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Lochmann van Bennekom MWH, IntHout J, Gijsman HJ, Akdede BBK, Yağcıoğlu AEA, Barnes TRE, Galling B, Gueorguieva R, Kasper S, Kreinin A, Nielsen J, Nielsen RE, Remington G, Repo-Tiihonen E, Schmidt-Kraepelin C, Shafti SS, Xiao L, Correll CU, Verkes RJ. Efficacy and tolerability of antipsychotic polypharmacy for schizophrenia spectrum disorders. A systematic review and meta-analysis of individual patient data. Schizophr Res 2024; 272:1-11. [PMID: 39142215 DOI: 10.1016/j.schres.2024.07.035] [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] [Received: 12/10/2023] [Revised: 07/14/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Antipsychotic polypharmacy (APP) is frequently prescribed for schizophrenia-spectrum disorders. Despite the inconsistent findings on efficacy, APP may be beneficial for subgroups of psychotic patients. This meta-analysis of individual patient data investigated moderators of efficacy and tolerability of APP in adult patients with schizophrenia-spectrum disorders. DESIGN We searched PubMed, EMBASE, and the Cochrane Central Register of Randomized Trials until September 1, 2022, for randomized controlled trials comparing APP with antipsychotic monotherapy. We estimated the effects with a one-stage approach for patient-level moderators and a two-stage approach for study-level moderators, using (generalized) linear mixed-effects models. Primary outcome was treatment response, defined as a reduction of 25 % or more in the Positive and Negative Syndrome Scale (PANSS) score. Secondary outcomes were study discontinuation, and changes from baseline on the PANSS total score, its positive and negative symptom subscale scores, the Clinical Global Impressions Scale (CGI), and adverse effects. RESULTS We obtained individual patient data from 10 studies (602 patients; 31 % of all possible patients) and included 599 patients in our analysis. A higher baseline PANSS total score increased the chance of a response to APP (OR = 1.41, 95 % CI 1.02; 1.94, p = 0.037 per 10-point increase in baseline PANSS total), mainly driven by baseline positive symptoms. The same applied to changes on the PANSS positive symptom subscale and the CGI severity scale. Extrapyramidal side effects increased significantly where first and second-generation antipsychotics were co-prescribed. Study discontinuation was comparable between both treatment arms. CONCLUSIONS APP was effective in severely psychotic patients with high baseline PANSS total scores and predominantly positive symptoms. This effect must be weighed against potential adverse effects.
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Affiliation(s)
- Marc W H Lochmann van Bennekom
- Pro Persona Mental Health Care, Expertise Center for Depression, Nijmeegsebaan 61, 6525 DX Nijmegen, the Netherlands; Donders Institute for Brain, Cognition, and Behaviour, Radboud University, Nijmegen, the Netherlands.
| | - Joanna IntHout
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands.
| | | | - Berna B K Akdede
- Dokuz Eylul University Faculty of Medicine, Department of Psychiatry, Balçova, İzmir, Turkey.
| | - A Elif Anıl Yağcıoğlu
- Hacettepe University Faculty of Medicine, Department of Psychiatry, Sıhhiye, Ankara, Turkey.
| | | | - Britta Galling
- Department of Child and Adolescent Psychiatry and Psychotherapy, Centre for Integrative Psychiatry, School of Medicine, Kiel, Germany
| | | | - Siegfried Kasper
- Medical University of Vienna, Center for Brain Research, Department of Molecular Neuroscience, Vienna, Austria.
| | | | - Jimmi Nielsen
- Department of Clinical Medicine, University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark; Mental health Centre Glostrup, Mental health service Capital Region Denmark, Copenhagen, Denmark.
| | - René Ernst Nielsen
- Psychiatry, Aalborg University Hospital, Aalborg, Denmark; Aalborg University, Department of Clinical Medicine, Aalborg, Denmark.
| | - Gary Remington
- Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, Ontario, Canada.
| | | | - Christian Schmidt-Kraepelin
- Kaiserswerther Diakonie, Florence-Nightingale-Hospital, Department of Psychiatry and Psychotherapy, Düsseldorf, Germany; LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany.
| | - Saeed S Shafti
- University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Le Xiao
- The National Clinical Research Center for Mental Disorders, Mood Disorders Center, Beijing Anding Hospital Capital Medical University, Beijing, China
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Northwell Health, New Hyde Park, NY, USA; Charité - Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany; DZPG, German Center for Mental Health, Partner Site Berlin, Germany.
| | - Robbert-Jan Verkes
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands; Donders Institute for Brain, Cognition, and Behaviour, Radboud University, Nijmegen, the Netherlands.
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Köhler-Forsberg O, Højlund M, Rohde C, Kemp AF, Gregersen AT, Mellentin AI, Correll CU. Efficacy and acceptability of interventions to reduce antipsychotic polypharmacy: A systematic review and meta-analysis of randomized clinical trials. Schizophr Res 2024; 270:135-143. [PMID: 38908279 DOI: 10.1016/j.schres.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/26/2024] [Accepted: 06/03/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Antipsychotic polypharmacy (APP) is frequent but evidence-based guidelines on reducing APP to antipsychotic monotherapy (APM) are sparse. We aimed to systematically review clinical interventions randomizing patients to reducing APP to APM versus continuing APP. METHODS Systematic literature review searching Medline and Embase (latest search January 10, 2024) for randomized clinical trials (RCTs) studying interventions comparing individuals randomized to reduction of APP to APM with individuals continuing on APP. Two independent reviewers performed the literature screening, data extraction, and risk of bias assessment (RoB2). We performed random effects meta-analyses on the main outcome all-cause discontinuation/"acceptability" of the treatment strategy and secondary outcomes change in psychopathology, functional level, and side effects. RESULTS The search identified 4672 hits, whereof 8 trials (N = 1204, 6 patient-level RCTs and 2 cluster-RCTs) were included, primarily in patients with schizophrenia. All trials were associated with high risk of bias. Compared to APP continuation, reduction to APM was associated with no significant change in all-cause discontinuation (studies = 6, n = 455, RR = 1.48, 95%CI = 0.74-2.95, I2 = 78 %) or inefficacy-related discontinuation (studies = 5, n = 351, RR = 1.60, 95%CI = 0.46-5.55, I2 = 70 %). Patients randomized to APM showed a trend towards greater reduction in psychopathology (studies = 5, n = 244, SMD = -0.24, 95%CI = -0.49, 0.02, I2 = 0 %) but no difference in functional level nor side effects. The cluster-RCTs found that interventions at the departmental level can result in lower rates of APP. CONCLUSION Although switching patients from APP to APM can be a viable approach, too few RCTs exist on this important topic. Clinicians need to evaluate potential benefits and risks of APP and APM on an individual basis. PROSPERO REGISTRATION CRD42022329955.
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital - Psychiatry, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Mikkel Højlund
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, University of Southern Denmark, Odense, Denmark; Department of Psychiatry Aabenraa, Mental Health Services in the Region of Southern Denmark, Aabenraa, Denmark
| | - Christopher Rohde
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark
| | - Adam F Kemp
- Department of Psychiatry Aabenraa, Mental Health Services in the Region of Southern Denmark, Aabenraa, Denmark; Department of Psychiatry Odense, Mental Health Services in the Region of Southern Denmark, Denmark
| | - Anton T Gregersen
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, University of Southern Denmark, Odense, Denmark; Department of Psychiatry Aabenraa, Mental Health Services in the Region of Southern Denmark, Aabenraa, Denmark
| | - Angelina I Mellentin
- Unit of Psychiatric Research, Odense University Hospital, Odense C, Denmark; Center of Digitalized Psychiatry, Mental Health Services in the Region of Southern Denmark, Denmark; Brain Research-Inter-Disciplinary Guided Excellence (BRIDGE), Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Christoph U Correll
- German Center for Mental Health (DZPG), Berlin, Germany; Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany; Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
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Lee J, Oh S, Moon SY, Loh SK, Kim M, Lee TY, Kwon JS. Impact of long-acting injectable aripiprazole on the concomitant medication and antipsychotic polypharmacy: a retrospective, observational study of 127 patients with psychosis. Int Clin Psychopharmacol 2024; 39:250-256. [PMID: 37982292 DOI: 10.1097/yic.0000000000000492] [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: 11/21/2023]
Abstract
Antipsychotic polypharmacy (APP) has become prevalent over the years, but several concerns have been raised over APP. Accumulating evidence suggests that aripiprazole long-acting injectable (LAI) may reduce the rate of APP, but the association remains speculative. This retrospective observational study included 127 patients with psychosis and observed them for 1.8 ± 1.3 years, up to 4 years. Prescription data of antipsychotics (APs), mood stabilisers, benzodiazepines, and anti-extrapyramidal side effect medications were obtained at baseline and the last observation. Daily chlorpromazine equivalent (CPZ) dose of APs decreased from 124.40 ± 235.35 mg to 77.95 ± 210.36 mg ( P = 0.027). The daily dose of anticholinergics and beta-blockers also significantly decreased after introducing aripiprazole LAI. Among the patients having APP, the number of concurrent APs along with daily CPZ dose of APs decreased after initiation of aripiprazole LAI from 1.28 ± 0.62 to 0.85 ± 0.73 ( P < 0.001) and 298.33 ± 308.70 mg to 155.43 ± 280.53 mg ( P = 0.004), respectively. Treatment with aripiprazole LAI for up to 4 years in patients with psychosis was associated with a reduced number of prescribed APs in patients having an APP and a reduced dose of APs and concurrent psychotropic medications.
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Affiliation(s)
- Junhee Lee
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul
- Department of Psychiatry, Uijeongbu Eulji Medical Center, Uijeongbu
| | - Sanghoon Oh
- Department of Psychiatry, Uijeongbu Eulji Medical Center, Uijeongbu
| | - Sun-Young Moon
- Department of Psychiatry, Hallym University Kangnam Sacred Heart Hospital
| | - Silvia Kyungjin Loh
- Department of Psychiatry, Seoul National University College of Medicine, Seoul
| | - Minah Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul
| | - Tae Young Lee
- Department of Neuropsychiatry, Pusan National University Yangsan Hospital, Yangsan
| | - Jun Soo Kwon
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul
- Department of Psychiatry, Seoul National University College of Medicine, Seoul
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
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Luykx JJ, Correll CU, Manu P, Tanskanen A, Hasan A, Tiihonen J, Taipale H. Pneumonia Risk, Antipsychotic Dosing, and Anticholinergic Burden in Schizophrenia. JAMA Psychiatry 2024:2820399. [PMID: 38922592 PMCID: PMC11209197 DOI: 10.1001/jamapsychiatry.2024.1441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Abstract
Importance Antipsychotic drugs (particularly clozapine) have been associated with pneumonia in observational studies. Despite studies of the associations between antipsychotic use and incident pneumonia, it remains unclear to what degree antipsychotic use is associated with increased risk of pneumonia, whether dose-response associations exist, and what agents are specifically associated with incident pneumonia. Objective To estimate pneumonia risk associated with specific antipsychotics and examine whether polytherapy, dosing, and receptor binding properties are associated with pneumonia in patients with schizophrenia. Design, Setting, and Participants This cohort study identified patients with schizophrenia or schizoaffective disorder (hereafter, schizophrenia) aged 16 years or older from nationwide Finnish registers from 1972 to 2014. Data on diagnoses, inpatient care, and specialized outpatient care were obtained from the Hospital Discharge Register. Information on outpatient medication dispensing was obtained from the Prescription Register. Study follow-up was from 1996 to 2017. Data were analyzed from November 4, 2022, to December 5, 2023. Exposures Use of specific antipsychotic monotherapies; antipsychotics modeled by dosage as low (<0.6 of the World Health Organization defined daily dose [DDD] per day), medium (0.6 to <1.1 DDDs per day), or high dose (≥1.1 DDDs per day); antipsychotic polypharmacy; and antipsychotics categorized according to their anticholinergic burden as low, medium, and high. Main Outcomes and Measures The primary outcome was hospitalization for incident pneumonia. Pneumonia risk was analyzed using adjusted, within-individual Cox proportional hazards regression models, with no antipsychotic use as the reference. Results The study included 61 889 persons with schizophrenia (mean [SD] age, 46.2 [16.0] years; 31 104 men [50.3%]). During 22 years of follow-up, 8917 patients (14.4%) had 1 or more hospitalizations for pneumonia and 1137 (12.8%) died within 30 days of admission. Compared with no antipsychotic use, any antipsychotic use overall was not associated with pneumonia (adjusted hazard ratio [AHR], 1.12; 95% CI, 0.99-1.26). Monotherapy use was associated with increased pneumonia risk compared with no antipsychotic use (AHR, 1.15 [95% CI, 1.02-1.30]; P = .03) in a dose-dependent manner, but polytherapy use was not. When categorized by anticholinergic burden, only the use of antipsychotics with a high anticholinergic burden was associated with pneumonia (AHR, 1.26 [95% CI, 1.10-1.45]; P < .001). Of specific drugs, high-dose quetiapine (AHR, 1.78 [95% CI, 1.22-2.60]; P = .003), high- and medium-dose clozapine (AHR, 1.44 [95% CI, 1.22-1.71]; P < .001 and AHR, 1.43 [95% CI, 1.18-1.74]; P < .001, respectively), and high-dose olanzapine (AHR, 1.29 [95% CI, 1.05-1.58]; P = .02) were associated with increased pneumonia risk. Conclusions and Relevance Results of this cohort study suggest that in patients with schizophrenia, antipsychotic agents associated with pneumonia include not only clozapine (at dosages ≥180 mg/d) but also quetiapine (≥440 mg/d) and olanzapine (≥11 mg/d). Moreover, monotherapy antipsychotics and antipsychotics with high anticholinergic burden are associated with increased pneumonia risk in a dose-dependent manner. These findings call for prevention strategies aimed at patients with schizophrenia requiring high-risk antipsychotics.
