Clinical characteristics and associated factors in antipsychotic-induced akathisia of Asian patients with schizophrenia

Characteristics of adverse reactions among antipsychotic drugs using the Korean Adverse Event Reporting System database from 2010 to 2019

BACKGROUND

Retrospective studies using spontaneous reporting system databases have provided a great understanding of adverse drug reactions (ADRs) in the real world, complementing the data obtained from randomized controlled trials. However, there have been few reports on large-scale epidemiological studies on the adverse effects of antipsychotics in Asia.

AIM

This study aimed to investigate the characteristics of antipsychotic ADRs using a nationwide pharmacovigilance database.

METHODS

Data were collected from the Korea Adverse Event Reporting System database between 2010 and 2019. The study subjects were selected using the International Classification of Disease codes for diseases related to psychosis and Electronic Data Interchange codes for amisulpride, aripiprazole, clozapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone. The causality assessment of "possible," "probable," or "certain" by the World Health Organization-Uppsala Monitoring Center System causality category was selected. All data were descriptively analyzed.

RESULTS

In total, 5067 adverse events associated with antipsychotic drugs were reported. The antipsychotics that commonly resulted in ADRs were quetiapine (47.7%), olanzapine (11.3%), and clozapine (10.7%). Serious ADRs were most commonly observed with clozapine. Gastrointestinal and central nervous system problems occurred within a month when ADRs were classified according to the time of onset. In contrast, metabolic and bone marrow-related symptoms occurred after long-term use. Sedation and nausea were the most common ADRs in children and adolescents, whereas constipation and dizziness were common in adults and the elderly.

CONCLUSIONS

This study extends our knowledge of antipsychotic ADRs in the Asian population.

Effectiveness of antipsychotic drugs in schizophrenia: a 10-year retrospective study in a Korean tertiary hospital

Extensive research has been carried out on the comparative effectiveness of antipsychotic medications. Most studies, however, have been performed in Western countries. The purpose of this study was to compare the effectiveness, indicated by time to any-cause discontinuation, of antipsychotic drugs in a large number of patients with schizophrenia in South Korea. We identified 1458 patients with schizophrenia or schizophreniform disorder who were treated with antipsychotic medications using a clinical data warehouse at the Seoul National University Hospital between March 2005 and February 2014. Kaplan–Meier survival analyses were used to estimate the time to discontinuation of antipsychotic drugs. We compared the survival curves of different antipsychotics using log-rank tests. Overall, the median time to discontinuation for any cause was 133 days (95% CI, 126–147). The longest time to discontinuation was observed for clozapine, followed by aripiprazole, paliperidone, olanzapine, amisulpride, risperidone, quetiapine, ziprasidone, and haloperidol. Specifically, clozapine was significantly different from all other antipsychotic drugs (all p < 0.001). Aripiprazole also had a significantly longer time to discontinuation than amisulpride (p = 0.001), risperidone (p < 0.001), quetiapine (p < 0.001), ziprasidone (p < 0.001), and haloperidol (p < 0.001). In Asian patients with schizophrenia, clozapine was the most effective antipsychotic in terms of time to discontinuation, followed by aripiprazole. This study extends the findings of previous effectiveness studies from Western populations and suggests the need to develop guidelines for the pharmacotherapy of schizophrenia tailored to Asian individuals.

Long-Acting Injectable Antipsychotics: Analysis of Prescription Patterns and Patient Characteristics in Mental Health from a Spanish Real-World Study

BACKGROUND AND OBJECTIVE

Long-acting injectable antipsychotics (LAIs) have been widely studied in schizophrenia and evidence suggests that they could be also used for the treatment of bipolar and schizoaffective disorders. Nonetheless, there are no studies evaluating their role in other psychiatric disorders. We aimed to evaluate the use of the newest monthly and 3-monthly LAIs-aripiprazole once monthly, paliperidone 1- and 3-monthly (PP1M, PP3M)-against the 2-weekly LAIs, using the following clinical outcomes: (1) the number of hospital re-admissions, (2) the number of documented suicidal behaviors/attempts, and (3) the use of concomitant treatments, including benzodiazepines, oral antipsychotics, and biperiden.

