Ziprasidone: an atypical antipsychotic drug for the treatment of schizophrenia

Recent Advances in representative small-molecule DRD2 inhibitors: Synthetic Routes and clinical applications

The dopamine D2 receptor (DRD2) represents a pivotal target for therapeutic intervention in the treatment of neuropsychiatric disorders, including schizophrenia, bipolar disorder, and Parkinson's disease. The successful discovery of numerous effective DRD2 inhibitors has led to their clinical application and ongoing evaluation in various clinical trials. This review explores the synthetic approaches and clinical applications of prototypical small-molecule DRD2 inhibitors that have received approval or are currently undergoing clinical trials, highlighting their therapeutic potential and challenges. The synthesis of these inhibitors employs various chemical strategies, including modifications of phenothiazine and butyrophenone structures, which have yielded significant antipsychotic agents like chlorpromazine and haloperidol. Additionally, newer classes of inhibitors, such as aripiprazole, exhibit partial agonist activity at DRD2, offering a unique therapeutic profile. Clinically, DRD2 inhibitors demonstrate efficacy in managing positive symptoms of schizophrenia, manic episodes in bipolar disorder, and dopaminergic imbalance in Parkinson's disease. However, the emergence of adverse effects, including tardive dyskinesia, extrapyramidal symptoms and metabolic syndrome, presents substantial challenges. Advances in the development of second-generation antipsychotics aim to balance efficacy with a better side effect profile by targeting additional neurotransmitter receptors. This review aims to deliver an overview of the synthesis and clinical applications of representative small-molecule DRD2 inhibitors across various clinical phases, thereby offering strategic insights for the advancement of DRD2 inhibitor development.

Exploration of the potential neuroprotective compounds targeting GluN1-GluN2B NMDA receptors

The N-methyl-d-aspartic acid (NMDA) receptors belongs to the family of ionotropic glutamate receptors, which could mediate most excitatory synaptic transmission in the brain. It is interesting to know if some available drugs have regulatory effects on the NMDARs. Herein, the present study reports the discovery of drugs targeting NMDAR using virtual screening. In this study, talniflumate with the EC50 value at 61.49 nM was successfully screened. The interaction analysis of this compound was further explored through molecular dynamics simulation. It is indicated that talniflumate could form stable interactions with GluN1-GluN2B NMDA receptors. In particular, H-bond interactions with high occupancies between GluN1-GluN2B NMDA receptors and talniflumate were observed. Compared to de novo drug discovery, this approach could be an alternative choice for development of safety and efficiency NMDAR inhibitors from available drugs.Communicated by Ramaswamy H. Sarma.

Dexmedetomidine Infusion as a Novel Supportive Therapy for Fluphenazine-Induced Neuroleptic Malignant Syndrome in a 10-Year-Old Boy: A Case Report and Review of Literature

A 10-year-old male child patient developed symptoms of neuroleptic malignant syndrome (NMS) 1 month following initiation of fluphenazine for behavioral therapeutic management. Dexmedetomidine infusion was able to adequately control the symptoms of NMS with resolution of encephalopathy. This was the first report of novel dexmedetomidine utilization for the treatment of NMS. We suggest using dexmedetomidine as an adjunctive agent to control NMS symptomatology without attendant risk of respiratory depression.

Psychopharmacologic Treatment of Schizophrenia in Adolescents and Children

An increasing number of antipsychotic medications have demonstrated efficacy in randomized placebo-controlled trials in the treatment of children and adolescents with schizophrenia. This review summarizes and synthesizes relevant antipsychotic medication studies, with particular emphasis on second-generation agents, and discusses other clinical considerations that may influence medication selection. With the exception of clozapine demonstrating superior efficacy in the improvement of psychotic symptoms in treatment-resistant patients, many antipsychotic agents have been shown to be similarly efficacious, including first-generation medications. Consideration of the side-effect profile, which can differ substantially from medication to medication, is essential when choosing treatment options.

Strategies to counter antipsychotic-associated weight gain in patients with schizophrenia

Introduction: Patients living with schizophrenia have a marked risk of clinically significant weight gain and obesity compared to the general population. The risks have been highlighted following the introduction of second-generation antipsychotics. In turn, obesity is associated with a higher prevalence of cardiovascular disease, the most common cause of premature mortality in patients with schizophrenia.Areas covered: In this review, the authors outline possible mechanisms that induce obesity in patients with schizophrenia taking antipsychotics. The authors discuss the safety and effectiveness of three main approaches for attenuating antipsychotic-associated weight gain (AAWG), including lifestyle interventions, switching antipsychotics, and augmentation with other medications.Expert opinion: When selecting antipsychotics, effective treatment of psychotic symptoms should be highest priority but obesity and related metabolic comorbidities associated with antipsychotics should not be neglected. Further research into mechanisms of weight gain associated with antipsychotics will guide future treatments for AAWG and development of antipsychotics that produce minimal metabolic adverse effects. With current strategies only producing modest weight loss in already overweight and obese individuals, clinicians should transition to an approach where they aim to prevent weight gain when initiating antipsychotic treatment.

Psychocutaneous disease: Pharmacotherapy and psychotherapy

Building a strong therapeutic alliance with the patient is of utmost importance in the management of psychocutaneous disease. Optimal management of psychocutaneous disease includes both pharmacotherapy and psychotherapy. This article reviews psychotropic medications currently used for psychocutaneous disease, including antidepressants, antipsychotics, mood stabilizers, and anxiolytics, with a discussion of relevant dosing regimens and adverse effects. Pruritus management is addressed. In addition, basic and complex forms of psychotherapy, such as cognitive-behavioral therapy and habit-reversal training, are described.

An Inter-Ethnic Comparison Study of Ziprasidone Plasma Levels, Dosage and Clinical Response in Patients with Schizophrenia

OBJECTIVE

The aim of this study was to investigate ziprasidone plasma concentration, daily dose and clinical efficacy and safety in Han Chinese and Mongolian patients with first-episode schizophrenia.

METHODS

A total of 123 inpatients affected by schizophrenia were recruited from the Mental Health Center of Inner Mongolia in China. Ziprasidone plasma concentration, clinical efficacy and side effects were systematically evaluated at baseline, and at 1, 2, 4, and 6 weeks. Metabolic measures such as changes in weight, body mass index (BMI), fasting blood glucose (FBG), triglycerides, and cholesterol, were also recorded.

RESULTS

90 patients completed the study. Compared with Han patients, on average, Mongolian patients received a significantly higher ziprasidone dosage for adequate symptom control during the 6-week period and had a lower plasma concentration-to-dose ratio. The Mongolian patients also experienced greater increases in weight and BMI. No significant differences between the two ethnic groups were found in the rate of reduction in the Positive and Negative Syndrome Scale (PANSS) score, Treatment Emergent Symptom Scale (TESS) total score, FBG, triglycerides, cholesterol or Q-Tc interval.

CONCLUSION

Compared to Han Chinese patients, Mongolian patients appeared to have increased ziprasidone clearance and require higher doses to achieve effective treatment for schizophrenia.