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Affiliation(s)
- Jurjen J. Luykx
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, the Netherlands
- GGZ inGeest Mental Health Care, Amsterdam, the Netherlands
- Neuroscience Mood, Anxiety, Psychosis, Stress & Sleep Research Program, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
- Public Health Mental Health Research Program, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Christoph U. Correll
- Department of Psychiatry, the Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Manu
- Department of Psychiatry, Hofstra/Northwell School of Medicine, Hempstead, New York
- Department of Medicine, Hofstra/Northwell School of Medicine, Hempstead, New York
- South Oaks Hospital, Northwell Health System, Amityville, New York
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- German Center for Mental Health, München, Germany
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Center for Psychiatric Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
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Maekawa M, Yokota M, Sato T, Sato Y, Kumondai M, Sato Y, Suzuka M, Kobayashi D, Sakamoto K, Matsuura M, Kikuchi M, Komatsu H, Fujii K, Ozeki Y, Tomita H, Mano N. Development of a simultaneous LC-MS/MS analytical method for plasma: 16 antipsychotics approved in Japan and 4 drug metabolites. ANAL SCI 2024:10.1007/s44211-024-00619-2. [PMID: 38918311 DOI: 10.1007/s44211-024-00619-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 05/29/2024] [Indexed: 06/27/2024]
Abstract
The increased risk of adverse drug reactions due to the concomitant use of antipsychotics is problematic in the treatment of schizophrenia. Therefore, the simultaneous analysis of their plasma concentrations is required. In this study, we developed a simultaneous liquid chromatography/tandem mass spectrometry (LC-MS/MS) method for analyzing plasma antipsychotics approved in Japan for therapeutic drug monitoring (TDM) applications. First, we counted the prescriptions for 16 antipsychotics and concomitant drugs used at the Tohoku University Hospital. LC-MS/MS was used for the simultaneous analysis of 16 antipsychotics and four drug metabolites. This analysis was conducted using a combination of selected reaction monitoring mode and reversed-phase chromatography. Following the examination of the MS/MS and LC conditions, an analytical method validation test was conducted. The developed method was used to analyze plasma antipsychotic levels in patients with schizophrenia. One-third of the patients received treatment with multiple antipsychotics. Under LC-MS/MS conditions, LC separation was performed using a combination of a C18 column and ammonium formate-based mobile phases with a gradient flow. The calibration curves were optimized by adjusting the ion abundance, and 11 compounds met the criteria for intra- and inter-day reproducibility tests. Some stability test results did not meet these criteria; therefore, further investigation is required. The developed method permitted the measurement of all the plasma parameters, including concentrations above the therapeutic range. Therefore, this method may be useful in the daily TDM practice of antipsychotics.
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Affiliation(s)
- Masamitsu Maekawa
- Faculty of Pharmaceutical Sciences, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Maki Yokota
- Faculty of Pharmaceutical Sciences, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Toshihiro Sato
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yu Sato
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masaki Kumondai
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yuji Sato
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masato Suzuka
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Daisuke Kobayashi
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Kotaro Sakamoto
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masaki Matsuura
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masafumi Kikuchi
- Faculty of Pharmaceutical Sciences, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hiroshi Komatsu
- Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Kumiko Fujii
- Department of Psychiatry, Shiga University of Medical Science, Otsu, 520-2192, Japan
| | - Yuji Ozeki
- Department of Psychiatry, Shiga University of Medical Science, Otsu, 520-2192, Japan
| | - Hiroaki Tomita
- Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Nariyasu Mano
- Faculty of Pharmaceutical Sciences, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Lin CH, Huang CJ, Lin TC, Chan HY, Chen JJ. Schizophrenia patients discharged on antipsychotic polypharmacy from a public psychiatric hospital in Taiwan, 2006-2021. Psychiatry Res 2023; 330:115575. [PMID: 37913621 DOI: 10.1016/j.psychres.2023.115575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/22/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
The aim of this study was to identify the factors associated with antipsychotic polypharmacy (APP), investigate whether APP could affect the risk of rehospitalization, and explore temporal trends in APP use. Schizophrenia patients discharged from the study hospital between 2006 and 2021 (n = 16,722) were included in the analysis. The logistic regression model was employed to determine the predictors significantly associated with APP use. Survival analysis was used to compare time to rehospitalization between APP and antipsychotic monotherapy (AMT). The temporal trend of APP use was analyzed using the Cochran-Armitage Trend test. In comparison with the patients (n = 10,909) who were discharged on AMT, those (n = 5,813) on APP were significantly more likely to be male gender, to receive LAIs, to take clozapine, to take anticholinergic agents, to have a greater number of previous hospitalizations, and to have a higher CPZ equivalent dose of antipsychotic prescription. The prescription rate of APP significantly increased from 18.4 % in 2006 to 44.9 % in 2021. Compared with AMT, APP was associated with more clozapine use, more LAI use, higher doses of antipsychotics, and an increased risk of rehospitalization. In addition, the prescription of APP continued to increase during the study period.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chun-Jen Huang
- Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ta-Chun Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hung-Yu Chan
- Department of General Psychiatry, Taoyuan Psychiatric Center, Taoyuan, Taiwan; Department of Psychiatry, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Jiahn-Jyh Chen
- Department of General Psychiatry, Taoyuan Psychiatric Center, Taoyuan, Taiwan
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Lassen S, Heintz T, Pedersen T, Jentz C, Nathanielsen N, Heilmann P, Sørensen LU. Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients. Int J Circumpolar Health 2023; 82:2218654. [PMID: 37300837 DOI: 10.1080/22423982.2023.2218654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi2 or Fisher's exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi2, p = 0.010), olanzapine (Fisher's test, p = 0.003), and aripiprazole (Fisher's test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi2, p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.
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Affiliation(s)
- Stine Lassen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Thale Heintz
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Tilde Pedersen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Christian Jentz
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Naaja Nathanielsen
- The Directorate of Correctional Services, Prison and Probation Service, Nuuk, Greenland
| | | | - Lisbeth Uhrskov Sørensen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
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Ajayi SU, Arora P. A Survey Study on Clinicians' Rationale and Attitude Towards the Prescription of Antipsychotic Polypharmacy in the East Perth Metropolitan Area in Western Australia. Cureus 2023; 15:e37234. [PMID: 37064723 PMCID: PMC10098027 DOI: 10.7759/cureus.37234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 04/18/2023] Open
Abstract
Objective Patients challenging refractory and residual psychotic symptoms have led to the concomitant use of combined antipsychotics, which was later introduced and labelled 'antipsychotic polypharmacy' (APP). Many clinicians have become somewhat hesitant to adjust psychotropic medication dosages, resulting in a higher dose and combination prescription of antipsychotics and only achieving modest success. This study examines and investigates clinician perspectives and the rationale for the prescription of antipsychotic polypharmacy. Methods A structured questionnaire designed to reflect 15 target-directed questions evaluating clinicians' attitudes and rationale on antipsychotic polypharmacy prescription was administered from November to December 2022. Information was obtained from inpatient and outpatient prescribers (psychiatric consultants) in two government-funded psychiatric facilities and outpatient clinics in the East Perth Metropolitan Area in Western Australia. Results After exclusion, a total of 45 participants' responses were analysed. These results suggest a higher frequency of questions relating to the prescription of APP based on previous prescribers' consultation and recommendation from a prior treating team; senior nurses' pressure impacting clinicians' decisions on APP perception; and the patient's risk of aggression impacting the clinician's rationale for the prescription of APP. Conclusions Clinicians' rationale and attitude towards the prescription of APP are mostly influenced by recommendations from prior treatment teams or consultations and patients' risk for aggression without compromising practice guidelines. Our findings also highlight the need to evaluate prescribers' attitudes and how it presents an opportunity to enhance patients' holistic outcomes.
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Affiliation(s)
| | - Praveena Arora
- Older Adult Mental Health Service, Royal Perth Bentley Health Service, Perth, AUS
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Vrublevska J. Case report: Successful administration of cariprazine in a young, severely ill patient with recurrent relapses of schizophrenia and persistent negative symptoms. Front Psychiatry 2023; 14:1134692. [PMID: 36970274 PMCID: PMC10034963 DOI: 10.3389/fpsyt.2023.1134692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
The present case report describes a young man diagnosed with schizophrenia and presents a "revolving door" (RD) phenomenon. He was hospitalized in an acute psychiatric clinic three times in 1 year. After each hospitalization, he was discharged with incompletely reduced psychotic symptoms, persistent negative symptoms, low functioning, lack of insight, and adherence. He had an insufficient response to maximally tolerated doses of antipsychotic monotherapy with haloperidol and risperidone. Moreover, his treatment was complicated due to the low accessibility of long-acting injectable atypical antipsychotics (LAI) in the country and his refusal of the only available atypical LAI paliperidone palmitate and refusal to take clozapine. Due to limited alternatives, the decision to administer combinations of antipsychotics was made. Since his diagnosis, he received several combinations of antipsychotics, i.e., haloperidol + quetiapine, risperidone + quetiapine, haloperidol + olanzapine, risperidone + olanzapine, but without sufficient clinical effectiveness. Although combinations of antipsychotics reduced his positive symptoms to some degree, persistent negative symptoms and extrapyramidal side effects were observed. After initiating cariprazine, which was combined with olanzapine, improvement in the patient's positive symptoms, negative symptoms, and overall functioning was detected. The combination of medications mentioned above facilitated the therapeutic alliance, thus providing control over the symptoms and preventing psychiatric hospitalizations.
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Torrico TJ. The pathophysiology of rapid fluctuations in mental status associated with olanzapine: A case report. Front Psychiatry 2022; 13:1028350. [PMID: 37082516 PMCID: PMC10111197 DOI: 10.3389/fpsyt.2022.1028350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/02/2022] [Indexed: 12/02/2022] Open
Abstract
BackgroundOlanzapine toxicity is reported to be a rare but specific phenomenon characterized by rapid fluctuations between somnolence and agitation, which has been referred to as “agitation despite sedation.” A similar phenomenon is observed as an adverse reaction of the long-acting injectable olanzapine formulation, which has been referred to as “delirium/sedation syndrome.”Case presentationThis case report describes a 48-year-old man diagnosed with schizophrenia who experienced rapid fluctuations between somnolence and agitation during a cross-titration of olanzapine to clozapine. The patient had normal serum levels of both medications and the symptoms resolved with the discontinuation of olanzapine.ConclusionRapid fluctuations in mental status between somnolence and agitation are not clearly described among other antipsychotics, and it is possible that this phenomenon may be specific to olanzapine. The findings of this case report suggested that this phenomenon was likely the result of the oversaturation of (H1) and (M1) receptors.
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Affiliation(s)
- Tyler J. Torrico
- Department of Psychiatry, Kern Medical, Bakersfield, CA, United States
- American Psychiatric Association Substance Abuse and Mental Health Services Administration (SAMHSA) Minority Fellowship, Washington, DC, United States
- *Correspondence: Tyler J. Torrico,
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Kamei H. Polypharmacy Management of Antipsychotics in Patients with Schizophrenia. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1584. [PMID: 36363541 PMCID: PMC9692600 DOI: 10.3390/medicina58111584] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2023]
Abstract
Schizophrenia is a chronic psychiatric disease that is characterized by psychotic symptoms, including positive, negative, affective, and aggressive symptoms, as well as cognitive dysfunction, and is primarily treated using drug therapy, the continuation of which is essential to prevent recurrence/recrudescence. Various second-generation antipsychotics with pharmacological properties or adverse events that differ from those of conventional antipsychotics have recently been introduced, and pharmaceutical management is required for drug efficacy assessments and adverse event monitoring/management of these drugs. Antipsychotic monotherapy (APM) is the gold standard treatment for schizophrenia and is recommended in various guidelines. However, a subgroup of patients with schizophrenia do not or only partially respond to APM. Therefore, antipsychotic polypharmacy (APP), in which ≥2 antipsychotics are combined, has been routinely utilized to compensate for insufficient responses to APM in clinical practice. APP has recently been proposed as an evidence-based treatment option, but does not consider clinicians' experience. However, the risk of APP-related adverse events is high. The application of APP needs to be carefully reviewed, whilst taking into consideration patient backgrounds. Furthermore, the risk of APP-related adverse events is higher in elderly patients than in the general population; therefore, caution is needed. This review discusses the merits of APP, matters that need to be considered, and a switch from APP to APM, and also focuses on the application of APP in clinical practice.