METHODS

A total of 431 patients were included who were treated with the corresponding LAI over at least 12 months and were previously diagnosed with a psychiatric disorder. Statistical analyses were performed using an ANCOVA model, Student's t test, and the Pearson's r test.

RESULTS

Our results showed significantly decreased re-admissions using PP3M versus the bi-weekly LAIs and aripiprazole once monthly, while no significant differences were found in suicidal behavior. Furthermore, we found a significantly lower intake of benzodiazepines in PP1M and PP3M groups versus the bi-weekly and aripiprazole once-monthly groups. In addition, patients treated with PP1M and PP3M used a significantly lower dose of haloperidol equivalents versus the bi-weekly LAIs group. Finally, significantly higher doses of biperiden were used by the bi-weekly LAIs group.

CONCLUSION

In conclusion, paliperidone LAIs reduced hospital re-admissions and, as aripiprazole once monthly, lowered concomitant psychiatric medication versus the bi-weekly LAIs. Further research and analysis of subgroups are needed; however, these findings might be useful for clinicians.

Incidence and risk factors of acute akathisia in 493 individuals with first episode non-affective psychosis: a 6-week randomised study of antipsychotic treatment

INTRODUCTION

Acute akathisia is a neuropsychiatric syndrome with a negative effect on illness outcome. Its incidence in patients treated with antipsychotics has shown to be highly variable across studies.

OBJECTIVES

Our goals were to investigate prevalence, risk factors for the development of acute akathisia, and differences in incidence between antipsychotics in a sample of 493 first episode non-affective psychosis patients.

METHODS

This is a pooled analysis of three prospective, randomized, flexible-dose, and open-label clinical trials. Patients were randomized assigned to different arms of treatment (haloperidol, quetiapine, olanzapine, ziprasidone, risperidone, or aripiprazole). Akathisia was determined using the Barnes Akathisia Scale at 6 weeks after antipsychotic initialization. Univariate analyses were performed to identify demographic, biochemical, substance use, clinical, and treatment-related predictors of acute akathisia. Considering these results, a predictive model based of a subsample of 132 patients was constructed with akathisia as the dependent variable.

RESULTS

The overall incidence of akathisia was 19.5%. No differences in demographic, biochemical, substance use, and clinical variables were found. Significant incidence differences between antipsychotics were observed (Χ ² = 68.21, p = 0.000): haloperidol (57%), risperidone (20%), aripiprazole (18.2%), ziprasidone (17.2%), olanzapine (3.6%), and quetiapine (3.5%). The predictive model showed that the type of antipsychotic (OR = 21.3, p = 0.000), need for hospitalization (OR = 2.6, p = 0.05), and BPRS total score at baseline (OR = 1.05, p = 0.03) may help to predict akathisia emergence.

CONCLUSIONS

Among second generation antipsychotics, only olanzapine and quetiapine should be considered as akathisia-sparing drugs. The type of antipsychotic, having been hospitalized, and a more severe symptomatology at intake seem to predict the development of acute akathisia.

The clinical challenges of akathisia

Akathisia is one of the most vexing problems in neuropsychiatry. Although it is one of the most common side effects of antipsychotic medications, it is often difficult to describe by patients, and is difficult to diagnose and treat by practitioners. Akathisia is usually grouped with extrapyramidal movement disorders (ie, movement disorders that originate outside the pyramidal or corticospinal tracts and generally involve the basal ganglia). Yet, it can present as a purely subjective clinical complaint, without overt movement abnormalities. It has been subtyped into acute, subacute, chronic, tardive, withdrawal-related, and "pseudo" forms, although the distinction between many of these is unclear. It is therefore not surprising that akathisia is generally either underdiagnosed or misdiagnosed, which is a serious problem because it can lead to such adverse outcomes as poor adherence to medications, exacerbation of psychiatric symptoms, and, in some cases, aggression, violence, and suicide. In this article, we will attempt to address some of the confusion surrounding the condition, its relationship to other disorders, and differential diagnosis, as well as treatment alternatives.

