6 455 324 unexposed mothers (mean maternal age range across countries: 24-31 years), 21 751 mothers exposed to atypical antipsychotic drugs (mean age range, 26-31 years), and 6371 mothers exposed to typical antipsychotic drugs (mean age range, 27-32 years) were included in the study cohort. Prevalence of any major malformation was 2.7% (95% CI, 2.7%-2.8%) in unexposed infants, 4.3% (95% CI, 4.1%-4.6%) in infants with atypical antipsychotic drug exposure, and 3.1% (95% CI, 2.7%-3.5%) in infants with typical antipsychotic drug exposure in utero. Among the most prevalent exposure-outcome combinations, adjusted relative risks (aRR) were generally close to the null. One exception was olanzapine exposure and oral cleft (aRR, 2.1 [95% CI, 1.1-4.3]); however, estimates varied across sensitivity analyses. Among moderately prevalent combinations, increased risks were observed for gastroschisis and other specific brain anomalies after atypical antipsychotic exposure (aRR, 1.5 [95% CI, 0.8-2.6] and 1.9 [95% CI, 1.1-3.0]) and for cardiac malformations after chlorprothixene exposure (aRR, 1.6 [95% CI, 1.0-2.7]). While the association direction was consistent across sensitivity analyses, confidence intervals were wide, prohibiting firm conclusions. Conclusions and Relevance In this study, considering the evidence from primary and sensitivity analyses and inevitable statistical noise for very rare exposure-outcome combinations, in utero antipsychotic exposure generally was not meaningfully associated with an increased risk of malformations. The observed increased risks of oral clefts associated with olanzapine, gastroschisis, and other specific brain anomalies with atypical antipsychotics and cardiac malformations with chlorprothixene requires confirmation as evidence continues to accumulate.
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Affiliation(s)
- Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Pär Karlsson
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Laura Pazzagli
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Kari Furu
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway,Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Mika Gissler
- Research Centre for Child Psychiatry, University of Turku, Turku, Finland,Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Helga Zoega
- School of Population Health, Faculty of Medicine & Health, UNSW Sydney, Sydney, New South Wales, Australia,Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carolyn E. Cesta
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jacqueline M. Cohen
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway,Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Maarit K. Leinonen
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Johan Reutfors
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Randi M. Selmer
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Elizabeth A. Suarez
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sinna Pilgaard Ulrichsen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Helle Kieler
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden,Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Lefebvre A, Pouchon A, Bioulac S, Mallet J, Polosan M, Dondé C. Management of schizophrenia in women during the perinatal period: a synthesis of international recommendations. Expert Opin Pharmacother 2022; 23:1337-1350. [PMID: 35835161 DOI: 10.1080/14656566.2022.2102421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The perinatal period in schizophrenia is associated with high risk of psychotic relapse and pregnancy/child outcomes. The extent to which antipsychotics may potentially affect the fetus or the child development is unclear and debated. Even though guidelines have been developed, there is a lack of consensual recommendations regarding the optimal strategy to manage schizophrenia during the perinatal period. AREAS COVERED This systematic review describes the current state of evidence with respect to the impact of recommended interventions for schizophrenia during the perinatal period, including childbearing age, pregnancy and post-partum. It compares recent international treatment guidelines for this specific group of women. Last, this review presents a set of major points to be discussed with patients and relatives for shared-decision making and a summary of key recommendations from the international guidelines. EXPERT OPINION Although treatment guidelines may be of significant help, discrepancies exist across them regarding the management of antipsychotics for schizophrenia women during the perinatal period. Shared decision-making and advance directives represent useful patient-centered approaches during this specific period. Further cohort-based evidence is needed to better identify maternal and fetal risks associated to antipsychotic treatment exposure.
