Extrapyramidal side effects are unacceptable

Efficacy and safety of prophylactic use of benzhexol after risperidone treatment

To test the effect of prophylactic use of benzhexol in schizophrenia patients after risperidone treatment. Sixty-nine drug naïve schizophrenia patients were recruited. All patients were administered risperidone. Patients in the benzhexol group were given a benzhexol tablet of 2 mg bid daily. The controls received a placebo tablet of 2 mg bid daily. The primary outcome measured using the Extrapyramidal Symptoms Rating Scale (ESRS). The Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS) measured secondary outcome. There were significant time and group effects on the ESRS scores of the two groups. The post hoc analysis yielded significant differences at 1, 2, 4, and 8 weeks between the two groups. There was a significant time effect on the PANSS scores of the two groups. No significant group and interaction effects on the PANSS scores of the two groups. There was a significant time effect on the BPRS scores of the two groups. No serious adverse events were found in this study. Prophylactic use of benzhexol reduced extrapyramidal symptom in schizophrenia patients after risperidone treatment and did not affect the antipsychotic action of risperidone.

Protein Succinylation and Malonylation as Potential Biomarkers in Schizophrenia

Two protein post-translational modifications, lysine succinylation and malonylation, are implicated in protein regulation, glycolysis, and energy metabolism. The precursors of these modifications, succinyl-CoA and malonyl-CoA, are key players in central metabolic processes. Both modification profiles have been proven to be responsive to metabolic stimuli, such as hypoxia. As mitochondrial dysfunction and metabolic dysregulation are implicated in schizophrenia and other psychiatric illnesses, these modification profiles have the potential to reveal yet another layer of protein regulation and can furthermore represent targets for biomarkers that are indicative of disease as well as its progression and treatment. In this work, data from shotgun mass spectrometry-based quantitative proteomics were compiled and analyzed to probe the succinylome and malonylome of postmortem brain tissue from patients with schizophrenia against controls and the human oligodendrocyte precursor cell line MO3.13 with the dizocilpine chemical model for schizophrenia, three antipsychotics, and co-treatments. Several changes in the succinylome and malonylome were seen in these comparisons, revealing these modifications to be a largely under-studied yet important form of protein regulation with broad potential applications.

Doenças cardiovasculares e uso de antipsicóticos na esquizofrenia: uma revisão

RESUMO Objetivo Realizar uma revisão de escopo a respeito dos efeitos adversos cardiovasculares e metabólicos associados ao uso de antipsicóticos em pessoas com o diagnóstico de esquizofrenia. Métodos Foi realizada uma revisão de escopo utilizando-se da base de dados PubMed, com descritores MeSH relacionados às doenças cardiovasculares e antipsicóticos. Foram encontrados 976 artigos, os quais foram filtrados por títulos, seguidos dos resumos e, na sequência, lidos na íntegra. Ao final, foram selecionados 71 artigos para a análise. Resultados O uso de antipsicóticos típicos e atípicos para tratamento da esquizofrenia associa-se a alterações glicêmicas e lipídicas, síndrome metabólica, hipertensão, ganho de peso e morbidade cardiovascular. Os estudos evidenciaram a existência de subdiagnóstico e subtratamento de doenças crônicas nessa população. A mortalidade por doença cardiovascular demonstrou aumento considerável nos pacientes em tratamento com agentes antipsicóticos, em comparação com a população geral. Conclusão Alguns fatores dos antipsicóticos, ainda não completamente determinados na psicofarmacologia, vêm se mostrando relacionados a maior risco de distúrbios metabólicos, comportamentais e intrínsecos às pessoas diagnosticadas com esquizofrenia, os quais podem agravar o curso clínico de tais doenças. Reconhece-se a necessidade de aprimorar o acompanhamento e o diagnóstico de doenças cardiovasculares e metabólicas entre pessoas com diagnóstico de esquizofrenia em tratamento com antipsicóticos típicos e atípicos.