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Affiliation(s)
- Hiroyuki Kamei
- Office of Clinical Pharmacy Practice and Health Care Management, Faculty of Pharmacy, Meijo University, Nagoya 468-8503, Japan
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12
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Abstract
Antipsychotic polypharmacy in psychotic disorders is widespread despite international guidelines favoring monotherapy. Previous evidence indicates the utility of low-dose partial dopamine agonist (PDAs) add-ons to mitigate antipsychotic-induced metabolic adverse effects or hyperprolactinemia. However, clinicians are often concerned about using PDAs combined with high-potency, full dopaminergic antagonists (FDAs) due to the risk of psychosis relapse. We, therefore, conducted a literature review to find studies investigating the effects of combined treatment with PDAs (i.e. aripiprazole, cariprazine and brexpiprazole) and FDAs having a strong D 2 receptor binding affinity. Twenty studies examining the combination aripiprazole - high-potency FDAs were included, while no study was available on combinations with cariprazine or brexpiprazole. Studies reporting clinical improvement suggested that this may require a relatively long time (~11 weeks), while studies that found symptom worsening observed this happening in a shorter timeframe (~3 weeks). Patients with longer illness duration who received add-on aripiprazole on ongoing FDA monotherapy may be at greater risk for symptomatologic worsening. Especially in these cases, close clinical monitoring is therefore recommended during the first few weeks of combined treatment. These indications may be beneficial to psychiatrists who consider using this treatment strategy. Well-powered randomized clinical trials are needed to derive more solid clinical recommendations.
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Lin HY, Lin FJ, Katz AJ, Wang IT, Wu CH. Antipsychotic Use in Early Pregnancy and the Risk of Maternal and Neonatal Complications. Mayo Clin Proc 2022; 97:2086-2096. [PMID: 36210203 DOI: 10.1016/j.mayocp.2022.04.006] [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] [Received: 09/02/2021] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 03/21/2023]
Abstract
OBJECTIVE To assess the association between antipsychotic use in early pregnancy and the risk of maternal and neonatal metabolic complications. METHODS We conducted a population-based retrospective cohort study (January 1, 2010, to December 31, 2016) using the Health and Welfare Database in Taiwan. Pregnant women (18 to 49 years of age) were grouped as antipsychotic users (ie, received oral antipsychotic monotherapy during the first 20 weeks of pregnancy) and nonusers. Antipsychotic users were further categorized into first-generation antipsychotic and second-generation antipsychotic users. Propensity score methods, including matching and inverse probability of treatment weighting, were used to balance covariates. Conditional logistic regression and Cox proportional hazards models were used to compare risks of maternal (gestational diabetes mellitus, preterm birth) and neonatal (low birth weight [LBW], macrosomia) outcomes. RESULTS Antipsychotic users had a notably higher risk of preterm birth compared with nonusers (adjusted HR, 1.29; 95% CI, 1.04 to 1.60), but the risk of gestational diabetes mellitus (HR, 1.21; 95% CI, 0.94 to 1.56), LBW (odds ratio [OR], 1.07; 95% CI, 0.84 to 1.37), and macrosomia (OR, 1.36; 95% CI, 0.63 to 2.92) did not differ between the two groups. Among women who received antipsychotics, the odds of LBW were significantly higher in second-generation antipsychotic users compared with first-generation antipsychotic users (adjusted OR, 1.32; 95% CI, 1.04 to 1.68). CONCLUSION This study found that using antipsychotics in early pregnancy did not result in a greater risk of metabolic complications both for mothers and newborns. For women requiring treatment with antipsychotics during pregnancy, they should be monitored for the risk of preterm birth and low infant birth weight.
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Affiliation(s)
- Hsuan-Yu Lin
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei City, Taiwan
| | - Fang-Ju Lin
- Department of Obstetrics and Gynecology, Taipei Medical University, Taipei City, Taiwan; Graduate Institute of Clinical Pharmacy and School of Pharmacy, College of Medicine, National Taiwan University; Department of Pharmacy, National Taiwan University Hospital
| | - Aaron J Katz
- Departments of Population Health and Radiation Oncology, University of Kansas School of Medicine, Kansas City, KS, USA; Department of Radiation Oncology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - I-Te Wang
- Department of Obstetrics and Gynecology, Taipei Medical University, Taipei City, Taiwan; Department of Obstetrics and Gynecology, Taipei Medical University Hospital
| | - Chung-Hsuen Wu
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei City, Taiwan.
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14
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Shakir M, Willems AE, van Harten PN, van Lutterveld R, Tenback DE. The effect on relapse rate and psychiatric symptomatology: Switching a combination of first- and second-generation antipsychotic polypharmacy to antipsychotic monotherapy in long-term inpatients with schizophrenia and related disorders. A pragmatic randomized open-label trial (SwAP trial). Schizophr Res 2022; 243:187-194. [PMID: 35397249 DOI: 10.1016/j.schres.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/30/2022] [Accepted: 03/17/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is little evidence to support the use of antipsychotic polypharmacy, and there are concerns about safety and side effects. Nonetheless, it is commonly used in the treatment of long-term inpatients with schizophrenia. This study investigated the effects of switching from a combination of first- and second-generation antipsychotics (FGA and SGA) to monotherapy (FGA or SGA) on relapse rates and psychiatric symptomatology. METHODS Institutionalized patients with chronic psychotic disorders using a combination of SGA and FGA (n = 136) participated in a randomized open-label trial. The SWITCH group discontinued either FGA or SGA, the STAY group continued combination treatment. Relapse and psychotic symptoms were measured at baseline and during follow-up at 3, 6, and 9 months. Psychiatric symptomatology was measured using the Brief Psychiatric Rating Scale (BPRS). Relapse was defined as (i) an increase in BPRS score of at least 2 points on any item, or (ii) an increase of at least 4 points in total BPRS score and an adjustment of antipsychotics. RESULTS A logistic regression model, corrected for sex, showed that the probability of relapse was significantly lower in the SWITCH group: 0.29 (95% CI 0.13-0.62). The protective effect of switching to monotherapy was attributable to patients continuing clozapine as monotherapy. For patients who did not experience a relapse nor dropped out, BPRS total scores decreased significantly more in the SWITCH group (p = 0.0001). CONCLUSION Switching from a combination of FGA and SGA to monotherapy in long-term inpatients does not increase the relapse rate and may even reduce it.
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Affiliation(s)
- Mushde Shakir
- Veldzicht Center for Transcultural Psychiatry, Custodial Institutions Agency (DJI), Ministry of Justice and Security, Balkbrug, the Netherlands; i-psy Haaglanden, Parnassia Group Mental Health Service, Den Haag, the Netherlands; Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht, the Netherlands.
| | - Anne E Willems
- Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht, the Netherlands; Psychiatric Center GGz Centraal, Amersfoort, the Netherlands
| | - Peter N van Harten
- Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht, the Netherlands; Psychiatric Center GGz Centraal, Amersfoort, the Netherlands
| | - Remko van Lutterveld
- Brain Research and Innovation Center, Ministry of Defence, Utrecht, the Netherlands; University Medical Center Utrecht, Department of Psychiatry, Utrecht, the Netherlands
| | - Diederik E Tenback
- Veldzicht Center for Transcultural Psychiatry, Custodial Institutions Agency (DJI), Ministry of Justice and Security, Balkbrug, the Netherlands; FPC de Oostvaarderskliniek, Custodial Institutions Agency (DJI), Ministry of Justice and Security, Almere, the Netherlands
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15
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Schmidt-Kraepelin C, Feyerabend S, Engelke C, Riesbeck M, Meisenzahl-Lechner E, Verde PE, Correll CU, Kluge M, Makiol C, Neff A, Lange C, Englisch S, Zink M, Langguth B, Poeppl TB, Reske D, Gouzoulis-Mayfrank E, Gründer G, Hasan A, Brockhaus-Dumke A, Jäger M, Baumgärtner J, Leucht S, Cordes J, Cordes J, Feyerabend S, Engelke C, Riesbeck M, Meisenzahl-Lechner E, Gaebel W, Deiß M, Sofie N, Galuba V, Wiechmann F, Janssen B, Kluge M, Makiol C, Kertzscher L, Neff A, Lange C, Englisch S, Zink M, Becker A, Muszinski S, Gründer G, Langguth B, Poeppl T, Frank E, Kreuzer P, Reske D, Gouzoulis-Mayfrank E, Veselinovic T, Hasan A, Falkai P, Wagner E, Brockhaus-Dumke A, Klos B, Jäger M, Lang F, Kling-Lourenço P, Baumgärtner J, Hasan A, Dreimüller N, Hiemke C, Leucht S, Heres S, Leucht C, Assion HJ, Kis B, Zilles-Wegner D, Kahl K, Correll C, Verde PE, Kolbe H, Rottmann A. Amisulpride and olanzapine combination treatment versus each monotherapy in acutely ill patients with schizophrenia in Germany (COMBINE): a double-blind randomised controlled trial. Lancet Psychiatry 2022; 9:291-306. [PMID: 35276079 DOI: 10.1016/s2215-0366(22)00032-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/03/2022] [Accepted: 01/19/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Combining antipsychotics is common in schizophrenia treatment, despite evidence-based guidelines generally not recommending such practice. Otherwise, evidence remains inconclusive, especially regarding specific combinations. The trial aimed to test whether a combination of amisulpride plus olanzapine is more effective than either intervention as a monotherapy. METHODS A multicentre, 16-week, randomised, double-blind, controlled trial was done at 16 psychiatric in-patient centres throughout Germany. Inclusion criteria were adults aged 18-65 years with non-first episode schizophrenia or schizoaffective disorder and with a Positive and Negative Syndrome Scale (PANSS) total score of at least 70 and at least two items of the positive symptoms subscale rated at least 4. Patients were randomly assigned to receive 16 weeks of treatment with either amisulpride plus olanzapine, amisulpride plus placebo, or olanzapine plus placebo (1:1:1), and block randomisation was stratified by study site. To keep patients and investigators masked throughout the duration of the trial, amisulpride, olanzapine, and placebo were administered as identical capsules. Flexibly dosed monotherapy of oral amisulpride (amisulpride plus placebo, 200-800 mg per day) or olanzapine (olanzapine plus placebo, 5-20 mg per day) was compared with a combination of amisulpride plus olanzapine. The primary outcome was symptom reduction measured by the PANSS total score after 8 weeks, in the modified intention-to-treat population (all patients randomly assigned to an intervention and receiving at least one study drug dose). As determined a priori, group differences were examined by t tests (Bonferroni-Holm-adjustment) followed by pre-planned Bayesian analyses as well as imputation methods based on mixed models to account for missing values and post-hoc ANCOVA adjusting for PANSS baseline scores. The study was registered on ClinicalTrials.gov, NCT01609153; the German Clinical Trials Register, DRKS00003603; and the European Union Drug Regulating Authorities Clinical Trials Database, EudraCT-No. 2011-002463-20. FINDINGS Between June 15, 2012, and Dec 15, 2018, 13 692 patients were assessed for eligibility. 13 364 patients were excluded (including for not meeting inclusion criteria, declining to participate, or inappropriate reasons for changing pharmacological treatment), and 328 were then randomly assigned to an intervention group. 112 patients were randomly assigned to receive amisulpride plus olanzapine, 109 were randomly assigned to receive amisulpride plus placebo, and 107 were randomly assigned to receive olanzapine plus placebo. 321 patients were analysed for the primary outcome in the modified intention-to-treat population after exclusion of screening failures and patients who did not receive the intervention (110 for amisulpride plus olanzapine, 109 for amisulpride plus placebo, and 102 for olanzapine plus placebo). Among the 321 patients who were randomly assigned to intervention groups and analysed for the primary outcome, 229 (71%) were male, 92 (29%) were female; the mean age was 40·2 years (SD 11·7); and 296 (92%) were White and 25 (8%) were classified as other ethnicity. PANSS total score improved significantly more at 8 weeks in the amisulpride plus olanzapine group (-29·6 [SD 14·5]) than in the olanzapine plus placebo group (-24·1 [13·4], p=0·049, Cohen's d=0·396). A significant difference was not observed in reduction of PANSS total score between the amisulpride and olanzapine group compared with the amisulpride and placebo group (-25·2 [SD 15·9], p=0·095, Cohen's d=0·29). After 8 weeks and 16 weeks, sexual dysfunction, weight, and waist circumference increase were significantly higher for patients receiving amisulpride plus olanzapine than for those receiving amisulpride plus placebo, with no differences in serious adverse events. Two patients died during study participation; one randomly assigned to the amisulpride plus olanzapine group, and one assigned to the olanzapine plus placebo group (both assessed with no relation to treatment). INTERPRETATION The advantages of amisulpride plus olanzapine have to be weighed against a higher propensity for side-effects. The use of this specific combination therapy could be an alternative to monotherapy in certain clinical situations, but side-effects should be considered. FUNDING German Federal Ministry of Education and Research.
