Second-generation antipsychotics and bone turnover in schizophrenia

The neglected association between schizophrenia and bone fragility: a systematic review and meta-analyses

Schizophrenia is associated with increased risk of medical comorbidity, possibly including osteoporosis, which is a public health concern due to its significant social and health consequences. In this systematic review and meta-analysis, we aimed to determine whether schizophrenia is associated with bone fragility. The protocol for this review has been registered with PROSPERO (CRD42020171959). The research question and inclusion/exclusion criteria were developed and presented according to the PECO (Population, Exposure, Comparison, Outcome) framework. Schizophrenia was identified from medical records, DSM-IV/5 or the ICD. The outcomes for this review were bone fragility [i.e., bone mineral density (BMD), fracture, bone turnover markers, bone quality]. A search strategy was developed and implemented for the electronic databases. A narrative synthesis was undertaken for all included studies; the results from eligible studies reporting on BMD and fracture were pooled using a random effects model to complete a meta-analysis. The conduct of the review and reporting of results adhered to PRISMA guidelines. Our search yielded 3103 studies, of which 29 met the predetermined eligibility criteria. Thirty-seven reports from 29 studies constituted 17 studies investigating BMD, eight investigating fracture, three investigating bone quality and nine investigating bone turnover markers. The meta-analyses revealed that people with schizophrenia had lower BMD at the lumbar spine [standardised mean difference (SMD) -0.74, 95% CI -1.27, -0.20; Z = -2.71, p = 0.01] and at the femoral neck (SMD -0.78, 95% CI -1.03, -0.53; Z = -6.18, p ≤ 0.001). Also observed was a higher risk of fracture (OR 1.43, 95% CI 1.27, 1.61; Z = 5.88, p ≤ 0.001). Following adjustment for publication bias, the association between schizophrenia and femoral neck BMD (SMD -0.63, 95% CI -0.97, -0.29) and fracture (OR 1.32, 95% CI 1.28, 1.35) remained. Significantly increased risk of bone fragility was observed in people with schizophrenia. This association was independent of sex, participant number, methodological quality and year of publication.

Long-term second-generation antipsychotics decreases bone formation and resorption in male patients with schizophrenia

RATIONALE

Patients with schizophrenia with second-generation antipsychotics (SGAs) treatment have shown an increased risk of bone fragility and susceptibility to fracture; however, it is still unclear whether this risk is derived from the effect of antipsychotics on balance of bone metabolism.

OBJECTIVES

We investigated the changes of two bone turnover biomarkers (BTMs) concentrations in people with schizophrenia receiving SGAs: procollagen type I aminoterminal propeptide (PINP) and C-terminal telopeptide of type I collagen (CTX-1) as BTMs of osteogenesis and bone resorption, respectively, to explore how antipsychotics contribute to bone fragility.

METHODS

We recruited 59 Chinese male patients with schizophrenia (32 drug-naïve first-episode (DNFE) patients and 27 chronic patients) to undergo 8 weeks SGAs treatment. Fasting peripheral blood samples of pre- and posttreatment were collected, plasma levels of PINP and CTX-1 were measured.

RESULTS

The interaction effects of group and time on PINP and CTX-1 concentrations were found (P = .016 and P = .008). There was a significant decrease for both BTMs concentrations of the posttreatment compared to the pretreatment (P<.001 and P = .003). Chronic patients had significantly higher changes of BTMs concentrations compared to DNFE patients (P = .048 and P = .024). There was a positive correlation of the two BTMs of pretreatment with disease course in DNFE group (r = .37, P = .039;r = .38, P = .035) and a negative correlation of PINP of pretreatment with age in the chronic group (r=-.40, P = .039).

CONCLUSION

Long-term SGAs medication inhibited osteogenesis in a dose- and time-dependent manner and damaged the balance of bone formation and bone resorption.

