Differential sensitivities to risperidone and olanzapine in a human immunodeficiency virus patient

A review of movement disorders in persons living with HIV

BACKGROUND

The human immunodeficiency virus (HIV) causes movement disorders in persons living with HIV (PLH).

OBJECTIVES AND METHODS

We conducted a systematic review on the spectrum of movement disorders in PLH using standard terms for each of the phenomenologies and HIV.

RESULTS

Movement disorders in PLH were commonly attributed to opportunistic infections (OI), dopamine receptor blockade reactions, HIV-associated dementia (HAD), presented during seroconversion, developed due to drug reactions or antiretroviral therapy (ART) itself and lastly, movement disorders occurred as a consequence of the HIV-virus. Parkinsonism in ART naïve PLH was associated with shorter survival, however when Parkinsonism presented in PLH on ART, the syndrome was indistinguishable from Idiopathic Parkinson's disease and responded to therapy. Tremor was often postural due to HAD, drugs or OI. Generalized chorea was most frequent in HIV encephalopathy and toxoplasmosis gondii caused most cases of hemichorea. Ataxia was strongly associated with JCV infection, ART efavirenz toxicity or due to HIV itself. Dystonia was reported in HAD, secondary to drugs and atypical facial dystonias. Both cortical/subcortical and segmental/spinal origin myoclonus were noted mainly associated with HAD. In patients with HIV related opsoclonus-myoclonus-ataxia-syndrome, seroconversion illness was the commonest cause of followed by IRIS and CSF HIV viral escape phenomenon.

CONCLUSIONS

Aetiology of movement disorders in PLH depend on the treatment state. Untreated, PLH are prone to develop OI and HAD and movement disorders. However, as the number of PLH on ART increase and survive longer, the frequency of ART and non-AIDS related complications are likely to increase.

Psychiatric side-effects of medications: recent developments

Medications often induce neuropsychiatric side-effects. This article reviews psychiatric side-effects that are well known and describes those induced by recently developed medications. Therapeutic innovations have been prominent in the treatment of HIV infection, Parkinson's disease and epilepsy and therefore psychiatric side-effects caused by these agents are described in more detail.

Neuropsychiatric Aspects of Infectious Diseases: An Update

Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system, human immunodeficiency virus infection, and AIDS.

Medicinal-Induced Behavior Disorders

Commonly used medications can have neuropsychiatric and behavioral effects that may be idiosyncratic or metabolic in nature, or a function of interactions with other drugs, toxicity, or withdrawal. This article explores an approach to the patient with central nervous system toxicity, depending on presentation of sedation versus agitation and accompanying physical signs and symptoms. The effects of antihypertensives, opioids, antibiotics, antiepileptic agents, steroids, Parkinson's disease medications, antipsychotics, medications for human immunodeficiency virus infection, cancer chemotherapeutics, and immunotherapies are discussed. A look at the prevalence of adverse reactions to medications and the errors underlying such occurrences is included.

Pharmacotherapy considerations in patients with HIV and psychiatric disorders: focus on antidepressants and antipsychotics

OBJECTIVE

To review the evidence for the efficacy and safety of pharmacologic agents for the treatment of depressive and psychotic disorders in patients with HIV infection and to provide clinical considerations for the treatment of depression and psychosis in these patients.

DATA SOURCES

PubMed was searched for articles published between 1966 and August 1, 2012, using the search terms antiretrovirals, HIV, AIDS, depression, psychosis, schizophrenia, antidepressant, antipsychotic, and individual drug names (fluoxetine, sertraline, paroxetine, citalopram, escitalopram, venlafaxine, duloxetine, mirtazapine, bupropion, haloperidol, perphenazine, fluphenazine, aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone).

STUDY SELECTION AND DATA EXTRACTION

For the purposes of evaluating efficacy data, we limited our selection to randomized placebo-controlled or active comparator-controlled trials for agents that have been used for depression and psychosis in HIV-infected patients.

DATA SYNTHESIS

We found 11 studies for depression treatment and 1 study for psychosis treatment that met our inclusion and exclusion criteria. Selective serotonin reuptake inhibitors (SSRIs; especially fluoxetine) and tricyclic antidepressants appear to be effective in treating depressive symptoms in patients with HIV infection without affecting immune status. Testosterone, stimulants, and dehydroepiandrosterone may also be effective in subsyndromal depression; however, studies on these agents in general were limited by small sample size. There are limited data for antipsychotics, with the only controlled study found for haloperidol and chlorpromazine used for AIDS delirium. Drug-drug interactions and potentiation of metabolic syndrome are concerns for the combined use of antidepressants and antipsychotics with antiretrovirals.

CONCLUSIONS

Larger controlled studies are needed to validate the current findings as well as expand knowledge for non-SSRI antidepressants and second-generation antipsychotics for use in HIV-infected patients.

Psychopharmacologic treatment of patients with HIV/AIDS

Psychiatric disorders are common among patients with HIV/AIDS, and psychopharmacologic treatment is a cornerstone of management. The efficacy of psychopharmacologic treatment for depression in HIV/AIDS is relatively well established. However, literature on the treatment of other disorders is limited, which means that we still must determine how standard treatment guidelines may need to be modified in consideration of several key aspects of HIV illness. These include the broad differential diagnosis for psychiatric symptoms and the potential for interactions between psychotropic medications and antiretroviral medications. This paper reviews the literature on psychopharmacologic treatments of key psychiatric disorders in HIV/AIDS as well as differential diagnosis and drug-drug interactions.

Neuropsychiatric aspects of infectious diseases

Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system.