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Affiliation(s)
- Christian Schmidt-Kraepelin
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Düsseldorf, Germany.
| | - Sandra Feyerabend
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Düsseldorf, Germany
| | - Christina Engelke
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Mathias Riesbeck
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Eva Meisenzahl-Lechner
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Pablo-Emilio Verde
- Coordination Centre for Clinical Trials, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christoph U Correll
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Berlin, Germany
| | - Michael Kluge
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Christian Makiol
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Andrea Neff
- LVR-Klinikum Langenfeld, Langenfeld, Germany
| | | | - Susanne Englisch
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Mainz, Germany
| | - Mathias Zink
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; District Hospital Mittelfranken, Ansbach, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Timm B Poeppl
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
| | | | | | - Gerhard Gründer
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
| | - Anke Brockhaus-Dumke
- Department of Psychiatry and Psychotherapy 1 and 2, Rheinhessen-Fachklinik Alzey, Academic Hospital of the University of Mainz; Alzey, Germany
| | - Markus Jäger
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Jessica Baumgärtner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - Joachim Cordes
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Düsseldorf, Germany
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Taurines R, Fekete S, Preuss-Wiedenhoff A, Warnke A, Wewetzer C, Plener P, Burger R, Gerlach M, Romanos M, Egberts KM. Therapeutic drug monitoring in children and adolescents with schizophrenia and other psychotic disorders using risperidone. J Neural Transm (Vienna) 2022; 129:689-701. [PMID: 35303169 PMCID: PMC9188514 DOI: 10.1007/s00702-022-02485-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/24/2022] [Indexed: 01/31/2023]
Abstract
Risperidone is commonly used to treat different psychiatric disorders worldwide. Knowledge on dose–concentration relationships of risperidone treatment in children and adolescents with schizophrenia or other psychotic disorders is, however, scarce and no age-specific therapeutic ranges have been established yet. Multicenter data of a therapeutic drug monitoring service were analyzed to evaluate the relationship between risperidone dose and serum concentration of the active moiety (risperidone (RIS) plus its main metabolite 9-hydroxyrisperidone (9-OH-RIS)) in children and adolescents with psychotic disorders. Patient characteristics, doses, serum concentrations and therapeutic outcomes were assessed by standardized measures. The study also aimed to evaluate whether the therapeutic reference range for adults (20–60 ng/ml) is applicable for minors. In the 64 patients (aged 11–18 years) included, a positive correlation between daily dose and the active moiety (RISam) concentration was found (rs = 0.49, p = 0.001) with variation in dose explaining 24% (rs2 = 0.240) of the variability in serum concentrations. While the RISam concentration showed no difference, RIS as well 9-OH-RIS concentrations and the parent to metabolite ratio varied significantly in patients with co-medication of a CYP2D6 inhibitor. Patients with extrapyramidal symptoms (EPS) had on average higher RISam concentrations than patients without (p = 0.05). Considering EPS, the upper threshold of the therapeutic range of RISam was determined to be 33 ng/ml. A rough estimation method also indicated a possibly decreased lower limit of the preliminary therapeutic range in minors compared to adults. These preliminary data may contribute to the definition of a therapeutic window in children and adolescents with schizophrenic disorders treated with risperidone. TDM is recommended in this vulnerable population to prevent concentration-related adverse drug reactions.
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Affiliation(s)
- R Taurines
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, Margarete-Hoeppel-Platz 1, 97080, Wuerzburg, Germany
| | - S Fekete
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, Margarete-Hoeppel-Platz 1, 97080, Wuerzburg, Germany
| | - A Preuss-Wiedenhoff
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, Margarete-Hoeppel-Platz 1, 97080, Wuerzburg, Germany
| | - A Warnke
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, Margarete-Hoeppel-Platz 1, 97080, Wuerzburg, Germany
| | - C Wewetzer
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, Clinics of the City Cologne GmbH, Cologne, Germany
| | - P Plener
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Ulm, Ulm, Germany.,Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - R Burger
- Department of Psychiatry, Psychosomatics and Psychotherapy, Laboratory for Therapeutic Drug Monitoring, Centre for Mental Health, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - M Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, Margarete-Hoeppel-Platz 1, 97080, Wuerzburg, Germany
| | - M Romanos
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, Margarete-Hoeppel-Platz 1, 97080, Wuerzburg, Germany
| | - K M Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Wuerzburg, Margarete-Hoeppel-Platz 1, 97080, Wuerzburg, Germany.
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17
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Kikkert MJ, Veling W, de Haan L, Begemann MJH, de Koning M, Sommer IE. Medication strategies in first episode psychosis patients: A survey among psychiatrists. Early Interv Psychiatry 2022; 16:139-146. [PMID: 33754470 PMCID: PMC9292219 DOI: 10.1111/eip.13138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/09/2021] [Accepted: 03/06/2021] [Indexed: 11/28/2022]
Abstract
AIM There is an ongoing debate regarding the optimal timing of discontinuation of antipsychotic drugs for patients with first episode psychosis. Although most guidelines recommend maintenance therapy for at least 1 or 2 years after reaching remission, study results indicate that early discontinuation may be beneficial for at least a subsample of patients. To date, little is known about which medication strategies are applied in patients recovering from a first psychotic episode. In this study, we examined the beliefs and practices of clinicians on medication discontinuation. METHODS We performed a survey among 50 experienced Dutch psychiatrists to assess how often specific treatment strategies have been applied in the past 12 months, as well as their knowledge and expectations with respect to medication discontinuation. RESULTS Psychiatrists estimated that, after remission, they continued medication at the same dose for at least 12 months in 51.2% of cases, continued in a reduced dose in 33.8% of cases and discontinued medication in 9.1% of cases after 4.4 months of remission on average. Although the medication is discontinued in only a relatively small proportion of patients, almost half of all clinicians (45.9%) used this strategy at least once in the past 12 months. CONCLUSIONS There is substantial practice variation in antipsychotic medication strategies after remission from a first psychotic episode. Future research on long-term effects of early medication discontinuation can guide clinicians in making evidence-based decisions when treating first-episode patients.
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Affiliation(s)
- Martijn J Kikkert
- Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands
| | - Wim Veling
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lieuwe de Haan
- Department of Early Psychosis, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
| | - Marieke J H Begemann
- Department of Biomedical Sciences of Cells & Systems, Cognitive Neurosciences, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Mariken de Koning
- Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands
| | | | - Iris E Sommer
- Department of Biomedical Sciences of Cells & Systems, Cognitive Neurosciences, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
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18
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Japanese Society of Neuropsychopharmacology: "Guideline for Pharmacological Therapy of Schizophrenia". Neuropsychopharmacol Rep 2021; 41:266-324. [PMID: 34390232 PMCID: PMC8411321 DOI: 10.1002/npr2.12193] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022] Open
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19
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Pae CU, Han C, Bahk WM, Lee SJ, Patkar AA, Masand PS. Consideration of Long-Acting Injectable Antipsychotics for Polypharmacy Regimen in the Treatment of Schizophrenia: Put It on the Table or Not? CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2021; 19:434-448. [PMID: 34294613 PMCID: PMC8316655 DOI: 10.9758/cpn.2021.19.3.434] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Antipsychotic monotherapy (APM) is considered best-acceptable treatment option regardless of antipsychotic class and formulation types for treating schizophrenia. However, antipsychotic polypharmacy (APP) has been also widely utilized in routine clinical practice. Despite APP has some clinical benefits it has also numerous pitfalls in relation with increased total number and doses of APs leading to adverse events as well as decrease of treatment adherence and persistence resulting in poor clinical outcomes. Recent introduction of long-acting injectable antipsychotics (LAIs) to the market has offered a chance for better medication adherence/persistence and also provided a simplification of treatment regime leading to more stabilized treatment for schizophrenia patients. When we cannot stay away from APP in the treatment of schizophrenia, clinicians need to find more proper APP regimens and thereby utilization of APP in efficient way should be a practical strategy to benefit schizophrenia patient in a real world treatment setting. With this regard, LAIs can be one of available APP regimen for treatment of schizophrenia in routine practice since their clinical utility and pharmacokinetic stability over oral APs have been well-elaborated today. However, when we have to commence LAIs as a part of APP with oral APs or other LAIs, every effort should be made before doing so whether or not validated and available treatment options or other clinical factors were not done or evaluated yet. Any treatment guidelines do not support APP regardless of the formulation of APP regimen or address two or more LAIs for treatment of schizophrenia till today.
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Affiliation(s)
- Chi-Un Pae
- Department of Psychiatry
- Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Korea
| | - Changsu Han
- Department of Psychiatry, Korea University College of Medicine, Seoul, Korea
| | | | | | - Ashwin A. Patkar
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
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20
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Kaikoushi K, Karanikola M, Middleton N, Bella E, Chatzittofis A. Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics. BJPsych Open 2021; 7:e149. [PMID: 34747353 PMCID: PMC8388008 DOI: 10.1192/bjo.2021.982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/01/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. AIMS We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. METHOD This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. RESULTS Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. CONCLUSIONS A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.
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Affiliation(s)
- Katerina Kaikoushi
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus; and Cyprus mental Health Services, Famagusta, Cyprus
| | - Maria Karanikola
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus
| | - Nicos Middleton
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus
| | | | - Andreas Chatzittofis
- Medical School, University of Cyprus, Cyprus; and Department of Clinical Sciences, Umeå University, Umeå, Sweden
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21
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Soares DDS, Carvalho DR, Ribeiro MDT, Diniz EJB, Rêgo AF. Prevalence and predictors of treatment-resistant schizophrenia in a tertiary hospital in Northeast Brazil. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2021; 43. [PMID: 34139114 PMCID: PMC8835382 DOI: 10.47626/2237-6089-2020-0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/31/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate epidemiological factors related to treatment-resistant schizophrenia (TRS) in Northeast Brazil, a region where data about mental health are still scarce. METHODS This retrospective cross-sectional study included all patients with schizophrenia currently receiving treatment at the outpatient psychiatric clinic of a tertiary hospital in Northeast Brazil. They were divided into TRS and treatment-responsive groups, and epidemiological characteristics of both groups were compared. A logistic regression model investigated factors related to treatment resistance. RESULTS Two hundred and five patients were included, 155 treatment-resistant and 50 treatment-responsive. The TRS group had higher use of benzodiazepines (36.1 vs. 18%, p = 0.017) and antiepileptics (36.8 vs. 8.0%, p < 0.001), antipsychotic polypharmacy (28.6 vs. 8%, p = 0.003) and suicide attempts (35.6 vs. 20%, p = 0.04). Age at onset was younger (19.7±7.3 vs. 24.6±8.6 years, p = 0.001) and CGI was higher in TRS (3.72±1.00 vs. 3.16±1.00, p = 0.001). In logistic regression, being married was a protector (odds ratio [OR] = 0.248, 95% confidence interval [95%CI] 0.091-0.679, p = 0.007) and younger age at onset was a predictor (OR = 1.076, 95%CI 1.034-1.120, p < 0.001) of treatment resistance. CONCLUSION Early onset of disease was associated with more treatment resistance, while being married with less resistance. Clinicians should identify early predictors of resistance in order to reduce unfavorable outcomes.
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Affiliation(s)
- Douglas de Sousa Soares
- Programa de Residência Médica em PsiquiatriaHospital de Saúde Mental Professor Frota PintoFortalezaCEBrazilPrograma de Residência Médica em Psiquiatria, Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, CE, Brazil.
| | - Danyelle Rolim Carvalho
- Programa de Residência Médica em PsiquiatriaHospital de Saúde Mental Professor Frota PintoFortalezaCEBrazilPrograma de Residência Médica em Psiquiatria, Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, CE, Brazil.
| | - Mellanie Dellylah Trinta Ribeiro
- Programa de Residência Médica em PsiquiatriaHospital de Saúde Mental Professor Frota PintoFortalezaCEBrazilPrograma de Residência Médica em Psiquiatria, Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, CE, Brazil.
| | - Elton Jorge Bessa Diniz
- Programa de EsquizofreniaDepartamento de PsiquiatriaUniversidade Federal de São PauloSão PauloSPBrazilPrograma de Esquizofrenia (PROESQ), Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.