Sex-specific associations between metabolic hormones, severe mental disorders and antipsychotic treatment

BACKGROUND

Metabolic dysregulation has been associated with severe mental disorders (SMD) and with antipsychotic (AP) treatment, but the role of sex is unknown. To identify possible sex-related processes linked to SMD and AP treatment, we investigated sex differences in associations between hormones involved in metabolic regulation in patients with SMD compared to healthy controls (HC) and AP treatment.

METHODS

We included patients with SMD (N = 1753) and HC (N = 1194) and measured hormones involved in metabolic regulation (insulin, cortisol, thyroid-stimulating hormone (TSH), thyroxine, leptin, adiponectin, testosterone, sex hormone-binding globulin (SHBG), prolactin). Patients were grouped according to use of first-generation AP (N = 163), second-generation AP (N = 1087) or no use of AP (N = 503). Hormones were used one by one as dependent variables in multiple regression analyses with interactions between sex and SMD patients versus HC, and between sex and AP treatment, followed by analyses in males and females separately.

RESULTS

We found significant interactions between sex and SMD patients versus HC for testosterone, SHBG and adiponectin, with significantly higher testosterone and lower adiponectin levels in females. Furthermore, we found significant interaction between sex and AP groups for TSH, testosterone and insulin, with significantly lower TSH levels in AP-treated females, and lower testosterone and higher insulin levels in AP-treated males.

CONCLUSIONS

Our findings suggest sex differences in metabolic hormones related to both SMD and AP treatment, indicating sex-dependent mechanisms. Clinicians should be aware of potential sex-specific metabolic changes during AP treatment and experimental studies are warranted to clarify the underlying mechanisms.

Association between gonadal hormones and osteoporosis in schizophrenia patients undergoing risperidone monotherapy: a cross-sectional study

Objective

Patients with schizophrenia are at increased risk of osteoporosis. This study first determined the osteoporosis rate in patients with schizophrenia and then then explored the association between serum gonadal hormone levels and osteoporosis among these patients.

Methods

A total of 250 patients with schizophrenia and 288 healthy controls were recruited. Osteoporosis was defined by decreased bone mineral density (BMD) of the calcaneus. Serum fasting levels of gonadal hormones (prolactin, estradiol, testosterone, progesterone, follicle-stimulating hormone, luteinizing hormone) were determined. The relationship between osteoporosis and hormone levels was statistically analyzed by binary logistic regression analysis.

Results

Our results showed that patients with schizophrenia had a markedly higher rate of osteoporosis (24.4% vs. 10.1%) than healthy controls (P < 0.001). Patients with osteoporosis were older, had a longer disease course, and had a lower body mass index (BMI) than patients without osteoporosis (all P < 0.05). Regarding gonadal hormones, we found significantly higher prolactin, but lower estradiol, levels in patients with osteoporosis than in those without osteoporosis (both P < 0.05). The regression analysis revealed that PRL (OR = 1.1, 95% CI [1.08–1.15], P < 0.001) and E2 level (OR = 0.9, 95%CI [0.96–0.99], P = 0.011) were significantly associated with osteoporosis in patients with schizophrenia.

Conclusion

Our results indicate that patients with schizophrenia who are being treated with risperidone have a high rate of osteoporosis. Increased prolactin and reduced estradiol levels are significantly associated with osteoporosis.

Study protocol for the systematic review and meta-analyses of the association between schizophrenia and bone fragility

INTRODUCTION

Individuals with schizophrenia are known to be at higher risk of comorbid conditions, both physical and psychological. Osteoporosis is possibly one of these, leading to public health concerns due to higher rates of associated mortality and morbidity. We aim to systematically search all available evidence across electronic databases regarding the relationship between schizophrenia and bone fragility.

METHODS AND ANALYSIS

A systematic search of the research databases CINAHL, MEDLINE Complete, Embase and PsycINFO will be conducted and identified papers reviewed for eligibility, with a second reviewer confirming inclusions. Searches will be run from database inception to 1 October 2020 and supplemented by the hand checking of references of identified articles. A previously published scoring system will be used for assessing the methodological quality and risk of bias. A meta-analysis is planned.