Psychopharmacology in HIV-infected patients

Neuropsychiatric disorders and syndromes may be underdiagnosed and inadequately treated in individuals infected with HIV. Depression in particular is among the most prevalent diagnoses, and data from controlled clinical studies have shown that antidepressant medications are efficacious and safe for treating depression in HIV-infected persons. A significant shortcoming of this literature is that most of the available data are from studies conducted before the advent of highly active antiretroviral therapy. In addition, apart from antidepressant medications, controlled studies systematically assessing efficacy and safety issues for other classes of psychotropic drugs (e.g., antipsychotic and anxiolytic medications) in HIV-infected persons are lacking. This review summarizes essential findings pertaining to the use of psychotropic medications to treat depression and other neuropsychiatric disorders in the context of HIV. It includes a discussion of clinically relevant treatment considerations (e.g., side effects, drug-drug interactions) derived from the existing literature as well as judgments that clinicians face in the absence of research data. Despite some shortcomings of the existing literature, overall there is compelling evidence that the appropriate use of psychotropic medications (coupled with behavioral therapy) can improve the quality of life of mentally ill HIV-infected individuals.

Effectiveness of olanzapine in neurosyphilis related organic psychosis: a case report

The clinicians usually do not consider syphilis in the differential diagnosis for patients with acute and chronic psychiatric symptoms. To familiarize clinicians particularly with neurosyphilis (NS) and to discuss the atypical antipsychotic alternatives, we wish to present a case with agitated, resistant psychotic symptoms related to neurosyphilis. The case was a 55-year-old male who has had anxiety, irritability, auditory hallucinations, ataxia, dysarthric speech, paranoid and persecutory delusions and agitated behaviour. Parenteral ziprasidone 20 mg/bid was initialized at the first day of admission to reduce agitation. Then it was switched to olanzapine velotab 10 mg/bid because of inefficacy. Parenteral cephtriaxon 1 g/daily was administered because of seropositive VDRl and TPHA and positive cerebrospinal fluid VDRl. Olanzapine velotab may be a good alternative antipsychotic and should be considered in reducing agitation and psychotic symptoms in NS.

Quetiapine vs. risperidone in treating psychosis in neurosyphilis: a case report

OBJECTIVE

A 44-year-old male patient presented with agitation, auditory hallucinations, and delusions of persecution was diagnosed as having neurosyphilis.

METHODS

He was treated with penicillin G 24 million units/day, risperidone 6 mg/day, and memantine 20 mg/day with partial response to psychotic symptoms and significant extrapyramidal symptoms.

RESULTS

On his follow-up, after 5 months, his cognitive status and serological tests remained the same, and his cell count was increased. A second therapy of penicillin was administered without any clinical improvement. On his second hospitalization for severe psychotic agitation after approximately 1 year, quetiapine 1200 mg/day was introduced and the psychiatric state improved immediately without significant side effect.

CONCLUSIONS

Quetiapine, which has a low potential for producing extrapyramidal side effects, should be considered in the treatment of psychotic symptoms of neurosyphilis.

Use of antipsychotic medications among HIV-infected individuals with schizophrenia

Persons with schizophrenia face elevated risk of infection with HIV. While HIV therapy is demanding, patients diagnosed with both conditions also require appropriate and consistent management of their psychiatric illness, for the same reasons that generally apply to persons with schizophrenia and because untreated psychiatric illness can interfere with full participation in HIV care. This study examines the correlates of use of and persistence on antipsychotic medications among HIV-infected individuals with schizophrenia, using merged New Jersey HIV/AIDS surveillance data and paid Medicaid claims. Persistence was defined as at least 2 months of medication use in a quarter. We identified 350 individuals who were dually diagnosed with HIV and schizophrenia. Overall, 81% of these beneficiaries had at least one claim for an antipsychotic medication at some point between 1992 and 1998. Multivariate techniques were used, including simple logistic regressions on use and robust longitudinal regressions that controlled for repeated observations on the same individual and treatment gaps. Among users of antipsychotic medications, persistence was very low at 37%. Racial/ethnic minorities were less likely to receive atypical antipsychotic medications. Use of atypical antipsychotics was associated with higher persistence. Our study confirmed past findings of racial disparities in the receipt of atypical antipsychotic medications. Findings suggest that use of atypical medications may benefit individuals dually diagnosed with HIV and serious mental illness.

Psychotropic viruses

Viruses are increasingly being recognized as important factors in the pathogenesis of acute and chronic mental illness. Here we review clinical and epidemiologic data concerning viral infection and mental illness, as well as animal models that provide insight into the myriad of mechanisms by which infection can cause brain dysfunction.

Pharmacologic treatment of mood disorders in acquired immune deficiency syndrome (AIDS)

Mood disorders in HIV are common and can impact on the course of the illness. With the increasing use of newer psychopharmacologic and antiviral medications, clinicians need to take precautions while prescribing them. This paper gives an overview of the most recent literature describing the pharmacologic treatment of mood disorders in HIVpositive patients. The authors of this paper focus on antidepressants, mood stabilizers, neuroleptics, and psychostimulants, as well as on areas of controversy. The authors' own clinical experiences are also included.

Psychopharmacological treatment of patients with HIV and AIDS

Psychopharmacological treatment of patients with HIV/AIDS is an important aspect of managing distress and enhancing quality of life. This article reviews the psychopharmacological management of depression, anxiety, mania, and psychosis in the context of HIV/AIDS, with a discussion of psychotropic-antiretroviral drug interactions. While psychopharmacological management of HIV/AIDS patients may be complex, there is a substantial amount of clinical and research information describing both conventional and novel approaches that are safe and effective.