Augmentation of clozapine with ziprasidone in refractory schizophrenia: a double-blind, placebo-controlled study

The present 16-week double-blind, randomized, placebo-controlled trial was aimed to explore the efficacy of ziprasidone add-on pharmacotherapy on clinical symptoms and cognitive functioning in 40 schizophrenic patients (active group, n = 20; placebo group, n = 20) with residual symptoms (Brief Psychiatric Rating Scale mean [SD] baseline total score in active group vs placebo, 40.4 [5.9] vs 37.9 [6.8]) despite receiving clozapine monotherapy at the highest tolerated dosage. The results obtained evidenced that ziprasidone augmentation of clozapine significantly reduced Positive and Negative Syndrome Scale "Negative" (P = 0.006, mean change [SD] in active group vs placebo, -2.7 [2.3] vs 1.1 [2.1], Cohen d = 1.7) and "General Psychopathology" (P = 0.009, mean change [SD] in active group vs placebo, -5.3 [3.8] vs -0.7 [2.0], Cohen d = 1.5). Regarding cognitive domains, ziprasidone was more effective than placebo in improving semantic fluency (P < 0.0001, mean change [SD] in active group vs placebo, 4.4 [3.5] vs -0.1 [4.1], Cohen d = 1.2). Ziprasidone had only a small effect on prolongation of heart-rate corrected QT interval (QTc) of the electrocardiogram, not significantly different from placebo (QTc milliseconds, mean [SD], week 16 in active group vs placebo, 408.17 [20.85] vs 405.45 [17.11], P = 0.321); within-group comparison revealed that QTc prolongation induced by ziprasidone was statistically significant (baseline vs week 16, P = 0.002). Ziprasidone added to clozapine was effective on negative and cognitive symptoms, although it may be proposed as a helpful treatment in schizophrenia, mainly for those patients who partially respond to clozapine monotherapy.

Treatment of bipolar mania with atypical antipsychotics

Acute manic episodes in bipolar disorder require rapid and effective relief. Pharmacotherapy has traditionally involved mood stabilizers such as lithium or divalproex. Evidence for the efficacy of atypical antipsychotics to treat bipolar mania, either as monotherapy or in combination with traditional mood-stabilizing agents, has increased in recent years. Since the combination of an atypical agent and a traditional mood stabilizer is generally well tolerated, it represents a first-line approach for the treatment of severe and treatment-resistant mania. Atypical antipsychotics have a superior neurological tolerability profile compared with typical antipsychotics and are preferentially recommended in most treatment guidelines. The atypical agents, olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole, have demonstrated efficacy in bipolar mania in large randomized, controlled studies, and offer efficacy across a broader range of symptoms than typical antipsychotics, and may even have mood-stabilizing properties traditionally associated with lithium and divalproex. Olanzapine, risperidone and quetiapine have been shown to be effective for manic episodes both as monotherapy and in combination with other agents such as lithium and divalproex. Although the tolerability profiles of atypicals as a class are superior to those of conventional antipsychotics, there are differences among the atypical agents in their propensity to cause certain adverse events such as extrapyramidal symptoms (EPS) and weight gain, particularly in the long-term. The ultimate choice of the atypical agent will depend on the patient's individual needs, but atypical antipsychotics are clinically effective options for achieving mood stabilization in the treatment of acute bipolar mania.

Behavioral and metabolic effects of the atypical antipsychotic ziprasidone on the nematode Caenorhabditis elegans

Atypical antipsychotics are associated with metabolic syndrome, primarily associated with weight gain. The effects of Ziprasidone, an atypical antipsychotic, on metabolic syndrome has yet to be evaluated. Here in, we evaluated lipid accumulation and behavioral changes in a new experimental model, the nematode Caenorhabditis elegans (C. elegans). Behavioral parameters in the worms were evaluated 24 h after Ziprasidone treatment. Subsequently, lipid accumulation was examined using Nile red, LipidTox green and BODIPY labeling. Ziprasidone at 40 µM for 24 h effectively decreased the fluorescence labeling of all markers in intestinal cells of C. elegans compared to control (0.16% dimethyl sulfoxide). Ziprasidone did not alter behaviors related to energetic balance, such as pharynx pumping, defecation cycles and movement. There was, however, a reduction in egg-production, egg-laying and body-length in nematodes exposed to Ziprasidone without any changes in the progression of larval stages. The serotoninergic pathway did not appear to modulate Ziprasidone’s effects on Nile red fluorescence. Additionally, Ziprasidone did not alter lipid accumulation in daf-16 or crh-1 deletion mutants (orthologous of the transcription factors DAF-16 and CREB, respectively). These results suggest that Ziprasidone alters reproductive behavior, morphology and lipid reserves in the intestinal cells of C. elegans. Our results highlight that the DAF-16 and CREB transcription factors are essential for Ziprasidone-induced fat store reduction.

Antipsychotics activate the TGFβ pathway effector SMAD3

Although effective in treating an array of neurological disorders, antipsychotics are associated with deleterious metabolic side effects. Through high-throughput screening, we previously identified phenothiazine antipsychotics as modulators of the human insulin promoter. Here, we extended our initial finding to structurally diverse typical and atypical antipsychotics. We then identified the transforming growth factor beta (TGFβ) pathway as being involved in the effect of antipsychotics on the insulin promoter, finding that antipsychotics activated SMAD3, a downstream effector of the TGFβ pathway, through a receptor distinct from the TGFβ receptor family and known neurotransmitter receptor targets of antipsychotics. Of note, antipsychotics that do not cause metabolic side effects did not activate SMAD3. In vivo relevance was demonstrated by reanalysis of gene expression data from human brains treated with antipsychotics, which showed altered expression of SMAD3 responsive genes. This work raises the possibility that antipsychotics could be designed that retain beneficial CNS activity while lacking deleterious metabolic side effects.

Clinical pharmacology of dopamine-modulating agents in Tourette's syndrome

Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.

Cardiologic side effects of psychotropic drugs

Psychotropic drugs can produce cardiovascular side effects associated with a degree of cardiotoxicity. The coexistence of a heart disease complicates the management of mental illness, can contribute to a reduced quality of life and a worse illness course. The co-occurrence of psychiatric disorders in cardiac patients might affect the clinical outcome and morbidity. Moreover, the complex underlying mechanism that links these two conditions remains unclear. This paper discusses the known cardiovascular complications of psychotropic drugs and analyzes the important implications of antidepressive treatment in patients with previous cardiac history.