Antipsychotic-like effects of a novel phosphodiesterase 10A inhibitor MT-3014 in rats

Phosphodiesterase (PDE) 10A is an attractive therapeutic target for schizophrenia. Here, we investigated the antipsychotic-like effects of a novel PDE10A inhibitor, 1-({2-(7-fluoro-3-methylquinoxalin-2-yl)-5-[(3R)-3-fluoropyrrolidin-1-yl]pyrazolo[1,5-α]pyrimidin-7-yl}amino)-2-methylpropan-2-ol hydrochloride (MT-3014) in rats. MT-3014 showed a potent and selective inhibitory effect against PDE10A (IC₅₀ = 0.357 nmol/L). Oral administration of MT-3014 (1.0-10 mg/kg) significantly increased the levels of cAMP, cGMP and cAMP response element-binding protein (CREB) phosphorylation in the rat striatum. MT-3014 decreased MK-801 (0.075 mg/kg)-induced hyperactivity (ED₅₀ = 0.30 mg/kg) in a dose-dependent manner, although it decreased spontaneous locomotion in control rats (ED₅₀ = 0.48 mg/kg); its effects were equivalent to those of risperidone. MT-3014 (0.3-3.0 mg/kg and 0.2 mg/kg) attenuated MK-801-induced prepulse inhibition deficits and cognitive deficits in rats, respectively, whereas risperidone attenuated MK-801-induced prepulse inhibition at only a high dose and failed to improve MK-801-induced cognitive deficits. Similar to risperidone (ID₅₀ = 0.63 mg/kg), MT-3014 suppressed the conditioned avoidance response (ID₅₀ = 0.32 mg/kg). Interestingly, MT-3014 did not elicit catalepsy and plasma prolactin increases at high doses. Furthermore, it also did not affect body weight. A positron emission tomography study using [¹¹C]IMA107 showed a plasma concentration-dependent increase in brain PDE10A occupancy after oral administration of MT-3014 within the pharmacological dose range in rats. Brain PDE10A occupancy corresponding to the ID₅₀ value in the conditioned avoidance response was approximately 60%, predicting the target occupancy in patients with schizophrenia. These results suggest that MT-3014 may be a novel antipsychotic drug, which is expected to have additional effects on cognitive impairment, without the prominent side effects associated with current atypical antipsychotics.

Patients with schizophrenia previously stabilized on conventional depot antipsychotics experience significant clinical improvements following treatment with long-acting risperidone

Background

Conventional depot antipsychotics can provide constant pharmacologic treatment, eliminating partial compliance and reducing relapse risk. Atypical antipsychotics, have improved clinical profiles but require daily dosing, compromising their overall effectiveness. As oral risperidone provides safety and efficacy benefits over oral haloperidol, improvements may be realized by replacing conventional with atypical agents in long-acting therapy. This report examines 50-weeks of long-acting risperidone therapy in patients previously stabilized with conventional depot antipsychotics.

Methods

A multi-center, open-label study enrolled 725 patients with schizophrenia or schizoaffective disorder, judged clinically stable and maintained on stable antipsychotic doses for ≥4 weeks. Assignment by clinician judgment to receive 25–75 mg of long-acting risperidone every 2 weeks for 50 weeks followed, with performance of standard safety and efficacy assessments. Data are presented on patients receiving conventional depot antipsychotic monotherapy at study entry.

Results

In the 188 (25.9%) patients receiving conventional depot antipsychotic monotherapy at entry, mild-to-moderate mean (±S.D.) Positive and Negative Syndrome Scale (PANSS)-total scores improved significantly after receiving long-acting risperidone (64.2 ± 18.9 to 58.2 ± 20.3; P < 0.001). Clinical improvement of ≥20%, 40%, or 60% reduction in PANSS-total score, occurred in 52%, 34%, and 16% of patients, respectively. ESRS subjective ratings and objective physician ratings (Parkinsonism) decreased significantly (P < 0.001).

Conclusion

Stable patients with mild, residual symptomatology treated with conventional depot antipsychotics experienced significant improvement in psychiatric and movement disorder symptomatology following 1-year of treatment with long-acting risperidone.