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Affiliation(s)
| | - Arnaud Pouchon
- Univ. Grenoble Alpes, Inserm, U1216, Adult Psychiatry Department CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - Stéphanie Bioulac
- Laboratoire de Psychologie et Neurocognition (CNRS-UMR 5105), Université Grenoble Alpes; Service Psychiatrie de l'enfant et l'adolescent, CHU Grenoble Alpes, France
| | - Jasmina Mallet
- Université de Paris, INSERM UMR1266, Institute of Psychiatry and Neuroscience of Paris France; AP-HP, Department of Psychiatry, Louis Mourier Hospital, Colombes, France
| | - Mircea Polosan
- Univ. Grenoble Alpes, Inserm, U1216, Adult Psychiatry Department CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - Clément Dondé
- Univ. Grenoble Alpes, Inserm, U1216, Adult Psychiatry Department CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France; Psychiatry Department, CH Alpes-Isère, F-38000 Saint-Egrève, France
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10
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Brand BA, Haveman YRA, de Beer F, de Boer JN, Dazzan P, Sommer IEC. Antipsychotic medication for women with schizophrenia spectrum disorders. Psychol Med 2022; 52:649-663. [PMID: 34763737 PMCID: PMC8961338 DOI: 10.1017/s0033291721004591] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 12/24/2022]
Abstract
There are significant differences between men and women in the efficacy and tolerability of antipsychotic drugs. Here, we provide a comprehensive overview of what is currently known about the pharmacokinetics and pharmacodynamics of antipsychotics in women with schizophrenia spectrum disorders (SSDs) and translate these insights into considerations for clinical practice. Slower drug absorption, metabolism and excretion in women all lead to higher plasma levels, which increase the risk for side-effects. Moreover, women reach higher dopamine receptor occupancy compared to men at similar serum levels, since oestrogens increase dopamine sensitivity. As current treatment guidelines are based on studies predominantly conducted in men, women are likely to be overmedicated by default. The risk of overmedicating generally increases when sex hormone levels are high (e.g. during ovulation and gestation), whereas higher doses may be required during low-hormonal phases (e.g. during menstruation and menopause). For premenopausal women, with the exceptions of quetiapine and lurasidone, doses of antipsychotics should be lower with largest adjustments required for olanzapine. Clinicians should be wary of side-effects that are particularly harmful in women, such as hyperprolactinaemia which can cause oestrogen deficiency and metabolic symptoms that may cause cardiovascular diseases. Given the protective effects of oestrogens on the course of SSD, oestrogen replacement therapy should be considered for postmenopausal patients, who are more vulnerable to side-effects and yet require higher dosages of most antipsychotics to reach similar efficacy. In conclusion, there is a need for tailored, female-specific prescription guidelines, which take into account adjustments required across different phases of life.
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Affiliation(s)
- Bodyl A. Brand
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Yudith R. A. Haveman
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Franciska de Beer
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Janna N. de Boer
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Paola Dazzan
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Iris E. C. Sommer
- Department of Biomedical Sciences of Cells & Systems, Section Cognitive Neurosciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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11
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Yoon J, Gu J, Martin KB. A Novel Treatment of Postpartum Depression and Review of Literature. Cureus 2022; 14:e22373. [PMID: 35371824 PMCID: PMC8938255 DOI: 10.7759/cureus.22373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/29/2022] Open
Abstract
Early-onset postpartum depression has been shown to have a unique neurobiological basis compared to major depressive disorder, implying a need for targeted treatments such as the recent Food and Drug Administration (FDA)-approved brexanolone. In this case report, a woman with a past medical history of major depressive disorder was diagnosed with postpartum depression due to worsening mood with suicidal and homicidal ideations. She was treated with vilazodone and aripiprazole with good effect after consideration of her past medication trials. Her regimen is unique in clinical practice and not reported in current literature for the treatment of postpartum depression. It may represent a safe and effective medication choice, especially in the context of current first-line treatments that have a high treatment failure rate. More research is needed to find treatments that address the unique challenges of postpartum women.