The effect of ziprasidone on body weight and energy expenditure in female rats

Ziprasidone, a novel antipsychotic agent with a unique receptor-binding profile, has been reported to have lower propensity for weight gain compared with other atypical antipsychotics. Here, we examined the effects of ziprasidone on resting energy expenditure, physical activity, thermogenesis, food intake, and weight gain in female Sprague-Dawley rats. Ziprasidone (20 mg/kg) or vehicle was administered once daily for 7 weeks; and body weight, food intake, resting energy expenditure, locomotor activity, colonic temperature on cold exposure, and abdominal fat were measured. Compared with control animals, ziprasidone-treated rats gained significantly less weight (P = .031), had a lower level of physical activity (P = .016), showed a higher resting energy expenditure (P < .001), and displayed a greater capacity for thermogenesis when subjected to cold (P < .001). In addition, ziprasidone-treated rats had a lower level of abdominal fat than did controls, although the difference was not significant. Ziprasidone had no effect on food intake. Our results indicate that, in female Sprague-Dawley rats, a 7-week treatment regimen of ziprasidone induces a significant decrease in weight gain by increasing resting energy expenditure without decreasing food intake and even with a lower level of physical activity. Further studies are needed to elucidate the precise mechanism of lower propensity of weight gain of ziprasidone.

Pattern of acute induction of Homer1a gene is preserved after chronic treatment with first- and second-generation antipsychotics: effect of short-term drug discontinuation and comparison with Homer1a-interacting genes

Homer1a is a glutamate-related gene whose expression is induced by antipsychotics acutely (i.e. 90 min after treatment). Acute Homer1a expression is preserved after prolonged antipsychotic treatments, while the effects of short-term discontinuation after chronic antipsychotic treatment have not yet been assessed. Here, we studied early and long-term effects on gene expression by antipsychotics for Homer1a and other components of glutamatergic synapses. In the first paradigm, we evaluated Homer1a acute expression by single administration of antipsychotics (haloperidol 0.8 mg/kg, ziprasidone 10 and 4 mg/kg, clozapine 15 mg/kg). Haloperidol and ziprasidone induced Homer1a in the striatum. Induction by ziprasidone was dose-dependent. These results suggest that acute Homer1a expression correlates with dopaminergic affinity and motor side effects of antipsychotics. In the second paradigm, we studied antipsychotic-mediated long-term changes in Homer1a and glutamate-related genes. Rats were treated (21 days) with haloperidol 0.8 mg/kg, ziprasidone 4 mg/kg, or vehicle, and then sacrificed at 90 min (early time-point) or 24 h (delayed time-point) after last injection. Gene expression at these two time-points was compared. Homer1a preserved its pattern of expression at the early but not at the delayed time-point. Significant changes were also observed for PSD-95. The results suggest that Homer1a preserves its expression profile after chronic antipsychotics.

Atypical Antipsychotics for the Treatment of ICU Delirium

Delirium is commonly described in critically ill patients as 1 factor contributing to increased length of intensive care unit and hospital stay, secondary complications, and increased mortality. Initial screening tools for delirium in hospitalized patients are generally easy to use; however, many centers have struggled with implementing these tools in a consistent and systematic manner. Haloperidol has traditionally been prescribed as the primary agent of choice for the treatment of delirium in critically ill patients. Clinicians have been challenged to consider alternative agents due to adverse effects such as extrapyramidal symptoms, QTc prolongation, and possible torsades de pointes with haloperidol use. The atypical antipsychotics are attractive alternatives to haloperidol with improved safety profiles but are flawed by limited data to support dosing and efficacy in this patient population. Future studies that provide large, prospective, double-blinded, placebo-controlled data to support the implementation of these agents as standard therapy over haloperidol are needed.

Effect of ziprasidone dose on all-cause discontinuation rates in acute schizophrenia and schizoaffective disorder: a post-hoc analysis of 4 fixed-dose randomized clinical trials

BACKGROUND

Higher dose ziprasidone has been associated with improved treatment outcomes in patients with schizophrenia or schizoaffective disorder. This study examines the relationship of ziprasidone dose and all-cause discontinuation in randomized clinical trials in patients with an acute exacerbation of schizophrenia or schizoaffective disorder.

METHOD

Data were analyzed for the first 28 days from 4 pivotal, randomized, double-blind, fixed-dose ziprasidone trials. Patients in these trials had a DSM-IV diagnosis of schizophrenia or schizoaffective disorder where ziprasidone was administered twice daily with food. Data were analyzed to examine the association between ziprasidone dose and all-cause discontinuation due to lack of efficacy, adverse events, or because of other reasons, relative to placebo. Differences in discontinuation were evaluated using Cox proportional hazard models and number needed to treat (NNT).

RESULTS

All-cause discontinuation for ziprasidone ranged from a low of 26.9% for the 160 mg/d dose group, to 40.9% for the 40 mg/d and 45.5% for the 80 mg/d groups, compared with 49.5% for placebo. The NNTs for avoiding 1 additional all-cause discontinuation compared with placebo were 12 (40 mg/d; n=186), 25 (80 mg/d; n=154), 9 (120 mg/d; n=125), and 4 (160 mg/d; n=104). The 120 mg/d and 160 mg/d groups were the only ziprasidone regimens associated with significantly lower all-cause discontinuation rates versus placebo in both the survival analysis (p=0.031 and <0.0001, respectively) and in examination of the NNT. The 160 mg/d group was associated with lower all-cause discontinuation rates versus lower-dose ziprasidone regimens (p=0.0158 for versus 40 mg/d, p=0.002 for versus 80 mg/d). Efficacy accounted for 51% of all medication discontinuations across ziprasidone groups, compared with 62% for placebo. Findings for overall discontinuation due to lack of efficacy are consistent with results for all-cause discontinuation.

CONCLUSIONS

Consistent with previous reports, higher doses of ziprasidone (120-160 mg/d, dosed twice daily with meals) are associated with significantly lower all-cause discontinuation rates and more favorable NNTs versus placebo. This was primarily driven by lower rates of discontinuation due to lack of efficacy.

In thrombin stimulated human platelets Citalopram, Promethazine, Risperidone, and Ziprasidone, but not Diazepam, may exert their pharmacological effects also through intercalation in membrane phospholipids in a receptor-independent manner

Intercalation of drugs in the platelet membrane affects phospholipid-requiring enzymatic processes according to the drugs' intercalation capability. We investigated effects of Promethazine, Citalopram, Ziprasidone, Risperidone, and Diazepam on phospholipase A(2) (PLA(2)) and polyphosphoinositide (PPI) metabolism in thrombin-stimulated human platelets. We also examined effects of the drugs on monolayers of glycerophospholipids using the Langmuir technique. Diazepam did not influence PLA( 2 ) activity, had no effects on PPI cycle, and caused no change in mean molecular area of phospholipid monolayers. The remaining psychotropic drugs affected these parameters in different ways and levels of potency suggesting that they act by being intercalated between the molecules of adjacent membrane phospholipids, thus causing changes in substrate availability for phospholipid-hydrolyzing enzymes (PLA(2) and Phospholipase C). We show that several psychotropic drugs can also have other cellular effects than receptor antagonism. These effects may be implicated in the psychotropic effects of the drugs and/or their side effects.

Weight gain and metabolic issues of medicines used for bipolar disorder

Patients with bipolar disorder are at high risk of gaining weight and developing metabolic illnesses, and pharmacologic treatment for the disorder may significantly increase this risk. This paper reviews the literature on the metabolic consequences of the medications used in bipolar disorder and describes the possible strategies to prevent, monitor, and treat the common metabolic illnesses that patients with bipolar disorder may develop during treatment.