ETHICS AND DISSEMINATION

Due to including published literature only, ethical permission will not be necessary. Results of this study will be published in a relevant scientific journal and presented at a conference in the field of interest.

PROSPERO REGISTRATION NUMBER

CRD42020171959.

Altered levels of BMD, PRL, BAP and TRACP-5b in male chronic patients with schizophrenia

Bone mineral density (BMD) has been found to decrease in schizophrenia patients. We examined BMD and the levels of prolactin (PRL), bone alkaline phosphatase (BAP) and tartrate resistant acid phosphatase isoform 5b (TRACP-5b) in male chronic schizophrenia patients and compared them with healthy controls in a Chinese Han population, which has not been reported before. Male patients with chronic schizophrenia (SPs; n = 79) and healthy controls (HCs; n  = 56) were recruited. BMD and plasma PRL, BAP and TRACP-5b levels were measured and compared between the two groups. The SPs group was further divided into two subgroups: the elevated PRL group (PRL ≥ 25 ng/ml, EPRL; n  = 38) and the normal PRL group (PRL < 25 ng/ml, NPRL; n = 41) in accordance with PRL levels. The levels of BAP and TRACP-5b were measured using sandwich enzyme-linked immunosorbent assay (ELISA) while serum PRL was measured with an Access Immunoassay Analyzer. BMD was determined by quantitative computed tomography. BMD levels significantly decreased and serum PRL and TRACP-5b levels were significantly higher in male chronic schizophrenia patients. The EPRL group had remarkably lower BMD and BAP level and higher TRACP-5b levels compared with the NPRL group and HCs. Moreover, there was a negative correlation between BMD and TRACP-5b in the EPRL group. We found that BMD, BAP and TRACP-5b levels in the EPRL group were significantly different than HCs and the NPRL group. PRL levels in schizophrenia patients may be related to BMD and bone metabolism. Monitoring BMD and markers of bone metabolism in clinical practice may therefore be helpful to understand the bone health status of schizophrenia patients.

The risk of bone fracture after long-term risperidone exposure is not increased compared to other atypical antipsychotics: A retrospective cohort study

OBJECTIVE

Antipsychotic agents can increase circulating serum prolactin levels, potentially leading to osteoporosis and increased risk of bone fracture. The risk appears to be lower for atypical antipsychotics. We investigated whether risperidone was associated with an increased fracture risk by estimating the incidence of hip/femur and non-hip/femur fractures in users of risperidone, other atypical, and typical antipsychotics.

METHODS

This retrospective cohort study with a nested case-control study used claims data from the Taiwan National Healthcare Insurance database. All new users of antipsychotics between 2000-2012 were included. Incident fractures were identified using ICD-9 codes from inpatient records. Cox proportional hazards models compared fracture incidence among exposure groups. Conditional logistic regression models compared antipsychotic exposure among fracture cases versus matched controls.

RESULTS

340,948 patients were included in the analysis. There were 2832 hip/femur fractures and 2693 non-hip/femur fractures: Hip/femur fracture incidence 636.8/100,000 person-years (Risperidone), 885.7/100,000 person-years (Other Atypical), 519.4/100,000 person-years (Typical). The adjusted hazard ratio of hip/femur fracture was 0.92 (95%CI 0.84-1.01) comparing Other Atypical with Risperidone, and 1.00 (95%CI 0.89-1.11) comparing Typical with Risperidone. The adjusted hazard ratio of non-hip/femur fracture was 1.08 (95%CI 0.98-1.20) for Other Atypical versus Risperidone, and 1.10 (95%CI 0.99-1.22) for Typical versus Risperidone. The adjusted odds ratio for hip/femur fractures was 0.92 (95% CI 0.83-1.01) in cases and controls exposed to other atypical antipsychotics compared with risperidone for 1 year prior to fracture date, 0.97 (95% CI 0.87-1.07) during 1-3 years, and 0.92 (95% CI 0.81-1.06) during 3-5 years prior to fracture date. The adjusted odds ratio for non-hip/femur fractures were 1.11 (95% CI 0.99-1.24), 1.02 (95% CI 0.0.91-1.14), and 0.95 (95% CI 0.82-1.09), respectively.