- Laboratório Interdisciplinar de Neurociências ClínicasDepartamento de PsiquiatriaUNIFESPSão PauloSPBrazilLaboratório Interdisciplinar de Neurociências Clínicas (LiNC), Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil.
| | - Alcides Ferreira Rêgo
- Programa de Residência Médica em PsiquiatriaHospital de Saúde Mental Professor Frota PintoFortalezaCEBrazilPrograma de Residência Médica em Psiquiatria, Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, CE, Brazil.
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22
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Soares DDS, Carvalho DR, Ribeiro MDT, Diniz EJB, Rêgo AF. Prevalence and predictors of treatment-resistant schizophrenia in a tertiary hospital in Northeast Brazil. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2021. [PMID: 34139114 DOI: 10.47626/2237-6089--2020-0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate epidemiological factors related to treatment-resistant schizophrenia (TRS) in Northeast Brazil, a region where data about mental health are still scarce. METHODS This retrospective cross-sectional study included all patients with schizophrenia currently receiving treatment at the outpatient psychiatric clinic of a tertiary hospital in Northeast Brazil. They were divided into TRS and treatment-responsive groups, and epidemiological characteristics of both groups were compared. A logistic regression model investigated factors related to treatment resistance. RESULTS Two hundred and five patients were included, 155 treatment-resistant and 50 treatment-responsive. The TRS group had higher use of benzodiazepines (36.1 vs. 18%, p = 0.017) and antiepileptics (36.8 vs. 8.0%, p < 0.001), antipsychotic polypharmacy (28.6 vs. 8%, p = 0.003) and suicide attempts (35.6 vs. 20%, p = 0.04). Age at onset was younger (19.7±7.3 vs. 24.6±8.6 years, p = 0.001) and CGI was higher in TRS (3.72±1.00 vs. 3.16±1.00, p = 0.001). In logistic regression, being married was a protector (odds ratio [OR] = 0.248, 95% confidence interval [95%CI] 0.091-0.679, p = 0.007) and younger age at onset was a predictor (OR = 1.076, 95%CI 1.034-1.120, p < 0.001) of treatment resistance. CONCLUSION Early onset of disease was associated with more treatment resistance, while being married with less resistance. Clinicians should identify early predictors of resistance in order to reduce unfavorable outcomes.
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Affiliation(s)
- Douglas de Sousa Soares
- Programa de Residência Médica em Psiquiatria, Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, CE, Brazil
| | - Danyelle Rolim Carvalho
- Programa de Residência Médica em Psiquiatria, Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, CE, Brazil
| | | | - Elton Jorge Bessa Diniz
- Programa de Esquizofrenia (PROESQ), Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Laboratório Interdisciplinar de Neurociências Clínicas (LiNC), Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Alcides Ferreira Rêgo
- Programa de Residência Médica em Psiquiatria, Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, CE, Brazil
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23
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Kim DD, Barr AM, Lian L, Yuen JWY, Fredrikson D, Honer WG, Thornton AE, Procyshyn RM. Efficacy and tolerability of aripiprazole versus D 2 antagonists in the early course of schizophrenia: a systematic review and meta-analysis. NPJ SCHIZOPHRENIA 2021; 7:29. [PMID: 34035313 PMCID: PMC8149726 DOI: 10.1038/s41537-021-00158-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/21/2021] [Indexed: 12/24/2022]
Abstract
Early intervention is essential for favorable long-term outcomes in schizophrenia. However, there is limited guidance in the scientific literature on how best to choose between dopamine D2 receptor (D2R) partial agonists and D2R antagonists in early stages of schizophrenia. The aim of this meta-analysis was to directly compare D2R partial agonists with D2R antagonists for efficacy and tolerability, using randomized controlled trials (RCTs) that involved participants diagnosed with first-episode psychosis, schizophrenia, or related psychotic disorders with a duration of illness ≤5 years. Fourteen RCTs, involving 2494 patients, were included in the meta-analysis. Aripiprazole was the only identified D2R partial agonist, and was not significantly different from pooled D2R antagonists for overall symptom reduction or all-cause discontinuation. However, aripiprazole was more favorable than pooled D2R antagonists for depressive symptoms, prolactin levels, and triglyceride levels. Specifically, aripiprazole was more favorable than paliperidone for triglyceride levels and more favorable than risperidone and olanzapine, but less favorable than ziprasidone, for weight gain. In addition, aripiprazole was less favorable for akathisia compared with second-generation D2R antagonists, in particular olanzapine and quetiapine, and less favorable for discontinuation due to inefficacy than risperidone. Lastly, aripiprazole was more favorable than haloperidol for various efficacy and tolerability outcomes. In conclusion, aripiprazole’s efficacy did not differ substantially from D2R antagonists in the early course of schizophrenia, whereas differential tolerability profiles were noted. More double-blind RCTs are required comparing the efficacy and tolerability of aripiprazole as well as other D2R partial agonists with D2R antagonists in early stages of schizophrenia.
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Affiliation(s)
- David D Kim
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada.,British Columbia Mental Health & Substance Use Services Research Institute, Vancouver, Canada
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada.,British Columbia Mental Health & Substance Use Services Research Institute, Vancouver, Canada
| | - Lulu Lian
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Jessica W Y Yuen
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Diane Fredrikson
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - William G Honer
- British Columbia Mental Health & Substance Use Services Research Institute, Vancouver, Canada.,Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Allen E Thornton
- British Columbia Mental Health & Substance Use Services Research Institute, Vancouver, Canada.,Department of Psychology, Simon Fraser University, Burnaby, Canada
| | - Ric M Procyshyn
- British Columbia Mental Health & Substance Use Services Research Institute, Vancouver, Canada. .,Department of Psychiatry, University of British Columbia, Vancouver, Canada.
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24
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Martinho S, Poças A, Simões M, Laureano C. Antipsychotic Polypharmacy and High-Dose Antipsychotics in Involuntary Patients: a Seven-Year Audit of Discharge Prescriptions in an Acute Care Unit. Psychiatr Q 2021; 92:1-14. [PMID: 32430698 DOI: 10.1007/s11126-020-09762-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Antipsychotic polypharmacy (APP) is a psychopharmacological practice in which two or more antipsychotics are prescribed simultaneously. Despite the absence of evidence to support it, it is highly prevalent in clinical settings. Another recurrent practice strongly associated with APP is the prescription of high-dose antipsychotics (HDAs). Compulsory treatment is a legal means to impose treatment on an individual suffering from mental illness who refuses therapeutic intervention. Compulsory treatment has been associated with APP and HDAs and rates of both have been proposed to represent indicators of the quality of prescribing. We aimed to perform an antipsychotic prescription audit in a vulnerable psychiatric population, at the psychiatry department of a district hospital in Portugal, across 7 years. We evaluated APP and HDAs in 403 compulsorily admitted patients by reviewing their files at discharge. We used logistic regression to search for factors associated with APP and HDAs. APP was found in 70.5% of individuals, whereas HDAs were found in 51.4%. After adjustment, APP was significantly associated with male gender (Odds Ratio[OR] = 1.85 [1.04; 3.30] 95% Confidence Interval [CI]), involuntary outpatient treatment (OR = .40 [.18; .82] 95% CI), activation of the hospital social services (OR = 1.91 [1.08; 3.38] 95%CI), prescription of antidepressants (OR = .43 [.22; .82] 95%CI) and long-acting injectables (LAI) (OR = 28.29 [13.13; 60.97] 95%CI). HDAs were associated with male gender (OR = 1.76 [1.06; 2.94] 95%CI), the prescription of LAI (OR = 12.92 [6.93; 24.09] 95%CI) and oral first-generation antipsychotics (OR = 2.90 [1.51; 5.60] 95%CI).
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Affiliation(s)
- Sérgio Martinho
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal.
| | - Ana Poças
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal
| | - Mário Simões
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal
| | - Cláudio Laureano
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal
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25
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Schmidt-Kraepelin C, Meisenzahl-Lechner E, Kujovic M, Cordes J, Engelke C, Riesbeck M, Zielasek J, Engemann S, Vrinssen J, Lehmann I, Tönnesen-Schlack A, Banger M, Grümmer M, Scherbaum N, Muysers J, Rinckens S, Marggraf R, Gouzoulis-Mayfrank E. [Antipsychotic Polypharmacy in the Treatment of Patients with Schizophrenia in Nine Psychiatric Hospitals of the Landschaftsverband Rheinland, Germany]. PSYCHIATRISCHE PRAXIS 2021; 48:250-257. [PMID: 33472267 DOI: 10.1055/a-1321-7866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Antipsychotics are the cornerstone in the treatment of schizophrenia and are primarily recommended as monotherapy by evidence-based guidelines. Nevertheless, antipsychotic polypharmacy (APP) is prevalent in routine practice and APP is also used as a quality indicator since 2016 in quality management programs. OBJECTIVE Based on routine data of nine psychiatric hospitals of the Landschaftsverband Rheinland (LVR)/Germany the prevalence of APP was determined and correlated with factors of routine healthcare in order to monitor the adoption of APP and to discuss its feasibility as a quality indicator. MATERIALS AND METHODS All cases with schizophrenia (ICD-10 F20.x; ≥ 18 years) discharged between June 1st, 2016, and June 1st, 2017, (in-patient and day clinic) were extracted from an established research database shared by all nine hospitals and analyzed regarding APP prevalence at the time of discharge. RESULTS Based on 6,788 cases, the prevalence of APP was 55.5 % with an average of 2.4 antipsychotics (SD = 0.6) administered simultaneously. In multivariate analyses, significant predictors for APP were: gender (male > female), the number of days in hospital (long > short), involuntary treatment (no > yes) and the location of the hospital. CONCLUSIONS We found a high proportion of polypharmacy in inpatient schizophrenia patients and significant differences between hospitals. The use of the results as a quality indicator (criteria ≥ 2 antipsychotics) remains dependent on the background of the individual treatment courses, which cannot be adequately represented by the existing routine data. The LVR has been using the quality indicator of ≥ 3 antipsychotics since 2018, which is discussed as a more appropriate approach for future evaluations.
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Affiliation(s)
| | - Eva Meisenzahl-Lechner
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf.,LVR-Institut für Versorgungsforschung, Köln
| | - Milenko Kujovic
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf
| | - Joachim Cordes
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf.,Kaiserswerther Diakonie, Florence-Nightingale-Krankenhaus, Düsseldorf
| | - Christina Engelke
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf
| | - Mathias Riesbeck
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf
| | | | | | | | | | | | | | | | - Norbert Scherbaum
- LVR-Klinikum Essen, Kliniken und Institut der Universität Duisburg-Essen
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26
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Hýža M, Šilhán P, Češková E, Skřont T, Kacířová I, Uřinovská R, Grundmann M. Plasma Levels of Long-Acting Injectable Antipsychotics in Outpatient Care: A Retrospective Analysis. Neuropsychiatr Dis Treat 2021; 17:1069-1075. [PMID: 33888983 PMCID: PMC8055351 DOI: 10.2147/ndt.s298050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/25/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Antipsychotic efficacy in schizophrenia depends on its availability in the body. Although therapeutic outcomes remain still far from satisfactory, therapeutic drug monitoring is not a common part of clinical practice during treatment with long-acting injectable antipsychotics (LAI AP). The real effectiveness of LAI AP is thus uncertain. PATIENTS AND METHODS We made a retrospective evaluation of plasma levels of LAI AP. Collection of blood samples was performed just before the drug application and one week later. Forty patients with a stabilized clinical condition and steady-state plasma levels were included. RESULTS In the observed cohort of patients, flupentixol decanoate (n = 23) was the most often used drug, followed by fluphenazine decanoate (n = 7), haloperidol decanoate (n = 5), paliperidone palmitate (n = 3), and risperidone microspheres (n = 2). Just 5 of 40 patients were treated with a monotherapy. In the period before the application, 60% of the patients did not reach the therapeutic reference range (TRR) and 20% of the patients had an undetectable plasma level. At the time of collection of the second blood samples performed after 7 days, 24% of the patients were under the TRR. CONCLUSION We have found a surprisingly high incidence of plasma levels under the TRR in patients treated with LAI AP. Notwithstanding individual variability in pharmacokinetics, it seems that LAI AP may be underdosed in usual clinical practice.