Hyperprolactinemia and amenorrhea associated with olanzapine normalized after addition of aripiprazole

Hyperprolactinemia is a frequent side-effect in the use of atypical antipsychotics. The propensity to induce hyperprolactinemia is highly substance dependent and hyperprolactinemia is not always associated with clinical side-effects. We report a case in which hyperprolactinemia and amenorrhea under the treatment with olanzapine gets normalized after the addition of aripiprazole.

Determination of ziprasidone in human plasma by liquid chromatography–electrospray tandem mass spectrometry and its application to plasma level determination in schizophrenia patients

An accurate, rapid and simple liquid chromatography-tandem mass spectrometry (LC-MS-MS) assay method was developed for the determination of ziprasidone (ZIP) in the plasma of schizophrenia patients. A simple one step liquid-liquid extraction with 20% methylene dichloride in pentane was used to isolate ZIP and the internal standard from the plasma matrix. The compounds were separated on a C-18 column by an isocratic elution and the eluted compounds were analyzed by a triple quadrupole mass spectrometer with a TurboIon spray interface using the positive ion atmospheric pressure electrospray ionization method and detected using multiple reaction monitoring mode. The ZIP standard calibration curve was linear over the range of 0.25-500ng/ml when 0.5ml of plasma was used for the analysis (r(2)>0.998). The intra-assay (within-day) and inter-assay (between-day) variations were less than 12% for the spiked standard curve and quality control samples. The absolute extraction efficiency was 82% for ZIP and 68% for INS-RSP. The analysis time for each sample was less than 3min and useful for high turnaround plasma level determinations. This LC-MS-MS assay method for ZIP is highly specific, sensitive, accurate and rapid and is currently being used for the plasma level determination of ZIP in schizophrenia patients treated with various daily oral doses of ZIP. The data showed large inter-individual variations.

Clinical Pharmacokinetics of Atypical Antipsychotics

In the past, the information about the dose-clinical effectiveness of typical antipsychotics was not complete and this led to the risk of extrapyramidal adverse effects. This, together with the intention of improving patients' quality of life and therapeutic compliance, resulted in the development of atypical or second-generation antipsychotics (SGAs). This review will concentrate on the pharmacokinetics and metabolism of clozapine, risperidone, olanzapine, quetiapine, amisulpride, ziprasidone, aripiprazole and sertindole, and will discuss the main aspects of their pharmacodynamics. In psychopharmacology, therapeutic drug monitoring studies have generally concentrated on controlling compliance and avoiding adverse effects by keeping long-term exposure to the minimal effective blood concentration. The rationale for using therapeutic drug monitoring in relation to SGAs is still a matter of debate, but there is growing evidence that it can improve efficacy, especially when patients do not respond to therapeutic doses or when they develop adverse effects. Here, we review the literature concerning the relationships between plasma concentrations of SGAs and clinical responses by dividing the studies on the basis of the length of their observation periods. Studies with clozapine evidenced a positive relationship between plasma concentrations and clinical response, with a threshold of 350-420 ng/mL associated with good clinical response. The usefulness of therapeutic drug monitoring is well established because high plasma concentrations of clozapine can increase the risk of epileptic seizures. Plasma clozapine concentrations seem to be influenced by many factors such as altered cytochrome P450 1A4 activity, age, sex and smoking. The pharmacological effects of risperidone depend on the sum of the plasma concentrations of risperidone and its 9-hydroxyrisperidone metabolite, so monitoring the plasma concentrations of the parent compound alone can lead to erroneous interpretations. Despite a large variability in plasma drug concentrations, the lack of studies using fixed dosages, and discrepancies in the results, it seems that monitoring the plasma concentrations of the active moiety may be useful. However, no therapeutic plasma concentration range for risperidone has yet been clearly established. A plasma threshold concentration for parkinsonian side effects has been found to be 74 ng/mL. Moreover, therapeutic drug monitoring may be particularly useful in the switch between the oral and the long-acting injectable form. The reviewed studies on olanzapine strongly indicate a relationship between clinical outcomes and plasma concentrations. Olanzapine therapeutic drug monitoring can be considered very useful in assessing therapeutic efficacy and controlling adverse events. A therapeutic range of 20-50 ng/mL has been found. There is little evidence in favour of the existence of a relationship between plasma quetiapine concentrations and clinical responses, and an optimal therapeutic range has not been identified. Positron emission tomography studies of receptor blockade indicated a discrepancy between the time course of receptor occupancy and plasma quetiapine concentrations. The value of quetiapine plasma concentration monitoring in clinical practice is still controversial. Preliminary data suggested that a therapeutic plasma amisulpride concentration of 367 ng/mL was associated with clinical improvement. A therapeutic range of 100-400 ng/mL is proposed from non-systematic clinical experience. There is no direct evidence concerning optimal plasma concentration ranges of ziprasidone, aripiprazole or sertindole.

Adverse Effects of Atypical Antipsychotics in the Elderly

Use of antipsychotic medication is very common in the elderly and often an essential therapy. However, successful treatment in the elderly requires appropriate multidimensional assessment of the patient, knowledge of possible multiple co-morbidities, and awareness of the complexities of polypharmacy, age-dependent changes in pharmacokinetics and pharmacodynamics, and drug-drug interactions in this age group. Antipsychotics are known to have a number of adverse effects. New antipsychotics, such as amisulpride, clozapine, olanzapine, risperidone, quetiapine, ziprasidone, zotepine and aripiprazole, may interact with both dopamine and serotonin receptors. However, compared with conventional antipsychotics, they are less likely to cause extrapyramidal symptoms and are better tolerated in the elderly. At the same time, consistent differences between atypical antipsychotics have been demonstrated. Use of clozapine, for example, is limited by the risk of agranulocytosis, whereas this is not a disadvantage of olanzapine, risperidone, quetiapine and, more recently, ziprasidone, which are being widely used with good results in schizophrenia. However, use of the latter agents to treat the behavioural and psychological symptoms of dementia has been restricted because of recent observations of increased cardiovascular events in patients taking risperidone and olanzapine treatment. Nonetheless, careful review of the literature suggests that the available evidence does not support any causal relationship between use of risperidone or olanzapine and cardiovascular events. This article focuses on some of the main adverse effects commonly reported during administration of atypical antipsychotics to elderly patients. Such effects may be partly explained by age-related changes in pharmacokinetics and pharmacodynamics, and partly by the characteristics of the drugs themselves and their different receptor binding profiles.

Psychotropic medication use at a private eating disorders treatment facility: A retrospective chart review and descriptive data analysis

BACKGROUND

The extent of psychotropic medication use in patients with eating disorders worldwide is unknown.

OBJECTIVES

THE PURPOSES OF THIS STUDY WERE TO: (1) describe the extent and pattern of psychotropic medication use at a private treatment facility for patients with eating disorders and (2) describe patient characteristics and treatment outcomes at the facility.