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12
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Germack HD, Combellick J, Cooper M, Koller K, McMichael B. Antidepressants Are the Most Commonly Discontinued Psychotherapeutic Medications in Pregnancy. Womens Health Issues 2021; 32:241-250. [PMID: 34840082 DOI: 10.1016/j.whi.2021.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 09/27/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Psychiatric illnesses are common during the perinatal period. The use of antipsychotic medication during pregnancy has increased over the past two decades. In many instances, clinicians agree that untreated psychiatric illness during the perinatal period is more dangerous than the risks imposed by continuing psychotherapeutic medication. We describe patterns of psychotherapeutic medication continuation and discontinuation during pregnancy in a large U.S. cohort. METHODS We assessed the relationship between the demographic and clinical characteristics of women who continued or discontinued psychotherapeutic medications-antidepressants, anxiolytics/sedatives, anticonvulsants, antipsychotics, mood stabilizers, and stimulants-during pregnancy. This study used data from 2008 to 2015 from the Medical Expenditure Panel Survey. We used t tests and Medical Expenditure Panel Survey Household Component longitudinal sampling weights in the analysis of this data. RESULTS There were few significant differences noted in clinical and demographic characteristics between women who continued and discontinued medications during pregnancy. Those who continued were less likely to be employed (46.95% of continuers were employed vs. 80.55% of discontinuers; p = .0053). Women taking antipsychotics were more likely to continue medications during pregnancy (64.60% continually used antipsychotics vs. 35.40% discontinued antipsychotics; p = .008), whereas women taking antidepressants were more likely to discontinue their use (19.62% continually used antidepressants vs. 80.38% discontinued antidepressants; p = .032). For each medication category, women resumed medication after pregnancy. CONCLUSIONS Antidepressants are the most commonly discontinued psychotherapeutic medication during pregnancy. We recommend further research examining factors that may influence this observed difference.
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Affiliation(s)
- Hayley D Germack
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania.
| | | | - Mandy Cooper
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Krista Koller
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
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13
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Freeman MP, Viguera AC, Góez-Mogollón L, Young AV, Caplin PS, McElheny SA, Church TR, Chitayat D, Hernández-Díaz S, Cohen LS. Reproductive safety of aripiprazole: data from the Massachusetts General Hospital National Pregnancy Registry for Atypical Antipsychotics. Arch Womens Ment Health 2021; 24:659-667. [PMID: 33710399 DOI: 10.1007/s00737-021-01115-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/12/2021] [Indexed: 12/16/2022]
Abstract
Aripiprazole has become one of the most commonly prescribed psychotropics, making a more comprehensive understanding of its reproductive safety profile a priority. The goal of the current analysis was to determine the risk of major malformations in infants exposed during the first trimester of pregnancy to aripiprazole compared to infants whose mothers had psychiatric diagnoses but did not use an atypical antipsychotic during pregnancy. The National Pregnancy Registry for Atypical Antipsychotics is a prospective pharmacovigilance program in which pregnant women are enrolled and interviewed during pregnancy and the postpartum period. Medical records are assessed to confirm presence or absence of major malformations. Pregnant women ages 18-45 with psychiatric diagnoses are enrolled. As of April 2020, N = 848 women who had delivered infants were eligible for analyses. A total of 158 women with first trimester exposure to aripiprazole were compared to 690 controls. For 163 infants born to women in the exposed group, seven major malformations were confirmed (4.29%), compared to fourteen of the 690 unexposed infants (1.99%). The unadjusted odds ratio for major malformations between aripiprazole-exposed and unexposed infants was 2.21 (95% confidence interval [CI] = (0.88, 5.57) The adjusted odds ratio for major malformations was 1.35 (95% confidence interval [CI] = (0.43, 4.20). After adjustment for confounding variables, the risk of major malformations after first trimester exposure to aripiprazole was not significant compared to controls. While these results are reassuring, they are limited by relatively small numbers of participants. Future analyses with larger numbers are expected to provide more of a complete and precise reproductive safety profile regarding aripiprazole use during pregnancy. Trial registration: clinicaltrials.gov NCT01246765.