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Affiliation(s)
- Martin Hýža
- Department of Psychiatry, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Petr Šilhán
- Department of Psychiatry, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Eva Češková
- Department of Psychiatry, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Tomáš Skřont
- Department of Psychiatry, University Hospital Ostrava, Ostrava, Czech Republic
| | - Ivana Kacířová
- Department of Clinical Pharmacology, Institute of Laboratory Diagnostics, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Romana Uřinovská
- Department of Clinical Pharmacology, Institute of Laboratory Diagnostics, University Hospital Ostrava, Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
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27
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Georgiou R, Lamnisos D, Giannakou K. Anticholinergic Burden and Cognitive Performance in Patients With Schizophrenia: A Systematic Literature Review. Front Psychiatry 2021; 12:779607. [PMID: 35027893 PMCID: PMC8748260 DOI: 10.3389/fpsyt.2021.779607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 10/21/2021] [Indexed: 01/06/2023] Open
Abstract
Objective: Cognitive impairment in schizophrenia forms the key cause of the disease's disability, leading to serious functional, and socioeconomic implications. Dopaminergic-cholinergic balance is considered essential to cognitive performance in schizophrenia and patients are often treated with many drugs with anticholinergic properties. This study aims to examine the cognitive impact of anticholinergic burden in patients with schizophrenia. Methods: A systematic literature review was performed on English-language studies published on PubMed, Embase, and Web of Science, from inception to June 2021, to identify research studies that examined the effect of anticholinergic load on cognition in clinically stable patients with schizophrenia. No restrictions on study design, age of participants, or geographical distribution were applied. Two researchers performed independently the screening and shortlisting of the eligible articles. A narrative synthesis of the main characteristics and findings of studies included was reported. Results: In total, 17 articles of varying methodological design met the inclusion criteria. Three of them found statistically significant improvement in cognition after anticholinergic tapering without adverse effects. Thirteen studies found a statistically significant association between high anticholinergic burden and cognitive impairment (neurocognitive composite scores and individual cognitive domains such as learning and memory, executive function, processing speed), apart from a study, related to the specific characteristics of clozapine. Conclusions: Medication with increased anticholinergic load has been found in most of the studies to negatively affect neurocognitive performance of patients with schizophrenia. However, the clinical and methodological heterogeneity of studies included limit our interpretation and conclusions.
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Affiliation(s)
- Rafaella Georgiou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - Demetris Lamnisos
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - Konstantinos Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
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Hjorth S. The More, the Merrier…? Antipsychotic Polypharmacy Treatment Strategies in Schizophrenia From a Pharmacology Perspective. Front Psychiatry 2021; 12:760181. [PMID: 34899422 PMCID: PMC8652414 DOI: 10.3389/fpsyt.2021.760181] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/22/2021] [Indexed: 12/11/2022] Open
Abstract
Antipsychotic polypharmacy/drug combination treatment (APP) is a remarkably common practice in the schizophrenia context, given the lack of general support in treatment Guidelines. There is also a vast literature on APP outcomes, but a paucity of high-quality evidence-based data to guide and optimize adequate use of APP. This seems particularly true regarding many pharmacology-based considerations involved in APP treatment strategies. This paper first briefly summarizes clinical literature related to the use of APP. Against this backdrop, the pharmacological target profile features are then described of frequently used antipsychotic agents, in relation to estimated free plasma exposure levels at clinically efficacious dosing. APP strategies based on the properties of these drugs are then scrutinized and gauged within the background literature framework. The anticipated usefulness of APP from the pharmacological standpoint is detailed regarding efficacy, adverse effect (AE)/tolerability, and safety perspective, including why, when, and how it may be used to its advantage. For the purpose, a number of theoretically beneficial combinations as well as instances with suboptimal-and even futile-APP approaches are exemplified and discussed from the rational pharmacodynamic and pharmacokinetic pros and cons point-of-view. In this exposé, particular attention is paid to the utility and features of 3rd Generation Antipsychotic dopamine (DA) D2-D3 agonists within an APP setting.
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Affiliation(s)
- Stephan Hjorth
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Pharmacilitator AB (Inc.), Vallda, Sweden
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Faden J, Kiryankova-Dalseth N, Barghini R, Citrome L. Does antipsychotic combination therapy reduce the risk of hospitalization in schizophrenia? Expert Opin Pharmacother 2020; 22:635-646. [PMID: 33251870 DOI: 10.1080/14656566.2020.1847274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION : Despite treatment with antipsychotic medication, approximately 1/3 of individuals with schizophrenia will fail to have an adequate response. To treat these patients, a commonly utilized approach is antipsychotic combination therapy. Antipsychotic combination therapy is controversial with mixed efficacy and tolerability results. It is also unclear if antipsychotic combination therapy reduces or increases the risk of psychiatric hospitalization. AREAS COVERED : The authors review the prevalence, efficacy and tolerability concerns, and rationale behind antipsychotic combination therapy. Evidence comparing antipsychotic monotherapy vs polypharmacy using hospitalization as an outcome measure is summarized. EXPERT OPINION : Psychiatric rehospitalization is a useful measure of treatment effectiveness, incorporating aspects of treatment efficacy and tolerability. The evidence comparing the impact of antipsychotic monotherapy vs combination therapy on rehospitalization is mixed. Evidence is primarily retrospective in nature, and there is high heterogeneity between studies, which could partially explain the mixed results. There is likely a subset of patients for whom antipsychotic combination therapy reduces the risk of hospitalization greater than antipsychotic monotherapy. Patients should be treated individually taking into account their specific pattern of response.
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Affiliation(s)
- Justin Faden
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Ruby Barghini
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Leslie Citrome
- Department of Psychiatry & Behavioral Sciences, New York Medical College, Valhalla, NY, USA
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Azorin JM, Simon N. Antipsychotic polypharmacy in schizophrenia: evolving evidence and rationale. Expert Opin Drug Metab Toxicol 2020; 16:1175-1186. [DOI: 10.1080/17425255.2020.1821646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Nicolas Simon
- Department of Clinical Pharmacology, Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
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Pae CU. Antipsychotic Polypharmacy in Treatment of Schizophrenia; Should or Should Not? Chonnam Med J 2020; 56:157-165. [PMID: 33014754 PMCID: PMC7520369 DOI: 10.4068/cmj.2020.56.3.157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 12/30/2022] Open
Abstract
Antipsychotics have been utilized as the standard treatment for schizophrenia regardless of illness phase where antipsychotic monotherapy (APM) is routinely recommended as the gold standard rather than antipsychotic polypharmacy (APP). However, approximately 20 to 40% of patients with schizophrenia do not respond to APM based on randomized controlled clinical trials and large practical clinical trials indicating that the subgroup of patients with schizophrenia would need differential treatment approaches beyond traditional treatment strategies such as APM. Numerous studies have supported the use of APP in particular for patients with certain clinical situations including: failure to show efficacy or tolerability from treatment with APM, need for different treatment for targeting specific symptom domains, severe illness, failure to treatment with clozapine, skepticism about following treatment guidelines, or cross titration periods. Furthermore, recent large cohort studies and practical clinical trials have proposed more benefits of APP rather than APM in terms of rehospitalization, mortality, and specific symptoms. APP has recently become more widely utilized and recognized as one of the next treatment strategies to clinicians for patients with schizophrenia. Some experts have already proposed the revision of treatment guidelines incorporating APP as evidence-based treatment option for certain patients with schizophrenia. Taken together, APP now deserves an evidence-based and acceptable treatment strategy, not an empirical or preferential treatment approach for treatment of schizophrenia in contemporary clinical practice.
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Affiliation(s)
- Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Brett J, Pearson SA, Daniels B, Wylie CE, Buckley NA. A cross sectional study of psychotropic medicine use in Australia in 2018: A focus on polypharmacy. Br J Clin Pharmacol 2020; 87:1369-1377. [PMID: 32881057 DOI: 10.1111/bcp.14527] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/23/2020] [Accepted: 07/28/2020] [Indexed: 12/29/2022] Open
Abstract
AIMS To examine prescribed psychotropic medicine use on a given day in Australia (25 September 2018; World Pharmacists Day), with a focus on psychotropic polypharmacy. METHODS We used a 10% sample of individual-level nationwide dispensing claims to examine psychotropic medicine use on a given day. We estimated the prevalence of psychotropic medicine use in all ages stratified by age and sex. We also calculated the observed vs expected (had medicines been randomly combined) prevalence of psychotropic combinations used. We focused on combinations of clinical significance as well combinations of psychotropics with medicines prescribed to manage cardiovascular risk and disease. RESULTS Serotonin reuptake inhibitors, serotonin-noradrenalin reuptake inhibitors/noradrenaline reuptake inhibitors, tricyclic antidepressants and gabapentinoids dominated psychotropic use. The use of any psychotropic as a proportion of people in the Australian population increased with age, peaking at the 85-89 year age group and declining thereafter. Combinations of medicines from the same subclass generally occurred at lower than expected frequencies. However, combinations including atypical antipsychotics occurred more frequently than expected; e.g. 7.4× with anticonvulsants and 2.2× with other atypical antipsychotics. This was also the case for combinations of sedatives, e.g. anxiolytic with hypnotic benzodiazepines (3.8×). Lipid-lowering drugs and antidiabetic medicines were combined with psychotropics at frequencies close to those expected had they been randomly combined. CONCLUSION Psychotropic use in older adults and certain psychotropic combinations that are not well supported with evidence remain prevalent and greater consideration of the drivers of this potentially inappropriate prescribing is required.
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Affiliation(s)
- Jonathan Brett
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia.,Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, The University of Sydney, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin Daniels
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Claire E Wylie
- Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, The University of Sydney, Sydney, NSW, Australia
| | - Nicholas A Buckley
- Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, The University of Sydney, Sydney, NSW, Australia
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Tural Hesapcioglu S, Ceylan MF, Kandemir G, Kasak M, Sen CP, Correll CU. Frequency and Correlates of Acute Dystonic Reactions After Antipsychotic Initiation in 441 Children and Adolescents. J Child Adolesc Psychopharmacol 2020; 30:366-375. [PMID: 32255662 DOI: 10.1089/cap.2019.0123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: To determine the incidence of acute dystonic reactions (ADRs) and risk factors for ADRs in children and adolescents treated with antipsychotics. Methods: This was a retrospective chart review-based cohort study of consecutive patients who attended a university hospital's child and adolescent psychiatry department between 2015 and 2017 and who were treated with antipsychotics and had at least two follow-up visits. Results: Thirty of 441 patients (6.8%) 4-19 years of age who were treated with antipsychotics for conduct disorders (21.5%), attention-deficit/hyperactivity disorder (13.2%) and, irritability and aggression that accompanied intellectual disability (12.9%) and followed for 99.5 ± 223.3 (median: 34) days developed ADRs. ADRs developed in 11/391 patients (2.8%) treated with one antipsychotic and 19/50 patients (38.0%) treated with two antipsychotics (p < 0.001). In patients treated with one antipsychotic that developed ADRs, the time to ADRs was 4.0 ± 4.0 days after antipsychotic initiation and 2.7 ± 2.4 days after an increase in the antipsychotic dose. The time to ADRs in those treated with two antipsychotics was 3.0 ± 2.3 days after the addition of the second antipsychotic and 1.6 ± 0.8 days after a dose increase in the second antipsychotic. The incidence of ADRs during antipsychotic monotherapy was 10.5% with first-generation antipsychotics (FGAs) and 2.2% with second-generation antipsychotics (SGAs; p = 0.037). The antipsychotic was changed due to ADRs in 12/30 (40.0%) of ADR cases. Independent factors associated with ADRs were antipsychotic polypharmacy (p < 0.0001), inpatient treatment (p = 0.013), FGA use (p = 0.015), and diagnoses of schizophrenia (p = 0.039) or bipolar disorder (p < 0.0001). Conclusion: SGAs and low-potency FGA monotherapy in children and adolescents were associated with a relatively low ADR risk, whereas high- and mid-potency FGAs were associated with a high risk. Independent predictors of ADRs were antipsychotic polypharmacy, inpatient treatment, FGAs, and schizophrenia or bipolar disorder diagnoses, which may be related to more aggressive antipsychotic dosing.
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Affiliation(s)
- Selma Tural Hesapcioglu
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Mehmet Fatih Ceylan
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Gözde Kandemir
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Meryem Kasak
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Cansu Pınar Sen
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Christoph U Correll
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York, USA.,Department of Child and Adolescent Psychiatry, Charité Universitäts medizin Berlin, Berlin, Germany
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Frequency, reasons, and factors associated with antipsychotic polypharmacy in Schizophrenia: A retrospective chart review in a tertiary hospital in India. Asian J Psychiatr 2020; 51:102022. [PMID: 32278888 DOI: 10.1016/j.ajp.2020.102022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/05/2020] [Accepted: 03/19/2020] [Indexed: 11/21/2022]
Abstract
The practice of antipsychotic polypharmacy in schizophrenia appears to be common although evidence-based guidelines do not routinely recommend it. The reasons for polypharmacy are however unclear. The objective of the study was to assess the frequency of polypharmacy, reasons for initiation and the factors associated with it. A retrospective chart review of case records of all the patients diagnosed with schizophrenia at the department of psychiatry from January 2011 to December 2018 was done. Frequency of antipsychotic polypharmacy, reasons influencing it and factors associated with polypharmacy were extracted using a proforma. Of 529 patients diagnosed with schizophrenia, 232 patients (43.9 %) were receiving antipsychotic polypharmacy. Common reasons for polypharmacy included the usage of depot along with oral antipsychotic for a prolonged period (37.7 %), augmentation of response with the second antipsychotic (17.7 %) and treatment of a different symptom domain like negative symptoms (9.5 %). In comparison to monopharmacy, antipsychotic polypharmacy was more commonly associated with side effects and extrapyramidal symptoms. Patients on polypharmacy had a higher number of hospitalizations too. As the trend of antipsychotic polypharmacy is on the rise, it is important to assess for reasons influencing polypharmacy to avoid undesirable side effects. The side effect burden of polypharmacy is significantly more than those receiving single antipsychotics. Oral antipsychotics should ideally be discontinued after the depot antipsychotic reaches steady-state levels. Irrational usage of second antipsychotic to augment the response of first antipsychotic agent needs to be avoided.