METHODS

This retrospective chart review included data from a private treatment facility (inpatient or outpatient) for patients with eating disorders in the greater Los Angeles area. Data from all patients of any age who attended the facility between January 1, 2004, and January 1, 2005, and who met the criteria for anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (ED NOS) defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were included. Two investigators used a consistent chart-review method for recording clinical status, including treatment-related adverse effects and discharge status (improved, no change, or decompensated from admission). Improved was defined as meeting 1 or more of the following criteria: achieved ideal body weight, stabilized mood, decreased eating disorder symptoms (binge-purge, restrictive, or ritualistic behavior), eating disorder remission, or decreased suicidal ideation plus another improvement in this list.

RESULTS

Data from 60 patients were included (31 with AN, 28 with 13N, and I with ED NOS). Ages ranged from 12 to 47 years, and the mean duration of treatment was 35 days. Fifty-eight (96.7%) patients received a psychotropic agent; 35 (58.3%) patients were prescribed 2 or more agents concomitantly. Selective serotonin reuptake inhibitors (SSRls) were the most commonly prescribed class of psychotropic medication (86.7%), followed by antipsychotics (38.3%). Fluoxetine, escitalopram, and aripiprazole were the most commonly prescribed agents (41.7%, 28.3%, and 23.3%, respectively). A total of 63.3% of patients had a comorbid diagnosis of major depressive disorder, with 96.7% of these patients prescribed an antidepressant. At discharge, 51.6% of the inpatients and 37.9% of the outpatients had improved (AN, 52.6% and 33.3%, respectively; BN, 54.5% and 41.2%, respectively). Of the patients prescribed an SSRI, 40.4% had improved. In the inpatient setting, 35.5% of patients receiving an antipsychotic had improved, versus 6.9% in the outpatient setting.

CONCLUSIONS

The results of this retrospective chart review and descriptive analysis of data from patients at a private eating disorders treatment facility in the United States suggest that psychotropics, particularly antidepressants and antipsychotics, were highly utilized, largely to treat comorbid symptoms. Fluoxetine, escitalopram, and aripiprazole were the most commonly prescribed agents. We observed that psychotropic medication selection was based on patient comorbidities and symptom expression and severity.

Antipsychotic drugs and QT prolongation

Antipsychotic drugs (AD) are effective and frequently prescribed to more females than males. AD may cause serious cardiovascular side-effects, including prolonged QT interval, eventually leading to torsades de pointes (TdP) and sudden death. Epidemiologic data and case-control studies indicate an increased rate of sudden death in psychiatric patients taking AD. This review summarizes current knowledge about the QT prolonging effects of AD and gives practical suggestions. Amisulpride, clozapine, flupenthixol, fluphenazine, haloperidol, melperone, olanzapine, perphenazine, pimozide, quetiapine, risperidone, sulpiride, thioridazine and ziprasidone cause a QT prolongation ranging from 4 ms for risperidone to 30 ms for thioridazine. Our knowledge about the QT-prolonging effects of many AD is still limited. Females are under-represented in most studies. Many studies were conducted or supported by pharmaceutical companies. To avoid prodysrhythmia caused by QT prolongation, other factors influencing QT interval have to be considered, such as other drugs affecting the same pathway, hypokalemia, hypomagnesemia, bradycardia, increased age, female sex, congestive heart failure and polymorphisms of genes coding ion channels or enzymes involved in drug metabolism. Because the response of a patient to AD is individual, an electrocardiogram recording the QT interval has to be performed at baseline, after AD introduction and after occurrence of any factor that might influence the QT interval.

Efficacy of olanzapine and ziprasidone for the treatment of schizophrenia: a systematic review

It is difficult to determine the relative efficacy of atypical antipsychotics for the treatment of schizophrenia, based on the available literature. The purpose of this article is to review and compare the efficacy of two atypical antipsychotics: olanzapine and ziprasidone.This review focused on randomised trials in which these two antipsychotics were compared with placebo, conventional antipsychotics and each other. Common efficacy measures were the Brief Psychiatric Rating Scale, Positive and Negative Syndrome Scale and Schedule for Assessment of Negative Symptoms. When sufficient data were available, the mean treatment effect (with 95% confidence intervals) was computed and presented. Olanzapine was consistently found to be significantly superior to placebo and comparable with, or superior to, haloperidol for the treatment of overall, positive and negative schizophrenic symptoms. Ziprasidone appears to have significantly greater efficacy than placebo for overall and negative symptoms, but it remains uncertain whether ziprasidone is comparable in efficacy with conventional antipsychotics such as haloperidol. Two unpublished clinical trials have directly compared olanzapine and ziprasidone. One of these trials found no significant efficacy differences between the two drugs, whereas the results of the other study favoured olanzapine. Compared with ziprasidone, olanzapine has a larger body of evidence supporting its efficacy, and a greater proportion of findings for olanzapine have been published, allowing for greater scrutiny of results. Both drugs appear to be superior to placebo for the treatment of overall and negative symptoms of schizophrenia, but olanzapine generally compares more favourably with conventional antipsychotics. Firm conclusions regarding the comparison between olanzapine and ziprasidone require additional published trials on ziprasidone, particularly in direct comparison with olanzapine.

Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review

Increasing numbers of reports concerning diabetes, ketoacidosis, hyperglycaemia and lipid dysregulation in patients treated with second-generation (or atypical) antipsychotics have raised concerns about a possible association between these metabolic effects and treatment with these medications. This comprehensive literature review considers the evidence for and against an association between glucose or lipid dysregulation and eight separate second-generation antipsychotics currently available in the US and/or Europe, specifically clozapine, olanzapine, risperidone, quetiapine, zotepine, amisulpride, ziprasidone and aripiprazole. This review also includes an assessment of the potential contributory role of treatment-induced weight gain in conferring risk for hyperglycaemia and dyslipidaemia during treatment with different antipsychotic medications. Substantial evidence from a variety of human populations, including some recent confirmatory evidence in treated psychiatric patients, indicates that increased adiposity is associated with a variety of adverse physiological effects, including decreases in insulin sensitivity and changes in plasma glucose and lipid levels. Comparison of mean weight changes and relative percentages of patients experiencing specific levels of weight increase from controlled, randomised clinical trials indicates that weight gain liability varies significantly across the different second generation antipsychotic agents. Clozapine and olanzapine treatment are associated with the greatest risk of clinically significant weight gain, with other agents producing relatively lower levels of risk. Risperidone, quetiapine, amisulpride and zotepine generally show low to moderate levels of mean weight gain and a modest risk of clinically significant increases in weight. Ziprasidone and aripiprazole treatment are generally associated with minimal mean weight gain and the lowest risk of more significant increases. Published studies including uncontrolled observations, large retrospective database analyses and controlled experimental studies, including randomised clinical trials, indicate that the different second-generation antipsychotics are associated with differing effects on glucose and lipid metabolism. These studies offer generally consistent evidence that clozapine and olanzapine treatment are associated with an increased risk of diabetes mellitus and dyslipidaemia. Inconsistent results, and a generally smaller effect in studies where an effect is reported, suggest limited if any increased risk for treatment-induced diabetes mellitus and dyslipidaemia during risperidone treatment, despite a comparable volume of published data. A similarly smaller and inconsistent signal suggests limited if any increased risk of diabetes or dyslipidaemia during quetiapine treatment, but this is based on less published data than is available for risperidone. The absence of retrospective database studies, and little or no relevant published data from clinical trials, makes it difficult to draw conclusions concerning risk for zotepine or amisulpride, although amisulpride appears to have less risk of treatment-emergent dyslipidaemia in comparison to olanzapine. With increasing data from clinical trials but little or no currently published data from large retrospective database analyses, there is no evidence at this time to suggest that ziprasidone and aripiprazole treatment are associated with an increase in risk for diabetes, dyslipidaemia or other adverse effects on glucose or lipid metabolism. In general, the rank order of risk observed for the second-generation antipsychotic medications suggests that the differing weight gain liability of atypical agents contributes to the differing relative risk of insulin resistance, dyslipidaemia and hyperglycaemia. This would be consistent with effects observed in nonpsychiatric samples, where risk for adverse metabolic changes tends to increase with increasing adiposity. From this perspective, a possible increase in risk would be predicted to occur in association with any treatment that produces increases in weight and adiposity. However, case reports tentatively suggest that substantial weight gain or obesity may not be a factor in up to one-quarter of cases of new-onset diabetes that occur during treatment. Pending further testing from preclinical and clinical studies, limited controlled studies support the hypothesis that clozapine and olanzapine may have a direct effect on glucose regulation independent of adiposity. The results of studies in this area are relevant to primary and secondary prevention efforts that aim to address the multiple factors that contribute to increased prevalence of type 2 diabetes mellitus and cardiovascular disease in populations that are often treated with second-generation antipsychotic medications.