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Affiliation(s)
- Marlene P Freeman
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Adele C Viguera
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Cleveland Clinic, Cleveland Clinic Neurological Institute, Cleveland, OH, USA
| | - Lina Góez-Mogollón
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA
| | - Amanda V Young
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA
| | - Phoebe S Caplin
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA
| | - Sara A McElheny
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA
| | - Taylor R Church
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA
| | - David Chitayat
- Prenatal Diagnosis and Medical Genetics Program, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Lee S Cohen
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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14
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Tasaki M, Yasui-Furukori N, Kubo K, Yokoyama S, Shinozaki M, Sugawara N, Inoue Y, Shimoda K. Relationship of Prolactin Concentrations to Steady-State Plasma Concentrations of Aripiprazole in Patients With Schizophrenia. Ther Drug Monit 2021; 43:589-592. [PMID: 33235024 DOI: 10.1097/ftd.0000000000000843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Aripiprazole is regarded as the first-line antipsychotic medication. Long-term aripiprazole therapy can cause hypoprolactinemia, which may result from its activity as a dopamine agonist. However, there is little information on hypoprolactinemia and steady-state aripiprazole concentrations. METHODS The subjects included 66 male and 177 female patients diagnosed with schizophrenia who were treated with aripiprazole. The plasma concentrations of aripiprazole and dehydroaripiprazole and the plasma concentration of prolactin were measured using high-performance liquid chromatography and enzyme immunoassay, respectively. A prolactin concentration of <5 ng/mL was defined as hypoprolactinemia. RESULTS Fifty-two of the 66 male patients (79%) and 58 of the 177 female patients (33%) had hypoprolactinemia. There were significant inverse correlations between plasma prolactin levels and plasma concentrations of aripiprazole (rs = -0.447, P < 0.001) and the active moiety (aripiprazole plus dehydroaripiprazole) (rs = -0.429, P < 0.001) in men. In women, significant inverse correlations were also found between plasma prolactin levels and plasma concentrations of aripiprazole (rs = -0.273, P < 0.01) and the active moiety (rs = -0.275, P < 0.01). CONCLUSIONS These findings suggest that lower prolactin levels are, to some extent, associated with higher plasma drug concentrations in male and female patients with schizophrenia treated with aripiprazole.
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Affiliation(s)
- Minami Tasaki
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan; and
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan; and
- Department of Neuropsychiatry, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kazuyoshi Kubo
- Department of Neuropsychiatry, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Saaya Yokoyama
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan; and
| | - Masataka Shinozaki
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan; and
| | - Norio Sugawara
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan; and
| | - Yoshimasa Inoue
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan; and
| | - Kazutaka Shimoda
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan; and
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15
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Medved S, Bajs JanoviĆ M, Štimac Z, MihaljeviĆ-Peleš A. Add-on Oxytocin in the Treatment of Postpartum Acute Schizophrenia: A Case Report. J Psychiatr Pract 2021; 27:326-332. [PMID: 34398584 DOI: 10.1097/pra.0000000000000557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An increasing body of research has been published concerning the potential impact of oxytocin (OT) in the pathophysiology of neuropsychiatric disorders that affect social functioning, such as schizophrenia. The possible therapeutic effect of OT in promoting mother-child bonding could be valuable in the management of postpartum psychosis. Studies on the efficacy of OT as an add-on therapy in the treatment of schizophrenia have found reductions in both positive and negative symptoms. The patient in the case reported here developed her second psychotic episode at the age of 22, a month after delivering her first child. Four weeks after treatment with aripiprazole was initiated, the patient's negative symptoms persisted, causing problems in the mother-child interaction. Intranasal OT (40 IU/d) was then added to the aripiprazole. Assessment scales [the Positive and Negative Syndrome Scale (PANSS), the Disability Assessment Schedule (WHODAS 2.0), and the Barkin Index of Maternal Functioning (BIMF)] and qualitative data from her caregiver were obtained at baseline and in the third and eighth weeks after the end of the OT therapy. Improvement was observed on almost all of the domains of the WHODAS 2.0 and the BIMF, as well as on the PANSS negative and general psychopathology scales. Data from the patient's caregiver indicated an overall improvement in mother-child interaction. These results, especially the improvement in results on the PANSS scale, are similar to findings from previous studies in patients with schizophrenia. OT seems to boost the antipsychotic effect on positive symptoms through the OT dopamine pathway, while the effect on negative symptoms probably involves a more general mechanism. Because the postpartum period is of immense significance for child development and mental well-being, future research to investigate the therapeutic efficacy of OT in the management of postpartum psychosis is warranted.