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Abstract
Background: Concurrent prescription of more than one type of antipsychotic for the same patient - antipsychotic polypharmacy (APP) - is associated with increased incidence of side effects, uncertain therapeutic benefit and general guidelines advise against it. Nevertheless, APP is common and there is little evidence about possible interventions to improve practice.Aims: To investigate the prevalence and documentation quality of APP in specialized psychiatric care and assess the feasibility and effect of a simple intervention to improve clinical practice.Methods: We examined the prevalence and the quality of documentation of APP in medical records from a large inpatient treatment department before and 6 months after an intervention, which consisted of giving feedback to doctors on their prescription practices as well as teaching about current guidelines. Prescription and documentation before and after intervention were compared between intervention and control wards.Results: One hundred and twenty-one medical records were examined at baseline. 43% of these had APP, of these 27% was satisfactory documented. After the intervention, the proportion with APP was reduced from 42% to 29% in the intervention group. There was a statistically significant interaction effect of the intervention group and the after-intervention condition on this reduction. The percentage with satisfactory documentation of APP was increased after the intervention in both groups, but we found no corresponding interaction effect.Conclusion: APP is prevalent in inpatient treatment of patients with mainly psychotic disorders but documentation of this is insufficient. Simple education and feedback on prescription and records documentation practices may increase adherence to guidelines.
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Affiliation(s)
- Hanne Høilund
- Department for Inpatient Treatment, Adult Mental Health, Clinic for Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - David P Galea
- Department for Inpatient Treatment, Adult Mental Health, Clinic for Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Petter Andreas Ringen
- Department for Inpatient Treatment, Adult Mental Health, Clinic for Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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36
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Vyas A, Alghaith G, Hufstader-Gabriel M. Psychotropic polypharmacy and its association with health-related quality of life among cancer survivors in the USA: a population-level analysis. Qual Life Res 2020; 29:2029-2037. [PMID: 32207028 DOI: 10.1007/s11136-020-02478-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Cancer survivors that use multiple psychotropic medications are at an increased risk of psychotropic polypharmacy. We examined the association between psychotropic polypharmacy and health-related quality of life (HRQoL) among cancer survivors living in the USA. METHODS We used the Medical Expenditure Panel Survey (MEPS) data for 2010, 2012, and 2014 to identify adult cancer survivors. Psychotropic polypharmacy was defined as use of at least two classes of psychotropic prescription medications. The physical component summary (PCS) and the mental component summary (MCS) were obtained from the 12-item Short Form Health Survey version 2 to measure HRQoL. Adjusted ordinary least square regressions were performed to evaluate the association between psychotropic polypharmacy and HRQoL. RESULTS Among 31 million US cancer survivors (weighted from a sample of 2609), 16.3% reported psychotropic polypharmacy. Lung cancer survivors had the highest prevalence of psychotropic polypharmacy (22.5%), followed by survivors of breast cancer (17.8%), colorectal, and other gastrointestinal cancers (16.0%). The unadjusted PCS and MCS scores for those with psychotropic polypharmacy were significantly lower than those without psychotropic polypharmacy, overall, and for each cancer type. In multivariable regressions, cancer survivors with psychotropic polypharmacy had significantly lower PCS scores (β = - 3.63, p < 0.0001) and MCS scores (β = - 2.28, p = 0.0138) compared to those without psychotropic polypharmacy. CONCLUSION Cancer survivors requiring multiple psychotropic medications have poorer quality of life.
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Affiliation(s)
- Ami Vyas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA.
| | - Ghadah Alghaith
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA.,Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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Farrell C, Brink J. The Prevalence and Factors Associated With Antipsychotic Polypharmacy in a Forensic Psychiatric Sample. Front Psychiatry 2020; 11:263. [PMID: 32528318 PMCID: PMC7247840 DOI: 10.3389/fpsyt.2020.00263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/18/2020] [Indexed: 12/21/2022] Open
Abstract
Despite clinical guidelines limiting the use of multiple concomitant antipsychotics to the most exceptional and treatment resistant cases, the prevalence of antipsychotic polypharmacy has been increasing worldwide. There has been minimal research investigating the prevalence of antipsychotic polypharmacy in forensic psychiatric samples and the correlates associated with antipsychotic polypharmacy. This cross-sectional study aimed to establish the prevalence of antipsychotic polypharmacy in a forensic psychiatric inpatient sample and to investigate the demographical, clinical, and forensic factors associated with polypharmacy. All patients (N = 142) were prescribed at least one antipsychotic at the time of the study. Antipsychotic polypharmacy was prescribed to 54.93% of patients. Logistic regression results indicated increased length of hospitalization, high/medium security level, treatment with clozapine, and depot antipsychotic prescription were predictive of being placed on an antipsychotic polypharmacy regimen. The results suggest that those who are prescribed multiple antipsychotics are long stay patients who present with higher clinical complexity. The results from this study can be used to inform clinical practice leaders about the prevalence of antipsychotic polypharmacy in a forensic psychiatric institution. More research is needed to understand the clinical justifications for prescribing multiple antipsychotics in a forensic psychiatric sample and ways to safely reduce the prevalence of antipsychotic polypharmacy.
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Affiliation(s)
- Christian Farrell
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Johann Brink
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Correll CU, Brevig T, Brain C. Patient characteristics, burden and pharmacotherapy of treatment-resistant schizophrenia: results from a survey of 204 US psychiatrists. BMC Psychiatry 2019; 19:362. [PMID: 31727015 PMCID: PMC6857350 DOI: 10.1186/s12888-019-2318-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 10/11/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Minimal/non-response to antipsychotic treatment, and persistent positive symptoms despite treatment, are common among patients with schizophrenia. The aim of this study was to characterize a US treatment-resistant schizophrenia (TRS) population in terms of patient demographics, burden of symptoms, treatment history, and factors influencing therapeutic choice. METHODS In an online survey, 204 psychiatrists self-selected and completed three patient records: two TRS and one schizophrenia ('non-TRS'). RESULTS Respondents reported that 29.5% of their schizophrenia caseload had TRS. Selected TRS (n = 408) vs non-TRS (n = 204) patients were more likely to be unemployed (74.5% vs 45.1%, p < 0.001), hospitalized at least once (93.4% vs 74.0%, p < 0.001), and to have physical/psychiatric comorbidities including obesity (40.2% vs 23.5%, p < 0.001) and depression (38.7% vs 25.0%, p = 0.001). Psychiatric symptoms were more frequent and severe in TRS, and interfered more with social and functioning domains. Of positive symptoms, eliminating delusions and hallucinations was considered most important to improve a patient's long-term prognosis. In TRS, clozapine monotherapy was the most common treatment (15.9%), though ranked fifth of ten options to treat TRS. Psychiatrists typically increased the antipsychotic dose or added a second antipsychotic before initiating clozapine or switching antipsychotics. Antipsychotic switches were most commonly due to lack of efficacy (TRS = 71.4% vs non-TRS = 54.3%, p < 0.001) and intolerability (34.4% vs 38.4%, p = 0.22) with the prior antipsychotic. Persistent hallucinatory behavior was the top symptom leading to treatment switches in TRS (63.9% vs 37.1%, p < 0.001). CONCLUSIONS According to psychiatrists, symptoms have a greater clinical burden on patients with TRS than non-TRS. TRS is commonly managed by antipsychotic dose increases/combinations, with clozapine the fifth preference despite being the only approved TRS medication. New treatments are needed for patients who do not respond to available antipsychotics.
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Affiliation(s)
- Christoph U. Correll
- grid.440243.5The Zucker Hillside Hospital, Department of Psychiatry, 75–59 263rd Street, Glen Oaks, New York 11004 USA ,Department of Psychiatry and Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA ,Department of Child and Adolescent Psychiatry, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Brevig
- 0000 0004 0476 7612grid.424580.fH. Lundbeck A/S, Valby, Copenhagen, Denmark
| | - Cecilia Brain
- 0000 0004 0476 7612grid.424580.fH. Lundbeck A/S, Valby, Copenhagen, Denmark
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Nguyen ML, Sunderland B, Lim S, Hattingh L, Chalmers L. The hidden magnitude of polypharmacy: using defined daily doses and maximum licensed daily doses to measure antipsychotic load. Int J Clin Pharm 2019; 41:1642-1651. [DOI: 10.1007/s11096-019-00930-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
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Evaluation of Risk Factors for Antipsychotic Polypharmacy in Inpatient Psychiatry Units of a Community Hospital: A Retrospective Analysis. Community Ment Health J 2019; 55:750-754. [PMID: 30805754 DOI: 10.1007/s10597-019-00381-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/15/2019] [Indexed: 10/27/2022]
Abstract
Antipsychotic polypharmacy (APP) is a common practice while treating severe mental illness but the benefits of APP over antipsychotic monotherapy is controversial. This is a retrospective analysis comparing risk factors for people on APP and those on non-APP in inpatient psychiatry units. Two years data with 72 people in non-APP group and 82 people in APP group were analyzed quantitatively. The diagnoses of schizoaffective disorder (OR 11.5), schizophrenia (OR 4.65) and depression (OR 0.31), and history of > 2 psychiatric admissions (OR 3.2) and > 2 psychiatric emergency visits (OR 2.87) in 2 years were studied as potential risk factors for APP. Similarly, history of violence (OR 1.7) and history of substance abuse (OR 0.51) were also studied. Schizophrenia spectrum disorder, higher number of psychiatric hospitalizations, and psychiatric emergency visits were positively associated while depression and substance abuse were negatively associated with APP in our study.
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Tiihonen J, Taipale H, Mehtälä J, Vattulainen P, Correll CU, Tanskanen A. Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia. JAMA Psychiatry 2019; 76:499-507. [PMID: 30785608 PMCID: PMC6495354 DOI: 10.1001/jamapsychiatry.2018.4320] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE The effectiveness of antipsychotic polypharmacy in schizophrenia relapse prevention is controversial, and use of multiple agents is generally believed to impair physical well-being. OBJECTIVE To study the association of specific antipsychotic combinations with psychiatric rehospitalization. DESIGN, SETTING, AND PARTICIPANTS In this nationwide cohort study, the risk of psychiatric rehospitalization was used as a marker for relapse among 62 250 patients with schizophrenia during the use of 29 different antipsychotic monotherapy and polypharmacy types between January 1, 1996, and December 31, 2015, in a comprehensive, nationwide cohort in Finland. We conducted analysis of the data from April 24 to June 15, 2018. Rehospitalization risks were investigated by using within-individual analyses to minimize selection bias. MAIN OUTCOMES AND MEASURES Hazard ratio (HR) for psychiatric rehospitalization during use of polypharmacy vs during monotherapy within the same individual. RESULTS In the total cohort, including 62 250 patients, 31 257 individuals (50.2%) were men, and the median age was 45.6 (interquartile range, 34.6-57.9) years. The clozapine plus aripiprazole combination was associated with the lowest risk of psychiatric rehospitalization in the total cohort, being superior to clozapine, the monotherapy associated with the best outcomes, with a difference of 14% (HR, 0.86; 95% CI, 0.79-0.94) in the analysis including all polypharmacy periods, and 18% in the conservatively defined polypharmacy analysis excluding periods shorter than 90 days (HR, 0.82; 95% CI, 0.75-0.89; P < .001). Among patients with their first episode of schizophrenia, these differences between clozapine plus aripiprazole vs clozapine monotherapy were greater (difference, 22%; HR, 0.78; 95% CI, 0.63-0.96 in the analysis including all polypharmacy periods, and difference, 23%; HR, 0.77; 95% CI, 0.63-0.95 in the conservatively defined polypharmacy analysis). At the aggregate level, any antipsychotic polypharmacy was associated with a 7% to 13% lower risk of psychiatric rehospitalization compared with any monotherapy (ranging from HR, 0.87; 95% CI, 0.85-0.88, to HR, 0.93; 95% CI, 0.91-0.95; P < .001). Clozapine was the only monotherapy among the 10 best treatments. Results on all-cause and somatic hospitalization, mortality, and other sensitivity analyses were in line with the primary outcomes. CONCLUSIONS AND RELEVANCE Combining aripiprazole with clozapine was associated with the lowest risk of rehospitalization, indicating that certain types of polypharmacy may be feasible in the treatment of schizophrenia. Because add-on treatments are started when monotherapy is no longer sufficient to control for worsening of symptoms, it is likely that the effect sizes for polypharmacy are underestimates. Although the results do not indicate that all types of polypharmacy are beneficial, the current treatment guidelines should modify their categorical recommendations discouraging all antipsychotic polypharmacy in the maintenance treatment of schizophrenia.