Rapid dose escalation with quetiapine: a pilot study

The original dosing recommendations for quetiapine in the treatment of schizophrenia suggested escalation to 400 mg/d using the following schedule, administered twice daily in divided doses: Day 1, 50 mg; Day 2, 100 mg; Day 3, 200 mg; Day 4, 300 mg; Day 5, 400 mg. In practice, however, clinicians often exceed these recommendations because of the need to obtain a therapeutic response in patients with psychosis as quickly as possible. This study was designed to determine a faster tolerable dosage-escalation schedule for quetiapine in acutely ill, hospitalized patients with schizophrenia. In this multicenter, placebo-controlled, double-blind pilot study, adult patients were randomly assigned to escalation schedules that would achieve a target dosage of 400 mg/d in either 5, 3, or 2 days. Safety and tolerability were assessed by interviews, physical examinations and vital signs, laboratory tests, and electrocardiograms. The enrolled population consisted of 69 patients who were randomized to 1 of the 3 dose-escalation schedules. Treatment-related adverse events were few among the 67 evaluable patients, with most rated as mild in intensity. Among 69 enrolled patients, only 3 withdrew because of an adverse event (agitation). Objective assessments and adverse events were similar between the 3 groups. In this study of patients with acute schizophrenia, quetiapine dosage was increased to 400 mg/d in 5, 3, and 2 days with similar safety and tolerability, suggesting that escalation to therapeutically effective dosages can be accomplished in less than 5 days.

Additive effects of ziprasidone and d,l-sotalol on the action potential in rabbit Purkinje fibres and on the hERG potassium current

INTRODUCTION

Ziprasidone, an atypical antipsychotic has been shown to be devoid of cardiac adverse effects in spite of its propensity to prolong the QT-interval via a hERG current inhibition. However, the effects of ziprasidone on the action potential (AP) parameters have not been published yet. Moreover, very little information is available concerning pharmacodynamic interactions between ziprasidone and other hERG channel blockers. Thus, we investigated the putative interaction between ziprasidone and D,L-sotalol on the hERG channels at therapeutic concentrations and their consequences on the action potential prolongation.

METHODS

AP were recorded at 1 and 0.2 Hz. Increasing concentrations of ziprasidone (0.01-10 micromol/L) were successively superfused for 30 min alone or in D,L-sotalol 10 micromol/L pre-treated fibres. Moreover, the effects of ziprasidone, alone or in association with d,l-sotalol, were investigated on the hERG current.

RESULTS

Ziprasidone (1-10 microM) induced a concentration and reverse frequency-dependent increase in APD(90) (APD(90): +27% and +36%, respectively at 1 Hz and +50% and +70%, respectively at 0.2 Hz) due to a hERG current blockade (IC50: 0.24 micromol/L). A pre-treatment with D,L-sotalol 10 micromol/L led to an increase in APD(90) of +23% at 1 Hz, stable at 66+/-4 min. In these pre-treated fibres, ziprasidone (1 and 10 micromol/L) induced an additional AP prolongation (APD(90): +16% and +18%, respectively at 1 Hz) as compared to D,L-sotalol pre-treatment. Moreover, D,L-sotalol did not interact with the pharmacological profile of ziprasidone on the hERG channel.

CONCLUSION

The present study demonstrates that ziprasidone induces an AP prolongation due to its propensity to block the hERG channel. Moreover, ziprasidone and d,l-sotalol, superfused concomitantly exhibit additive effects on the AP duration since they do not interact as competitors for the hERG channel.

Striatal dopaminergic D2 receptor occupancy and clinical efficacy in psychosis exacerbation: a 123I-IBZM study with ziprasidone and haloperidol

OBJECTIVE

The aim of this study was to compare striatal dopaminergic D2 receptor occupancy (D2 RO) induced by ziprasidone and haloperidol and its relationship with clinical response and extrapyramidal side effects (EPS) in patients with acute psychosis exacerbation.

METHOD

Twenty patients hospitalized with an acute psychosis exacerbation were randomised in a single-blind study to receive either ziprasidone (80-120 mg/day) or haloperidol (5-20 mg/day) for more than 2 weeks. When stable doses were achieved, data on 123I-IBZM single-photon emission computed tomography (SPECT), as well as data on clinical efficacy (positive and negative symptoms scale [PANSS]) and EPS (Simpson Angus scale [SAS]), were compared between the two groups of patients. Clinical response was defined as a percentage of change of >30% in PANSS. Striatal D2 RO and clinical data were also compared between responders and nonresponders on each treatment group.

RESULTS

All patients on haloperidol and four patients on ziprasidone showed EPS. Mean D2 RO was significantly higher in the haloperidol (74.7+/-3.5) than in the ziprasidone (60.2+/-14.4) group (Mann Whitney U-test [M-W U-test] 8.50; p=0.002). Five patients were responders, and five were nonresponders on each group of treatment. Haloperidol responders and nonresponders did not differ in D2 RO, duration of treatment, doses or EPS. Ziprasidone responders were on higher doses than nonresponders and showed higher D2 RO although below 74%. A positive correlation of ziprasidone D2 RO was found with dose (r Spearman 0.87; p=0.001) and with SAS scores (r Spearman 0.88; p=0.001).

CONCLUSIONS

Ziprasidone induces lower D2 RO and EPS than haloperidol, which is consistent with an atypical antipsychotic profile. A direct relationship of ziprasidone D2 RO with dose, clinical efficacy and EPS has been found in this study. These data suggest that high ziprasidone doses might be more beneficial in patients with psychosis exacerbation and claim for caution regarding EPS appearance with such high dosages.