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16
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Orsolini L, Sceusa F, Pompili S, Mauro A, Salvi V, Volpe U. Severe and persistent mental illness (SPMI) in pregnancy and breastfeeding: focus on second-generation long acting injectable antipsychotics. Expert Opin Drug Saf 2021; 20:1207-1224. [PMID: 33966552 DOI: 10.1080/14740338.2021.1928634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction: Pregnant women and fetuses are more likely than ever to be exposed to antipsychotic drugs (APs) during pregnancy and postpartum period. Second-generation APs (SGA) are increasingly used among women in reproductive age. Key outcomes (i.e., congenital malformations, pregnancy and maternal outcomes, neonatal/infant risks, and developmental/long-term outcomes) following the exposure to APs remain limited in number and size and yield of inconsistent findings overall, particularly regarding long-acting injectable AP (LAI-APs) formulations.Areas covered: The review aims at providing a summary of current knowledge on potential risks and safety profile of LAI-APs during pregnancy and breastfeeding, specifically focusing on SGA.Expert opinion: The management of safety and tolerability of long-acting injectable AP (LAI-APs) is far from having solid scientific evidence. In fact, due to ethical reasons, there is a lack of randomized clinical trials that limits the reliability and generalizability of the available data on LAI-APs safety profile during the perinatal period, being limited in the scientific literature only to isolated case reports. Therefore, it seems to be important for the future pathways to perinatal mental health care, providing a network of specialized clinicians and systematically collecting data of pregnant/puerperal women on oral and/or LAI APs-therapy about mother and infant outcomes.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Francesca Sceusa
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Simone Pompili
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Antonella Mauro
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Virginio Salvi
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
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17
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Komaroff A. Aripiprazole and lactation failure: The importance of shared decision making. A case report. Case Rep Womens Health 2021; 30:e00308. [PMID: 33796446 PMCID: PMC7995469 DOI: 10.1016/j.crwh.2021.e00308] [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: 02/12/2021] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 12/01/2022] Open
Abstract
Bipolar disorder is a chronic and severe psychiatric illness affecting many patients during their childbearing years. Bipolar disorder is often managed with aripiprazole, a generally well tolerated second-generation antipsychotic medication. Published data regarding its safety profile are reassuring and aripiprazole is prescribed during pregnancy, postpartum and during lactation. Pregnancy and the postpartum period represent times of increased vulnerability for patients with bipolar disorder, especially those who are untreated, highlighting the need for medical management. However, aripiprazole may interfere with human milk production. Currently, there is limited evidence to understand lactation failure in patients who take aripiprazole. This case reinforces the need for shared decision making regarding the potential impact on lactation when aripiprazole is being considered for the pregnant patient with bipolar disorder. Bipolar disorder affects 2–4 % of the world’'s population and is the 4th leading cause of disability among young people. Aripiprazole is a second generation antipsychotic used for treatment of BD during pregnancy and lactation. Aripiprazole may cause lactation failure, interfering with maternal, infant bonding. Shared decision making is essential when working with patients who have Bipolar disorder during childbearing years.
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18
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Fernández-Abascal B, Recio-Barbero M, Sáenz-Herrero M, Segarra R. Long-acting injectable aripiprazole in pregnant women with schizophrenia: a case-series report. Ther Adv Psychopharmacol 2021; 11:2045125321991277. [PMID: 35186259 PMCID: PMC8851104 DOI: 10.1177/2045125321991277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/10/2021] [Indexed: 01/30/2023] Open
Abstract
Antipsychotic long-acting formulations (LAI-AP) have emerged as a new therapeutic choice to treat patients presenting a severe mental disorder. Despite that, to date, there is a lack of safety data and studies regarding the use of LAI-AP formulations in pregnant women. Here we present the first six-case series of pregnant women with schizophrenia treated with aripiprazole-LAI reported in the literature. All patients remained psychopathologically stable through pregnancy and the postpartum period, and all of them were in treatment with aripiprazole-LAI. To date, all infants remain healthy with normal developmental milestones, without the presence of congenital malformations or adverse effects. Lack of information on safety data regarding the use of new antipsychotic formulations remains important in treating women with mental illness who desire to become pregnant. Further studies in this clinical population with a larger number of patients included remains necessary.