A systematic review of the safety and efficacy of rapid titration of quetiapine running header: Rapid titration of Quetiapine- A systematic review

Quetiapine is a second-generation antipsychotic that is most favoured for its low propensity for extrapyramidal side effects. However, Quetiapine requires slow titration, which is disadvantageous. The brief review discussed research that trialled rapid titration of Quetiapine The author searched PubMed, Proquest, Embase, Google Scholar and Google Web using the keyword 'rapid titration' and 'quetiapine'. A total of 18 articles were included. The process, safety and efficacy of rapid titration of Quetiapine was examined. In conclusion, preliminary results appear to show that there is minimal difference in efficacy, between the rapid and traditional titration of Quetiapine. Sedation tended to occur more frequently and earlier among experimental group, and this might render rapid titration of Quetiapine to be suitable for agitated patients. There is a need for more large-scale, multisite, randomized clinical trials to examine the safety and efficacy of rapid titration of Quetiapine.

Antipsychotic-like effects of a novel phosphodiesterase 10A inhibitor T-251 in rodents

Phosphodiesterase 10A (PDE10A) is a dual-substrate PDE that hydrolyzes both cAMP and cGMP. PDE10A is selectively expressed in medium spiny neurons in the striatum, suggesting the potential of PDE10A inhibitors in the treatment of schizophrenia. This study presents the pharmacological profile of a novel PDE10A inhibitor, 2-[(E)-2-(7-fluoro-3-methylquinoxalin-2-yl)vinyl]-6-pyrrolidin-1-yl-N-(tetrahydro-2H-pyran-4-yl)pyrimidin-4-amine hydrochloride (T-251) in rodent models of schizophrenia. T-251 showed a potent inhibitory activity against human PDE10A (IC₅₀ = 0.050 nmol/L) and showed high selectivity over other PDE families which have over 10,000-fold IC₅₀ values. Oral administration of T-251 (0.1-1.0 mg/kg) increased cAMP and cGMP in the striatum in a dose-dependent manner. Oral administration of T-251 attenuated MK-801 induced hyperactivity (ED₅₀ = 0.68 mg/kg) and suppressed conditioned avoidance response (ID₅₀ = 0.87 mg/kg) in rats in a dose dependent manner. Furthermore, T-251 significantly attenuated MK-801 induced prepulse inhibition deficits and cognitive deficits in rats. Unlike haloperidol and olanzapine, T-251 (1.0-30 mg/kg) did not cause catalepsy in rats. Moreover, T-251 (0.6 and 6.0 mg/kg) did not increase plasma levels of prolactin at 1 h after administration, whereas haloperidol and olanzapine significantly increased them. The antipsychotic-like effects and cognitive enhancement of T-251 without catalepsy or plasma prolactin elevation observed in rats suggests that T-251 would be a novel antipsychotic with an improved side-effect profile.

Dose Trends of Aripiprazole from 2004 to 2014 in Psychiatric Inpatients in Korea

Objective

Although aripiprazole has been widely used to treat various psychiatric disorders, little is known about the adequate dosage for Asian patients in clinical practice. Hence, we evaluated the initial and maximum doses of aripiprazole from 2004 to 2014 to estimate the appropriate dosage for Korean psychiatric inpatients in clinical practice.

Methods

In this retrospective study, we reviewed the medical records of patients who were hospitalized in five university hospitals in Korea from March 2004 to December 2014. The psychiatric diagnosis according to the text revision of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition during index hospitalization and the initial and maximum doses of aripiprazole were evaluated.

Results

There were 74 patients in Wave 1 (2004–2006), 201 patients in Wave 2 (2007–2010), and 353 patients in Wave 3 (2011–2014). The initial doses of aripiprazole in all diagnostic groups were significantly lower in Wave 3 than in Wave 2. The maximum doses of aripiprazole in each diagnostic group were not significantly different among Waves 1, 2, and 3.

Conclusion

The relatively low initial doses of aripiprazole documented in our study may reflect a strategy by clinicians to minimize the side effects associated with aripiprazole use, such as akathisia.

Drug-Induced Movement Disorders

Drug-induced movement disorders (DIMDs) pose a significant burden to patients, often resulting in nonadherence, disease relapse, and decreased quality of life. Dopamine-receptor blocking agents such as conventional antipsychotics (eg, haloperidol and chlorpromazine) and antiemetics (eg, metoclopramide and prochlorperazine) are most commonly implicated. DIMDs can be categorized by the onset of symptoms: acute reactions occurring hours to days after exposure, subacute DIMDs appearing within weeks, and tardive occurring months to years after drug exposure. The DIMDs of akathisia, tardive dyskinesia, dystonia, and parkinsonism are reviewed. Their epidemiology, mechanism, clinical presentation and differential diagnosis, risk factors, morbidity and mortality, and prevention and management are discussed. For many of these disorders, treatment inconsistently provides benefit, and therefore, primary prevention is essential. Clinicians and other healthcare professionals play a key role in the identification of patients with DIMDs, or those at risk, and in implementing prevention and treatment plans.