"First do no harm." A systematic review of the prevalence and management of antipsychotic adverse effects

AIMS

We aim to identify the prevalence and management strategies of nine clinically important categories of antipsychotic adverse effects, namely: extrapyramidal symptoms; sedation; weight gain; type II diabetes; hyperprolactinaemia; metabolic syndrome, dyslipidaemia; sexual dysfunction; and cardiovascular effects.

BACKGROUND

Antipsychotic drugs are widely prescribed for schizophrenia and other mental disorders. The adverse effects of antipsychotics are common, with a potential negative impact on adherence and engagement. Despite this, the scientific study of the prevalence or management of adverse antipsychotic effects is a neglected area.

METHOD

A systematic review was undertaken using pre-defined search criteria and three databases, with hand searching of citations and references. Inclusion was agreed on by two independent researchers after review of abstracts or full text. Quality analysis of included studies was conducted using pre-agreed criteria.

RESULTS

In total, 53 studies met inclusion criteria, revealing the following: (1) antipsychotic polypharmacy was associated with increased frequency of adverse effects, and (2) a longer duration of treatment is associated with greater severity (e.g. higher BMI); (3) clozapine was more strongly associated with metabolic disturbance than other antipsychotics in three studies and olanzapine was associated with the most weight gain in three studies; (4) hyperprolactinaemia was more common in women than men, but 50% men noted sexual dysfunction versus 25-50% in women; (5) despite clinical guideline recommendations there is a low rate of baseline testing for lipids and glucose; and (6) seven studies described adverse effect management strategies, but only two examined their efficacy - one found a significant reduction in weight with non-pharmacological group therapy and the other found a significant reduction in dyslipidaemia with statins.

CONCLUSIONS

Antipsychotic adverse effects are diverse and frequently experienced, but are not often systematically assessed. There is a need for further scientific study concerning the management of these side effects.

A placebo-controlled, double-blind study of the efficacy and safety of aripiprazole for the treatment of acute manic or mixed episodes in Asian patients with bipolar I disorder (the AMAZE study)

OBJECTIVES

To investigate the efficacy and safety of aripiprazole in Asian patients with manic or mixed episodes associated with bipolar I disorder.

METHODS

Subjects were randomised to aripiprazole (24 mg/day; reduced to 12 mg/day if needed for tolerability; n = 128) or placebo (n = 130) for 3 weeks in this multicentre, double-blind study. The primary efficacy measure was mean change from baseline in Young Mania Rating Scale (YMRS) Total score.

RESULTS

A total of 136 patients (aripiprazole 56.3%; placebo 49.2%) completed the study. The majority of patients (92.6%) received aripiprazole 24 mg/day. Aripiprazole produced statistically significant mean improvements in YMRS Total scores compared with placebo from Day 4 through to Week 3 (-11.3 vs. -5.3; P < 0.001). The most common adverse events (> 15% of patients; aripiprazole vs. placebo) were akathisia (22.0 vs. 5.6%) and insomnia (16.3 vs. 9.6%). Aripiprazole treatment resulted in no significant difference from placebo in change in mean body weight from baseline (-0.4 vs. -0.7 kg; P = 0.231). Aripiprazole was not associated with an elevated serum prolactin level.

CONCLUSIONS

Aripiprazole had significantly greater efficacy than placebo for the treatment of acute manic or mixed episodes associated with bipolar I disorder in Asian patients. Treatment was generally safe and well tolerated.