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Affiliation(s)
| | - Maria Recio-Barbero
- Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Margarita Sáenz-Herrero
- Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Spain
- Department of Psychiatry, Cruces University Hospital, Barakaldo, Spain
- Department of Neurosciences, University of the Basque Country (UPV/EHU), Leioa, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Spain
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19
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García Álvarez JC, González Sánchez L, García Resa E, Bonete Llácer JM, Román Rodríguez A, Pecino Esquerdo B, Pérez Martínez E. Clinical evolution of patients treated with aripiprazole long-acting injectable: a preliminary, prospective, observational study. Int J Psychiatry Clin Pract 2020; 24:10-17. [PMID: 31933402 DOI: 10.1080/13651501.2019.1711130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To evaluate the effectiveness of 6-month treatment with aripiprazole long-acting injectable (LAI) in improving psychotic symptoms, social functioning and side effects and reducing co-administered antipsychotic drugs.Methods: Multicentre, observational, prospective study that enrolled 53 patients with diagnosis of schizophrenia spectrum disorders who initiated or switched to aripiprazole LAI. The effectiveness of aripiprazole LAI was assessed through the Positive and Negative Syndrome Scale (PANSS), the Udvalg for Kliniske Undersogelser scale for side effects, the Global Assessment of Functioning and the Clinical Global Impression-Schizophrenia (CGI-SCH).Results: Upon treatment with aripiprazole LAI, patients significantly improved all the domains of PANSS (p < .05). Adverse event severity significantly improved after a 6-month aripiprazole LAI treatment (p < .05). Differences from baseline to month 6 in Global Assessment of Functioning score were significant (p = .0002). The proportion of severely ill patients decreased upon treatment with aripiprazole LAI (CGI-SCH scale). Prolactin levels were normalised after a 6-month treatment (from 43.0 to 14.7 ng/mL). Co-administered antipsychotic drugs significantly decreased after a 6-month treatment with aripiprazole LAI.Conclusion: A 6-month treatment with aripiprazole LAI improved the clinical status of our patients without modifying their metabolic profile, and allowed the reduction of co-administered antipsychotic drugs.Practice implicationsLong-acting injectable antipsychotics are effective treatment options for the maintenance of patients with schizophrenia and related disorders, and to ensure treatment adherence. This study describes the evolution of patients over six months of treatment with aripiprazole long-acting injectable. The results from this study support previous data on the efficacy and safety of this atypical antipsychotic. This study may be of wide interest to the community of psychiatrists and may help clinicians optimise treatment adherence in patients with schizophrenia spectrum disorders.Key pointsAripiprazole long-acting injectable is an atypical antipsychotic intended to improve treatment adherence and prevent relapses.This multicentre prospective study evaluated the effectiveness of aripiprazole long-acting injectable over six months of treatment on the control of a comprehensive set of clinical variables.Clinical rating scales showed that treatment with aripiprazole long-acting injectable improved clinical symptoms and social functioning, and reduced the severity of adverse events.Aripiprazole long-acting injectable contributed to the maintenance of adequate metabolic profiles and the normalisation of prolactin levels.Patients significantly decreased co-administered antipsychotic drugs after 6-month treatment with aripiprazole.
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20
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González-Rodríguez A, Seeman MV. The association between hormones and antipsychotic use: a focus on postpartum and menopausal women. Ther Adv Psychopharmacol 2019; 9:2045125319859973. [PMID: 31321026 PMCID: PMC6610461 DOI: 10.1177/2045125319859973] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 04/01/2019] [Indexed: 12/17/2022] Open
Abstract
During the postpartum and menopausal periods of women's lives, there is a well-established and significant drop of circulating estrogens. This may be the reason why both these periods are associated with an increased risk for onset or exacerbation of psychiatric disorders. Whether symptoms are mainly affective or mainly psychotic, these disorders are frequently treated with antipsychotic medications, which calls for an examination of the relationship between hormone replacement and antipsychotic agents at these time periods. The aim of this narrative review is to summarize what is known about the association of hormones and antipsychotics in the postnatal period and at menopause. In the review, we focus on estrogen and oxytocin hormones and include, for the most part, only papers published within the last 10 years. Both estradiol and oxytocin have at various times been implicated in the etiology of postpartum disorders, and estrogens, sometimes combined with progesterone, have been tested as potential treatments for these conditions. The role of estradiol as an adjunct to antipsychotics in the prevention of postpartum relapses is currently controversial. With respect to oxytocin, studies are lacking. Psychosis in menopausal and postmenopausal women has been successfully treated with estrogens and selective estrogen-receptor modulators, mainly raloxifene, in addition to antipsychotics. Some symptoms appear to respond better than others. No oxytocin study has specifically targeted postmenopausal women. Because of feedback mechanisms, there is a theoretical danger of therapy with exogenous hormones interfering with endogenous secretion and disturbing the balance among inter-related hormones. When used with antipsychotics, hormones may also affect the metabolism and, hence, the brain level of specific antipsychotics. This makes treatment with antipsychotics plus hormones complicated. Dose, timing and route of intervention may all prove critical to efficacy. While much remains unknown, this literature review indicates that, within standard dose ranges, the combination of hormones and antipsychotics for postnatal and menopausal women suffering severe mental distress can be beneficial, and is safe.