CONCLUSION

There was no increased risk of bone fracture in long-term users of risperidone compared to users of other atypical antipsychotics.

[Antipsychotics: features of undesirable adverse reactions in elderly and senile age]

This review summarizes and systematizes currently available literature on antipsychotics as one of the most frequently prescribed group of psychotropic drugs. Based on published data from clinical studies and meta-analyzes, the authors consider unwanted adverse reactions in patients taking antipsychotic medications. Mechanisms of development of undesirable drug reactions are discussed. Special attention is paid to those adverse reactions of antipsychotics that most often occur in old and very old age (increased risk of adverse cardiovascular and cerebrovascular events, sudden death, prolonged QTc interval, falls, fractures, orthostatic hypotension, extrapyramidal disorders, pneumonia, urinary tract infections, etc.).

Еffects of Antipsychotics on Bone Mineral Density in Schizophrenia

Previous researches have shown that patients with schizophrenia who were using antipsychotics in their treatment developed changes in Bone Mineral Density and body composition, leading to osteoporosis and modifications in weight, skeletal muscle mass index and percent of fat tissue. Results of many studies suggested that the use of antipsychotic causes hyperprolactinemia and consequently lower bone mineral density values were observed. Further, antipsychotics increase food intake and have possible effects on metabolism, causing changes in weight, glucose level and lipid status, all of which can be a risk for developing metabolic syndrome and result in changing of bone mineral density. Antipsychotics change cytokine profi les in patients with schizophrenia and on the other hand the influence of T cells, B cells and inflammatory cytokines on osteoclasts and on osteoblasts was also established. In assessing the effects of antipsychotic on bone metabolism very important is to consider the duration of the treatment and clinical course of the disease, but undeniable effect is careless life style and inadequate physical activity that patients with schizophrenia have. Our attempt is to give an overview of the newest findings in this field, regarding the direct effects of antipsychotics on the bone metabolism, but also through prolactine elevation, metabolic and immune changes. Better understanding of the underlying mechanisms of schizophrenia and changes in bone mineral density could improve our clinical practice: affect to choice of the individually most appropriate antipsychotic, point to the need to monitor possible immunmetabolic changes during the treatment and improvement of the life quality of this vulnerable population.

Prevalence, risk factors and clinical characteristics of osteoporosis in Chinese inpatients with schizophrenia

Patients with schizophrenia have a high prevalence of developing osteoporosis and osteoporosis-related fractures. We examined the prevalence of osteoporosis and its clinical correlates in Chinese patients with schizophrenia, which is not well-studied. A total of 199 inpatients (males/females=132/67; average age: 54.5±11.1years) and 107 healthy controls (males/females=22/85; average age: 41.7±11.9years) were recruited. Bone mineral density (BMD) was measured by ultrasonography of the calcaneus. The prevalence of osteoporosis and low BMD (osteoporosis and osteopenia) was 23.1% and 65.3% for the patient group, versus 7.5% and 39.3% for the control group (both p<0.001). Further, the average BMD T-score in patients was significantly lower than in controls (p<0.05). There was gender difference in the prevalence of low BMD conditions for the patients (males: 56.1% versus females: 76.1%; p<0.01) as well as the BMD T-score (p<0.001). Several risk factors correlated with the osteoporosis classification in the patient group: older age (58.9±11.2years vs. 53.3±11.0years), lower weight (63.7±12.2kg vs. 70.4±15.2kg) and body mass index (BMI) (22.8±4.1kg/m² vs. 24.2±4.7kg/m²; all p<0.01) than those without osteoporosis. Stepwise multiple logistic regression analysis indicated that age, weight and BMI remained significantly associated with osteoporosis. In addition, correlation analysis showed significant correlations between BMD T-score and the following parameters: gender, age and drug type (clozapine versus non-clozapine) (Bonferroni corrected p's<0.05). Our results suggest a higher prevalence of osteoporosis and osteopenia in Chinese schizophrenic inpatients, with both the expected risk factors of gender and age, as well as drug type.