The relationship between akathisia and subjective tolerability in patients with schizophrenia

Akathisia remains a significant issue even in the era of atypical antipsychotics. The purpose of the present study was to examine the association of akathisia with various domains of subjective tolerability in order to contribute to the renewed interest in akathisia and the subjective experience of antipsychotic treatment. Fifty schizophrenic outpatients receiving stable doses of risperidone were evaluated for akathisia, schizophrenic symptoms, and subjective tolerability. Subjective tolerability was comprehensively assessed using the Liverpool University Neuroleptic Side Effect Rating Scale. Analysis of covariance revealed that the akathisia group had a significantly higher total score as well as higher subscale scores of extrapyramidal side effect, psychic side effect, and autonomic side effect on the Liverpool University Neuroleptic Side Effect Rating Scale. Further analysis using binary logistic regression analysis revealed that these variables were significantly associated with akathisia. The results of our study suggest that akathisia is significantly associated with a wide range of subjective tolerability profiles, implying the necessity to effectively manage akathisia even its mild forms considering its strong association with subjective tolerability in general.

Effects of risperidone on glucose metabolism in Chinese patients with schizophrenia: a prospective study

BACKGROUND

While most of the second generation antipsychotic agents are associated with abnormal glucose metabolism, previous studies have shown that risperidone has relatively little effect upon blood glucose levels. This study aimed to explore the effect of risperidone on the glucose-regulating mechanism of patients with schizophrenia by using the oral glucose tolerance test (OGTT), measuring insulin and C-peptide levels.

METHODS

Thirty inpatients with schizophrenia taking risperidone were studied. All the patients were given a simplified OGTT at baseline and six weeks after treatment. Plasma glucose, insulin, and C-peptide concentrations were measured at fasting, then 1 and 2h after OGTT respectively. Other data, including demographic characteristics and plasma drug concentrations, were also recorded.

RESULTS

(1) There was no significant increase in the proportion of patients demonstrating abnormal plasma glucose levels compared with baseline (p=1.000, McNemar test); (2) risperidone was associated with elevated insulin concentrations (p=0.013), C-peptide levels (p=0.020), insulin/glucose ratio (p=0.020) and BMI (p<0.01); (3) no sex differences in glucose-related measures were observed.

CONCLUSION

Risperidone treatment may be associated with alterations in glucose-regulating mechanisms in patients with schizophrenia.

The Barnes Akathisia Rating Scale--revisited

Akathisia is a syndrome of motor restlessness, principally seen in association with antipsychotic medication. It is characterized by a subjective experience of mental unease and the urge to move, and manifests physically as particular patterns of restless movement. This review focuses on the signs and symptoms of the condition, and its diagnosis and assessment using the Barnes Akathisia Rating Scale. This scale was generated 15 years ago, and was derived from the findings of studies exploring the clinical features of antipsychotic-induced akathisia. Subsequently, its validity and reliability have been established, and it has been used extensively in clinical studies worldwide.

Prevalence and Characteristics of Subjective Akathisia, Objective Akathisia, and Mixed Akathisia in Chronic Schizophrenic Subjects

Akathisia is a complex syndrome that is characterized by subjective inner restlessness and objective motor manifestations, and it can be classified into several subtypes. The purpose of this study was to examine the prevalence of subjective akathisia, objective akathisia, and mixed akathisia, and to evaluate their relationships with other drug-induced movement disorders, in chronic schizophrenic subjects treated with antipsychotics. One hundred and forty-two in-patients were assessed for akathisia, drug-induced parkinsonism, and tardive dyskinesia. The subtypes of akathisia were specified according to the Barnes Akathisia Rating Scale. Drug-induced parkinsonism and tardive dyskinesia were assessed using the Simpson-Angus Scale and the Abnormal Involuntary Movement Scale, respectively. The prevalence of subjective, objective, and mixed akathisia was 11.3%, 6.3%, and 16.9%, respectively. Regarding concurrence rates of akathisia subtypes and other extrapyramidal syndromes, the comorbidity rates of mixed akathisia with parkinsonism and tardive dyskinesia were higher. In conclusion, the present study presented the prevalence of subjective, objective, and mixed akathisia among hospitalized schizophrenic subjects. Mixed akathisia showed an association with parkinsonism and tardive dyskinesia, suggesting a common vulnerability involved in these drug-induced movement disorders. Further studies are required to elucidate more detailed clinical characteristics of each subtype of akathisia.