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Affiliation(s)
| | - Mary V. Seeman
- Department of Psychiatry, University of Toronto,
260 Heath Street West, Suite 605, Toronto, Ontario M5P 3L6, Canada
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21
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Cuomo A, Beccarini Crescenzi B, Goracci A, Bolognesi S, Giordano N, Rossi R, Facchi E, Neal SM, Fagiolini A. Drug safety evaluation of aripiprazole in bipolar disorder. Expert Opin Drug Saf 2019; 18:455-463. [DOI: 10.1080/14740338.2019.1617847] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Alessandro Cuomo
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Department of Mental Health and Addiction Services, ASST Lombardy Health Care System, Carlo Poma Hospital, Mantova, Italy
| | | | - Arianna Goracci
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Simone Bolognesi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Nicola Giordano
- Department of Medicine, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Rodolfo Rossi
- Department of System Medicine (RR), Tor Vergata University, Rome, Italy
- Department of Mental Health & Drug Abuse, AUSL Modena, Modena, Italy
| | - Edvige Facchi
- Department of Mental Health, USL Toscana Sud East (EF), Siena, Italy
| | - Stephen M Neal
- Department of Psychiatry, West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA
| | - Andrea Fagiolini
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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22
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Breadon C, Kulkarni J. An update on medication management of women with schizophrenia in pregnancy. Expert Opin Pharmacother 2019; 20:1365-1376. [DOI: 10.1080/14656566.2019.1612876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Carolyn Breadon
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Australia
| | - Jayashri Kulkarni
- Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, Australia
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23
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Limandri BJ. Clinical Use of Dopamine Modulators as Third-Generation Antipsychotic Agents. J Psychosoc Nurs Ment Health Serv 2019; 57:7-11. [PMID: 30703220 DOI: 10.3928/02793695-20190116-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
When dopamine was identified as a primary target for schizophrenia, the dopamine antagonists, now referred to as first-generation antipsychotics, were added to our pharmacopeia. In the 1990s, with the discovery of risperidone and clozapine, the mechanism of dopamine receptor antagonism was paired with serotonin receptor antagonism to give rise to second-generation antipsychotics. A decade later these mechanisms were further refined to selective dopamine receptors antagonism and serotonin receptors antagonism and agonism to create a modulation or stabilization of dopamine nerve firing in differential ways. This new wave may be referred to as the third generation. The current article reviews the pharmacodynamics and pharmacokinetics of these dopamine modulators. [Journal of Psychosocial Nursing and Mental Health Services, 57(2), 7-11.].
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24
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Bovbjerg ML. Current Resources for Evidence-Based Practice, January 2019. J Obstet Gynecol Neonatal Nurs 2019; 48:99-111. [DOI: 10.1016/j.jogn.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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25
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Zhang X, Xiang Q, Zhao X, Ma L, Cui Y. Association between aripiprazole pharmacokinetics and CYP2D6 phenotypes: A systematic review and meta-analysis. J Clin Pharm Ther 2018; 44:163-173. [PMID: 30565279 DOI: 10.1111/jcpt.12780] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/24/2018] [Accepted: 11/15/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Xiaodan Zhang
- Department of Pharmacy; Base for Clinical Trial, Peking University First Hospital; Beijing China
| | - Qian Xiang
- Department of Pharmacy; Base for Clinical Trial, Peking University First Hospital; Beijing China
| | - Xia Zhao
- Department of Pharmacy; Base for Clinical Trial, Peking University First Hospital; Beijing China
| | - Lingyue Ma
- Department of Pharmacy; Base for Clinical Trial, Peking University First Hospital; Beijing China
| | - Yimin Cui
- Department of Pharmacy; Base for Clinical Trial, Peking University First Hospital; Beijing China
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