Testosterone, DHEA and DHEA-S in patients with schizophrenia: A systematic review and meta-analysis

Neuroactive steroids, including testosterone, dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S) might play an important role in the pathophysiology of schizophrenia. Therefore, we performed a systematic review and meta-analysis of studies comparing the levels of testosterone, DHEA and DHEA-S in patients with schizophrenia and healthy controls. We searched electronic databases from their inception until Oct 29, 2017. Effect size (ES) estimates were calculated as Hedges' g. Data analysis was performed using random-effects models. Our analysis included 34 eligible studies, representing 1742 patients and 1604 controls. Main analysis revealed elevated DHEA-S levels in the whole group of patients (ES = 0.75, 95%CI: 0.23-1.28, p = 0.005). In subgroup analyses, patients with first-episode psychosis (FEP) had significantly higher levels of free testosterone (ES = 1.21, 95%CI: 0.30-2.12, p = 0.009) and DHEA-S (ES = 1.19, 95%CI: 0.66-1.71, p < 0.001). Acutely relapsed schizophrenia patients presented significantly higher levels of total testosterone (ES = 0.50, 95%CI: 0.21-0.70, p < 0.001). Total testosterone levels were also elevated in stable multi-episode schizophrenia (sMES) females (ES = 0.56, 95%CI: 0.33-0.80, p < 0.001) and reduced in sMES males (ES = -0.62, 95%CI: -1.07 to 0.18, p = 0.006). Increased levels of biologically active, free testosterone and DHEA-S in FEP suggest that these alterations might appear as a response to stress that becomes blunted during subsequent exacerbations of schizophrenia. Differential changes in total testosterone levels in male and female sMES patients might represent medication effects related to prolactin-releasing effects of antipsychotics.

Effects of Antipsychotics on Bone Mineral Density in Patients with Schizophrenia: Gender Differences

Low bone mineral density (BMD) and osteoporosis are common in patients with schizophrenia and detrimental to illness prognosis and life quality. Although the pathogenesis is not fully clear, series of studies have revealed factors related to low BMD such as life style, psychotic symptoms, medication use and the activity of bone absorption markers. It has been known that antipsychotic-induced hyperprolactinemia plays a critical role on decreased BMD. However, it remains uncertain whether the risk factors differ between men and women. According to the effect on prolactin, antipsychotics can be classified into two groups: prolactin-sparing (PS) and prolactin-raising (PR). Our previous study has demonstrated that clozapine which is among the PS antipsychotics is beneficial for BMD when compared with PR antipsychotics in women with chronic schizophrenia. We have also found that risks factors associated with low BMD are different between men and women, suggesting that gender-specific risk factors should be considered for intervention of bone loss in patients with schizophrenia. This article reviews the effects of antipsychotics use on BMD with particular discussion for the differences on gender and age, which implicate the alterations of sex and other related hormones. In addition, currently reported protective and risk factors, as well as the effects of medication use on BMD including the combination of antipsychotics and other psychotropic agents and other potential medications are also reviewed.

Relationship between antipsychotic medication, serum prolactin levels and osteoporosis/osteoporotic fractures in patients with schizophrenia: a critical literature review

INTRODUCTION

Using an antipsychotic medication can increase prolactin (PRL) levels, causing hyperprolactinemia (HPRL). Although the occurrence of osteoporosis within the population of patients with schizophrenia has been recognized, the precise nature of the association between antipsychotic treatment, PRL, osteoporosis, and the disease itself seems to be elusive.

AREAS COVERED

The aim of this review is to critically review the literature regarding the association between osteoporosis and PRL and to summarize the available evidence with respect to the impact of PRL-elevating antipsychotics on bone mineral density (BMD) and fractures in non-elderly patients with schizophrenia.