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Affiliation(s)
- Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | | | - Christoph U. Correll
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York ,Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, New York,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,National Institute for Health and Welfare, The Impact Assessment Unit, Helsinki, Finland
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Vyas AM, Kogut SJ, Aroke H. Real-World Direct Health Care Costs Associated with Psychotropic Polypharmacy Among Adults with Common Cancer Types in the United States. J Manag Care Spec Pharm 2019; 25:555-565. [PMID: 31039063 PMCID: PMC10397647 DOI: 10.18553/jmcp.2019.25.5.555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Psychotropic polypharmacy is not uncommon among cancer patients and may contribute to the increased direct health care cost burden in this population. OBJECTIVE To estimate average direct health care costs in the year following cancer diagnosis among cancer patients receiving psychotropic polypharmacy compared with those without psychotropic polypharmacy, using a multivariable analysis framework. METHODS A retrospective cross-sectional study was conducted among patients aged 18 years and older diagnosed with the most commonly occurring cancers (breast, prostate, lung, and colorectal) in the United States during 2011-2012 using the deidentified Optum Clinformatics Data Mart commercial claims database. Psychotropic polypharmacy was defined as concurrent use of 2 or more psychotropic medications for at least 90 days. Direct health care costs in the year following cancer diagnosis were estimated as total medical payments made by the health plans and were derived from claims files. A generalized linear regression model with log-link function and gamma distribution was used to model average direct health care costs, controlling for baseline patient demographic and clinical covariates. RESULTS Average annual direct health care costs for cancer patients with psychotropic polypharmacy ($53,497; SD $72,590) were higher than those without psychotropic polypharmacy ($38,255; SD $59,844), with an unadjusted average cost difference of $15,242 (P < 0.0001). In the adjusted regression model, the average difference in costs shrunk to $5,888 but remained notable. When examined by type of cancer, average direct health care costs for all cancer patients with psychotropic polypharmacy were significantly higher than those for patients without psychotropic polypharmacy, except for colorectal cancer patients. CONCLUSIONS Overall health care costs were higher among cancer patients with psychotropic polypharmacy compared with those without psychotropic polypharmacy. Our findings support the need for future research to better understand the benefits and risks of psychotropic polypharmacy, given its potential to cause adverse health outcomes and avoidable health care utilization and costs for this vulnerable patient population. DISCLOSURES This study was funded by the American Association of Colleges of Pharmacy (AACP) New Investigator Award mechanism, which was received by Vyas. Aroke was partially supported by the AACP grant for conducting data analysis of the study. Kogut is partially supported by Institutional Development Award Number U54GM115677 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health and the AACP. The authors report no conflicts of interest. An abstract of this study was presented as a poster at the American Association of Colleges of Pharmacy Annual Meeting on July 22, 2018, in Boston, MA.
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Affiliation(s)
- Ami M. Vyas
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
| | - Stephen J. Kogut
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
| | - Hilary Aroke
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston
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Aroke HA, Vyas AM, Buchanan AL, Kogut SJ. Prevalence of Psychotropic Polypharmacy and Associated Healthcare Resource Utilization during Initial Phase of Care among Adults with Cancer in USA. Drugs Real World Outcomes 2019; 6:73-82. [PMID: 31020617 PMCID: PMC6520416 DOI: 10.1007/s40801-019-0153-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The use of psychotropic medications is not uncommon among patients with newly diagnosed cancer. However, the impact of psychotropic polypharmacy on healthcare utilization during the initial phase of cancer care is largely unknown. METHODS We used a claims database to identify adults with incident breast, prostate, lung, and colorectal cancers diagnosed during 2011-12. Psychotropic polypharmacy was defined as concurrent use of two or more psychotropic medication classes for at least 90 days. A multivariable logistic regression was performed to identify significant predictors of psychotropic polypharmacy. Multivariable Poisson and negative binomial regressions were used to assess the associations between psychotropic polypharmacy and healthcare utilization. RESULTS Among 5604 patients included in the study, 52.6% had breast cancer, 30.6% had prostate cancer, 11.4% had colorectal cancer, and 5.5% had lung cancer. During the year following incident cancer diagnosis, psychotropic polypharmacy was reported in 7.4% of patients, with the highest prevalence among patients with lung cancer (14.4%). Compared with patients without psychotropic polypharmacy during the initial phase of care, patients with newly diagnosed cancer with psychotropic polypharmacy had a 30% higher rate of physician office visits, an 18% higher rate of hospitalization, and a 30% higher rate of outpatient visits. The rate of emergency room visits was similar between the two groups. CONCLUSION Psychotropic polypharmacy during the initial phase of cancer care was associated with significantly increased healthcare resource utilization, and the proportion of patients receiving psychotropic polypharmacy differed by type of cancer. IMPACT Findings emphasize the importance of evidence-based psychotropic prescribing and close surveillance of events causing increased healthcare utilization among patients with cancer receiving psychotropic polypharmacy.
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Affiliation(s)
- Hilary A Aroke
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Ami M Vyas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA.
| | - Ashley L Buchanan
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Stephen J Kogut
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
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McInnis P, Kasinathan J. Combination long-acting injectable (LAI) antipsychotic medication in adolescents with severe psychosis and aggression: a case series. Australas Psychiatry 2019; 27:160-164. [PMID: 30474388 DOI: 10.1177/1039856218815744] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We examine the use of combination long-acting injectable (LAI) antipsychotic medication for adolescents with severe psychosis and aggression. We discuss benefits and risks with this approach, for a highly challenging small group of young people. METHODS A clinical summary is given of three adolescents admitted to a secure adolescent forensic inpatient unit, and the literature is reviewed. RESULTS In these adolescents with severe psychosis, aggression and violent offending, combination LAI antipsychotics effectively treated psychosis and enabled transfer to less restrictive settings. Brief Psychiatric Rating Scale (BPRS) scores decreased significantly with treatment, without any severe adverse effects. CONCLUSIONS Combination LAI antipsychotics may be an effective treatment for adolescents with severe psychosis and aggression where clozapine is not a realistic therapeutic option. Close monitoring for side-effects, clear documentation of clinical reasoning and appropriate safeguards are important.
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Affiliation(s)
- Peter McInnis
- Consultant Child and Adolescent Psychiatrist, Sydney Local Health District, Sydney, NSW, Australia
| | - John Kasinathan
- Consultant Forensic, Child and Adolescent Psychiatrist, Adolescent Unit, The Forensic Hospital, Matraville, NSW, and; Conjoint Senior Lecturer, School of Psychiatry, University of New South Wales, Sydney, NSW, Child and Adolescent Mental Health Service, ACT Health, Sydney, NSW, and; Visiting Fellow, Centre for Mental Health Research, Australian National University, Canberra, ACT, and; The Level 8 Practice, Sydney, NSW, Australia
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Abstract
There is substantial overlap between the symptoms of gastroparesis and a variety of alternative disorders. These conditions include rumination syndrome, drug-induced gastric emptying delay, cannabinoid hyperemesis syndrome, and eating disorders, which can be identified based on the history alone. The remaining patients require a diagnostic approach of physical examination, laboratory tests, evaluation with esophagogastroduodenoscopy or contrast radiography, and a test to measure gastric emptying. Symptomatic patients who have normal nutritional status and gastric emptying that is either normal or mildly delayed should be diagnosed with functional dyspepsia, whereas patients with moderate or severe gastric emptying delay are diagnosed with gastroparesis.
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Affiliation(s)
- Lawrence A Szarka
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Bir Eğitim ve Araştırma Hastanesinde Yatan Psikotik Bozukluk Tanılı Hastaların Sosyodemografik ve Klinik Özellikleri. JOURNAL OF CONTEMPORARY MEDICINE 2018. [DOI: 10.16899/gopctd.430045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Kadra G, Stewart R, Shetty H, MacCabe JH, Chang C, Taylor D, Hayes RD. Long-term antipsychotic polypharmacy prescribing in secondary mental health care and the risk of mortality. Acta Psychiatr Scand 2018; 138:123-132. [PMID: 29845597 PMCID: PMC6099447 DOI: 10.1111/acps.12906] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To investigate the association between long-term antipsychotic polypharmacy use and mortality; and determine whether this risk varies by cause of death and antipsychotic dose. METHODS Using data from a large anonymised mental healthcare database, we identified all adult patients with serious mental illness (SMI) who had been prescribed a single antipsychotic or polypharmacy, for six or more months between 2007 and 2014. Multivariable Cox regression models were constructed, adjusting for sociodemographic, socioeconomic, clinical factors and smoking, to examine the association between APP use and the risk of death. RESULTS We identified 10 945 adults with SMI who had been prescribed long-term antipsychotic monotherapy (76.9%) or APP (23.1%). Patients on long-term APP had a small elevated risk of mortality, which was significant in some but not all models. The adjusted hazard ratios for death from natural and unnatural causes associated with APP were 1.2 (0.9-1.4, P = 0.111) and 1.1 (0.7-1.9, P = 0.619) respectively. The strengths of the associations between APP and mortality outcomes were similar after further adjusting for % BNF antipsychotic dose (P = 0.031) or olanzapine equivalence (P = 0.088). CONCLUSION The findings suggest that the effect of long-term APP on mortality is not clear-cut, with limited evidence to indicate an association, even after controlling for the effect of dose.
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Affiliation(s)
- G. Kadra
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - R. Stewart
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
- South London and Maudsley NHS Foundation TrustLondonUK
| | - H. Shetty
- South London and Maudsley NHS Foundation TrustLondonUK
| | - J. H. MacCabe
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - C.‐K. Chang
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - D. Taylor
- South London and Maudsley NHS Foundation TrustLondonUK
| | - R. D. Hayes
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
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John AP, Ko EKF, Dominic A. Delayed Initiation of Clozapine Continues to Be a Substantial Clinical Concern. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:526-531. [PMID: 29682998 PMCID: PMC6099752 DOI: 10.1177/0706743718772522] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | | | - Arun Dominic
- 3 Rockingham General Hospital, Perth, WA, Australia
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Pathak S, Duff E. Antipsychotic use in older adults: Canadian best practices. Nurse Pract 2018; 43:50-55. [PMID: 29757837 DOI: 10.1097/01.npr.0000532766.14251.c7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Due to the physiologic changes of aging, managing behavioral issues and antipsychotic use is associated with adverse reactions that are more complex in older adults than in younger adults. Therefore, appropriate prescribing and evaluating the need to continue antipsychotics are necessary to enhance optimum patient outcomes. This article discusses best practice recommendations for NPs in Canada to help ensure safe use of antipsychotic medications in the older adult population.
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Affiliation(s)
- Sushila Pathak
- Sushila Pathak is an NP at Shellbrook Primary Care Clinic, Saskatchewan Health Authority, Shellbrook, Saskatchewan, Canada. Elsie Duff is an NP at Selkirk Quickcare and an instructor at Sask Polytech, Regina, Saskatchewan, Canada
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Complex Polypharmacy in Patients With Schizophrenia-Spectrum Disorders Before a Psychiatric Hospitalization: Prescribing Patterns and Associated Clinical Features. J Clin Psychopharmacol 2018; 38:180-187. [PMID: 29620698 DOI: 10.1097/jcp.0000000000000876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current evidence-based guidelines provide unclear support for many common polypharmacy practices in schizophrenia. Excessive or complex polypharmacy (≥4 psychotropics) has been studied in patients with bipolar disorder, but not in schizophrenia to date. METHODS We conducted a digital medical record data extraction of 829 patients consecutively admitted to a psychiatric hospital and diagnosed as having schizophrenia-spectrum disorders. RESULTS In those prescribed psychiatric medication preadmission, 28.1% (n = 169) met the criteria for complex polypharmacy. Complex polypharmacy patients were older, female, white, and disabled, and had more comorbidities compared with those without complex polypharmacy. In multivariable analysis, complex polypharmacy was specifically associated with being white and disabled, and having a comorbid anxiety disorder, tobacco use disorder, metabolic condition, and neurological condition compared with noncomplex polypharmacy patients. CONCLUSIONS Although there is little evidence to support complex polypharmacy in schizophrenia, rates were relatively high in patients requiring hospitalization, especially when they are also diagnosed as having comorbid psychiatric and medical conditions. Future research is needed to study the risk-benefit profile for these patients, especially considering their higher medical burden and related health risks.
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