Neuroleptic malignant syndrome associated with ziprasidone in an adolescent

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal disorder characterized by fever, muscular rigidity, delirium, and autonomic instability. Although the classic presentation of NMS has been most commonly associated with the typical neuroleptic medications, sporadic cases in association with atypical neuroleptic medications have been reported.

OBJECTIVE

We describe a case report of a pediatric patient with NMS associated with the use of the atypical antipsychotic medication ziprasidone hydrochloride.

METHODS

After a MEDLINE search of relevant literature (key terms: atypical antipsychotic, ziprasidone, neuroleptic malignant syndrome, and NMS; years: 1995-2004), no reports of NMS in association with ziprasidone in the pediatric population were identified.

RESULTS

The patient was a 15-year-old male adolescent with a history of schizoaffective disorder treated with ziprasidone capsules, 80 mg QD for 8 weeks prior to presentation. He was brought to the emergency department because the family noted that the child had a tactile fever; was rigid, diaphoretic, tremulous, and difficult to arouse; and had persistent urinary incontinence. The patient was admitted to the pediatric intensive care unit, where he remained rigid and unresponsive except for incoherent speech. He was treated for a presumptive diagnosis of NMS with IV dantrolene sodium (2 mg/kg q6h) to reduce the sequele of NMS; urinary alkalinization with sodium bicarbonate to maintain a urinary pH of 6.5 to 7.0; cardiac, pulse oximetry, and vital sign monitoring; and supportive care, including IV saline hydration.

CONCLUSION

We present this case to alert physicians of the possibility of NMS in adolescent patients treated with ziprasidone.

Ziprasidone: first year experience in a hospital setting

BACKGROUND

The antipsychotic drug ziprasidone, FDA-approved and introduced in the United States in February 2001 for the treatment of schizophrenia, appears to have similar efficacy but better tolerability than older antipsychotics and requires further evaluation under clinical conditions.

METHODS

We analyzed medical records of McLean Hospital inpatients treated with ziprasidone between March 2001 and February 2002, gathering data on DSM-IV diagnoses, presenting symptoms, dosing, concomitant psychotropic medications, clinical changes, adverse effects, and electrocardiographic (ECG) findings.

RESULTS

Ziprasidone was given to 151 inpatients (3.4% of admissions; 108 women, 43 men), aged 37.5 +/- 11.4 years, who presented with depression (n = 79), psychosis (n = 46), mania (n = 18), bipolar mixed-states (n = 4), or other conditions (n = 4). Daily doses averaged 49.8 +/- 34.1 mg initially and 83.2 +/- 46.3 mg at discharge; the greatest dose increases during hospitalization (by a mean of 61%) were in patients with schizoaffective disorder (n = 46; 30% of cases). In 41 cases (27%), ziprasidone was the only antipsychotic at discharge; in 61 (40%) it was used with other antipsychotics. Ziprasidone was discontinued during hospitalization in 49 cases (32.5%), due to lack of efficacy (n = 26; 17.2%), adverse effects (n = 13, 8.6%), or reasons not stated (n = 10, 6.6%). Of 70 patients for whom ECG data were obtained during treatment with ziprasidone, 8 (11%) had QTc intervals > 450 msec during treatment, but none of the 39 patients with ECGs both before and during ziprasidone treatment showed clinically meaningful increases in QTc intervals. Ziprasidone was discontinued in 4 patients (2.6%) due to concern about QTc intervals, but in no case was the QTc interval > or = 500 msec or associated with clinical cardiac toxicity. Improvements in CGI and GAF scores from admission to discharge were similar across diagnoses and unrelated to length of stay or ziprasidone dose.

CONCLUSIONS

Ziprasidone was well tolerated by hospitalized patients with various major psychiatric disorders and may be of value in conditions other than schizophrenia.

Weight decline in patients switching from olanzapine to quetiapine

This open-label study investigated the strategy of switching patients who had gained excessive weight on olanzapine to quetiapine, with assessments of safety and continued efficacy as well as weight change. Patients who were psychiatrically stable on olanzapine but had gained >20% in weight and had body mass index >25 mg/kg(2) were switched to quetiapine over a 4-week period and followed for 6 weeks, the total study duration being 10 weeks. Assessments included weight change, antipsychotic efficacy using the Positive and Negative Symptom Syndrome Scale (PANSS), extrapyramidal adverse events using the Simpson-Angus Scale (SAS), and laboratory studies for metabolic measures. Of 16 enrolled patients, 12 completed the study. Mean weight loss was 2.25 kg (Cohen's d = 0.12; P = 0.03). There were no significant changes in PANSS total scores, SAS scores, or metabolic parameters. Switching patients to quetiapine, appears to be a viable strategy for managing olanzapine-induced weight gain as indicated by this 10-week open-label study. Prospective controlled trials of longer duration and larger number of subjects are needed.

Dose response and atypical antipsychotics in schizophrenia

Based on information from clinical trials, both the efficacy and adverse effects of conventional antipsychotics in the treatment of schizophrenia are dose related. The overlapping nature of these dose-response profiles limits the use of these agents. Atypical antipsychotics provide greater relief across the comorbid symptom domains of schizophrenia, but dose-response studies and clinical experience have revealed that some of these drugs also have dose limitations. This article reviews the dose-response relationships of the atypical antipsychotics as presented predominantly in pivotal, randomised studies (double-blind and otherwise). Limited data indicate that clozapine shows dose-related efficacy up to 600 mg/day in patients with treatment-resistant schizophrenia. However, higher dosages of clozapine may be associated with the risk of seizures. Risperidone demonstrates dose-related adverse events that compromise efficacy. The dose-response relationships for ziprasidone, quetiapine and aripiprazole are less well established. The efficacy of olanzapine appears to be dose related within the recommended dosage range of 10-20 mg/day, but clinical trials that have explored higher dosages suggest improved efficacy. Furthermore, the higher doses are not associated with a significantly increased incidence of adverse events. Further studies are clearly needed to fully characterise the dose-response relationships of atypical antipsychotics.

Antipsychotic treatment of psychosis associated with multiple sclerosis

This case report deals with the antipsychotic treatment in multiple sclerosis (MS). Psychiatric symptoms are a frequent event in patients with MS. However, there are only few systematic studies of antipsychotic treatment in MS patients. Most of the studies are related to clozapine due to the lack of neurological, particularly extrapyramidal side effects (EPS). Therefore, experiences with other atypical drugs are requested. This paper discusses the pros and cons of different atypical drugs using the example of one patient, who showed adverse effects after treatment with quetiapine and olanzapine. Risperidone was not administered with respect to possible EPS. However, ziprasidone was tolerated well and appeared to be effective.