EXPERT OPINION

Although long-standing HPRL can have an impact on the rate of bone metabolism and, when associated with hypogonadism, may lead to decreased bone density in both female and male subjects, the relative contribution of antipsychotic-induced HPRL in bone mineral loss in patients with schizophrenia remains unclear. Methodological shortcomings of existing studies, including the lack of prospective data and the focus on measurements of BMD instead of bone turnover markers, preclude definitive conclusions regarding the relationship between PRL-raising antipsychotics and BMD loss in patients with schizophrenia. Therefore, more well conducted prospective trials of these biomarkers are necessary to establish the precise relationship between antipsychotics, PRL levels and osteoporosis/osteoporotic risk.

Acute Effects of Haloperidol, Amisulpride, and Quetiapine on Bone Turnover Markers in Patients With Schizophrenia

OBJECTIVE

This prospective study sought to compare the acute effects of haloperidol, amisulpride, and quetiapine on serum markers of bone formation and resorption in relatively young patients with minimal previous exposure to antipsychotic drugs.

METHODS

Patients included in the study were randomly assigned to receive haloperidol, amisulpride, or quetiapine monotherapy in an open-label manner. Serum osteocalcin (OC, a marker of bone formation), C-terminal peptide of type I collagen (CTX, a marker of bone resorption), prolactin (PRL), estradiol, and testosterone were measured in 70 patients at baseline and after 4 weeks of antipsychotic treatment.

RESULTS

A repeated-measures analysis of variance revealed a significant difference in CTX levels and in the OC to CTX ratio between treatment groups (F = 4.481, P < 0.05; F = 8.114, P < 0.01). After 4 weeks of treatment, only the amisulpride group had significantly increased CTX levels and decreased OC/CTX. In addition, an obvious increase in PRL level and a reduction of sex hormone secretion after amisulpride treatment were found. No significant changes in bone turnover were observed in the haloperidol or quetiapine groups. Notably, a positive correlation between the CTX change to the change in PRL after treatment (r = 0.255, P < 0.05) was observed.

CONCLUSIONS

The PRL-raising antipsychotic drug amisulpride influenced bone turnover balance very early in the course of treatment, which may require long-term monitoring of bone metabolism. Bone resorption marker changes induced by acute antipsychotic drug treatment are likely related to increased PRL levels.

Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder

People with severe mental illness have a considerably shorter lifespan than the general population. This excess mortality is mainly due to physical illness. Next to mental illness-related factors, unhealthy lifestyle, and disparities in health care access and utilization, psychotropic medications can contribute to the risk of physical morbidity and mortality. We systematically reviewed the effects of antipsychotics, antidepressants and mood stabilizers on physical health outcomes in people with schizophrenia, depression and bipolar disorder. Updating and expanding our prior systematic review published in this journal, we searched MEDLINE (November 2009 - November 2014), combining the MeSH terms of major physical disease categories (and/or relevant diseases within these categories) with schizophrenia, major depressive disorder and bipolar disorder, and the three major psychotropic classes which received regulatory approval for these disorders, i.e., antipsychotics, antidepressants and mood stabilizers. We gave precedence to results from (systematic) reviews and meta-analyses wherever possible. Antipsychotics, and to a more restricted degree antidepressants and mood stabilizers, are associated with an increased risk for several physical diseases, including obesity, dyslipidemia, diabetes mellitus, thyroid disorders, hyponatremia; cardiovascular, respiratory tract, gastrointestinal, haematological, musculoskeletal and renal diseases, as well as movement and seizure disorders. Higher dosages, polypharmacy, and treatment of vulnerable (e.g., old or young) individuals are associated with greater absolute (elderly) and relative (youth) risk for most of these physical diseases. To what degree medication-specific and patient-specific risk factors interact, and how adverse outcomes can be minimized, allowing patients to derive maximum benefits from these medications, requires adequate clinical attention and further research.