The tolerability of intramuscular ziprasidone and haloperidol treatment and the transition to oral therapy

The intramuscular (i.m.) formulation of ziprasidone offers promise as an alternative to conventional i.m. agents for the short-term management of agitated patients with psychosis. This 7-day, randomized, open-label study evaluated the tolerability of ziprasidone i.m. and haloperidol i.m. in hospitalized patients with a psychotic disorder and moderate psychopathology. Patients received three fixed doses of ziprasidone i.m. 5 mg qid (n=69), 10mg qid (currently maximum recommended daily dose in USA; n=71), 20mg qid (n=66), or flexible-dose/ flexible-schedule haloperidol i.m. up to 10 mg bid-qid (n=100) for 3 days. This was followed by oral treatment with the same medication for 4 days. Ziprasidone i.m. was associated with a notably lower burden of movement disorders than haloperidol i.m. (mean 11 mg/day). No bradycardia, sinus pauses, disinhibition, confusion, excessive sedation or respiratory depression was observed with ziprasidone. No safety issues were identified with the coadministration of lorazepam with the i.m. formulations of either agent. All three ziprasidone i.m. doses and haloperidol i.m. maintained control of symptoms and, following the transition to oral treatment, symptoms remained controlled. Ziprasidone i.m. 5,10, and 20 mg qid, given for 3 days were well tolerated. The transition from i.m. to oral ziprasidone was well tolerated with continuing maintenance of symptom control.

Ziprasidone in Huntington's disease: the first case reports

Huntington's disease (HD) is a relentlessly progressive neuropsychiatric disorder with an underlying autosomal dominantly inherited genetic defect. Classical antipsychotics (i.e. phenothiazines or butyrophenones) are the most used medication to reduce the (probably dopamine-born) choreiform hyperkinesias. Ziprasidone is the latest of a new class of atypical antipsychotics; it has not been studied so far in this indication. We report three genetically confirmed HD patients who improved significantly in several categories of the motor scale of the Unified HD Rating Scale.

The relevance of prolonged QTc measurement to pediatric psychopharmacology

OBJECTIVE

To consider the relevance of prolonged QTc (QT interval corrected for rate) to pediatric psychopharmacology.

METHOD

The authors reviewed publications on QTc prolongation and publications on sudden death in Medline from 1968 to November 2002.

RESULTS

The search yielded more than 20,000 publications. Review manuscripts with clinical recommendations outnumber the few pediatric studies of QTc duration during treatment. Most reviews have been published in the past 5 years, during a time when the Food and Drug Administration restricted five psychotropic medications because of QTc prolongation (sertindole: not approved; thioridazine, mesoridazine, and droperidol: black-box warning; and ziprasidone: bolded warning) and nine somatic medications because of QTc prolongation.

CONCLUSION

Pretreatment screening, careful selection of psychotropic and/or somatic medication combinations, and recognition of QTc prolongation in electrocardiographic tracings during treatment with medications that prolong QTc are important components of clinical practice.

Sexual dysfunction and antipsychotic treatment

Human sexual function is complex and affected in many different ways by schizophrenia and the antipsychotic drugs used in its treatment. The evaluation of the effects of antipsychotics on sexual function in patients with schizophrenia is also complex because the deleterious effects of conventional antipsychotics are superimposed on the effects of the disease itself. Although not extensively researched, sexual dysfunction seems to be frequent in patients with schizophrenia, especially in men. Sexual dysfunction appears, in significant part, to be a direct consequence of dopamine antagonism, combined with indirect effects due to increased serum prolactin concentration. Atypical antipsychotics have a number of potential advantages over standard agents with regard to their impact on sexual function. Clinical reports indicate that atypical antipsychotics are associated with a lower incidence of sexual adverse events than conventional antipsychotics and that there may also be important differences between them in this regard. For example, dose-related increases in prolactin concentrations occur with risperidone whereas olanzapine is associated with mild and transient increases in long-term treatment. Treatment with clozapine does not result in prolactin elevation and, like olanzapine, only transient increases occur with ziprasidone therapy, but the risk of agranulocytosis with clozapine restricts its use. Quetiapine has no more effect on serum prolactin than placebo across its full dose range. Together with its low frequency of reproductive or hormonal side effects and a low incidence of extrapyramidal symptoms, the tolerability profile of quetiapine may be particularly beneficial for many patients. Sexual dysfunction can be an important source of distress to patients and adversely affects compliance, and is one of the factors that must be taken into account when selecting treatment.

Conventional and Atypical Antipsychotics in the Elderly

Psychoses are major mental disorders marked by derangement of personality and loss of contact with reality, and are common in the elderly. Various hypotheses suggest the pivotal role of abnormal neurotransmitter and neuropeptide systems in psychotic patients, the most studied of which are the dopaminergic, serotonergic and glutamatergic systems. In particular, long-term treatment with antagonists at dopamine (D) and serotonin (5-hydroxytryptamine; 5-HT) receptors and agonists at glutamate receptors may improve symptoms. Treatment with antipsychotics is very common in the elderly and often indispensable. However, for successful treatment it is essential to have an adequate multidimensional assessment of the geriatric patient and of his or her polypathology and polypharmacy, together with knowledge of age-dependent pharmacokinetics and pharmacodynamic changes and drug-drug interactions.Conventional antipsychotics such as haloperidol, chlorpromazine, promazine, tiapride and zuclopenthixol are D(2)-receptor antagonists and inhibit dopaminergic neurotransmission in a dose-related manner. They decrease the intensity of all psychotic symptoms, although not necessarily to the same extent and with the same time course. Negative symptoms may persist to a much more striking extent than delusions, hallucinations and thought disorders, and there is a dose-related incidence of extrapyramidal side effects (EPS). Newer antipsychotics, such as clozapine, olanzapine, risperidone, quetiapine and ziprasidone, have a different receptor-binding profile, interacting with both D and 5-HT receptors; they less frequently cause EPS and are better tolerated in the elderly. Their use is advantageous because they are effective both on positive and negative symptoms of schizophrenia and may also be used in the treatment of behavioural disturbances in elderly and/or demented individuals. The use of clozapine is limited by the onset of agranulocytosis, whereas olanzapine, risperidone, quetiapine and, more recently, ziprasidone are widely used, with good results in the above-mentioned diseases.

Relapse and rehospitalisation rates in patients with schizophrenia: effects of second generation antipsychotics

Recent studies suggest that the risk of relapse in patients with schizophrenia is approximately 3.5% per month. Predictors of more frequent relapses include poor compliance with antipsychotic drug treatment, severe residual psychopathology, poor insight into the illness and the need for treatment, comorbid substance abuse, and poor relationships between patients, families and care providers. Although conventional antipsychotic drugs, such as haloperidol and fluphenazine, are effective in preventing relapse, second generation antipsychotic drugs, such as clozapine, risperidone and olanzapine, appear to be superior in preventing relapse and improving the patient's quality of life. The development of adverse events can undermine treatment response and relapse prevention. Minimising adverse effects thus helps to improve treatment compliance and prevent relapse. Second generation antipsychotic drugs tend to have fewer adverse effects than conventional agents, especially pseudoparkinsonism and akathisia. The societal costs of treating patients with schizophrenia can be lessened by employing strategies that decrease relapse and the need for rehospitalisation, the most costly treatment alternative.