A comparison of the effectiveness of risperidone, haloperidol and flupentixol long-acting injections in patients with schizophrenia--A nationwide study

BACKGROUND

Risperidone long-acting injection (RLAI), the first licensed, long-acting second-generation antipsychotic (SGA), has not yet been studied in terms of its effectiveness compared with first-generation antipsychotic (FGA) LAIs.

METHODS

The differences in the effectiveness of RLAI and two other FGA LAIs, haloperidol and flupentixol, were assessed by conducting a one-year pre-post study based on the Taiwanese National Health Insurance Research Database. Effectiveness was defined as reduced medical care utilization and relapse prevention.

RESULTS

A decreased number of relapses were identified in the haloperidol injection group in the post-LAI period than in the pre-LAI period (Wilcoxon signed rank test, p<0.05). The RLAI group had the largest number of acute admissions and relapses, the longest duration of admission (Wilcoxon signed rank test, p<0.005), and the lowest utilization of anticholinergic agents, such as benzodiazepine (BZD) and SGAs (except oral risperidone), among all of the LAI groups in the post-LAI period.

CONCLUSIONS

According to the results of this observational study, we suggest that the effectiveness of RLAI is not superior to that of FGA (haloperidol or flupentixol) LAIs, but that RLAI might have fewer adverse effects.

Cannabidiol effects in the prepulse inhibition disruption induced by amphetamine

RATIONALE

The information processing appears to be deficient in schizophrenia. Prepulse inhibition (PPI), which measures the inhibition of a motor response by a weak sensory event, is considered particularly useful to understand the biology of information processing in schizophrenia patients. Drugs that facilitate dopaminergic neurotransmission such as amphetamine induce PPI disruption in human and rodents. Clinical and neurobiological findings suggest that the endocannabinoid system and cannabinoids may be implicated in the pathophysiology and treatment of schizophrenia. Cannabidiol (CBD), a non-psychotomimetic constituent of the Cannabis sativa plant, has also been reported to have potential as an antipsychotic.

OBJECTIVE

Our aim was to investigate if CBD pretreatment was able to prevent PPI disruption induced by amphetamine. Since one possible mechanism of CBD action is the facilitation of endocannabinoid-mediated neurotransmission through anandamide, we tested the effects of an anandamide hydrolysis inhibitor (URB597) in the amphetamine-induced PPI disruption.

METHODS

Male Swiss mice were treated with CBD systemic or intra-accumbens, or URB597 (systemic) prior to amphetamine and were exposed to PPI test.

RESULTS

Amphetamine (10 mg/kg) disrupted PPI while CBD (15-60 mg/kg) or URB597 (0.1-1 mg/kg) administered alone had no effect. Pretreatment with CBD attenuated the amphetamine-disruptive effects on PPI test after systemic or intra-accumbens administration. Similar effects were also found with the inhibitor of anandamide hydrolysis.

CONCLUSION

These results corroborate findings indicating that CBD induces antipsychotic-like effects. In addition, they pointed to the nucleus accumbens as a possible site of these effects. The increase of anandamide availability may be enrolled in the CBD effects.

Metabolic side effects and pharmacogenetics of second-generation antipsychotics in children

Second-generation antipsychotics (SGAs) are increasingly being used to treat children for a range of mental health conditions, for example, anxiety disorder, attention deficit hyperactivity disorder and bipolar disorder. SGA treatment is associated with weight gain and cardiometabolic side effects such as dyslipidemia, insulin resistance and elevated blood pressure, in some, but not all children. This review provides an overview of the potential role of pharmacogenomics in predisposing a child to unhealthy weight gain and cardiometabolic side effects with SGA treatment. Specifically, the review includes a synopsis of the evidence for cardiometabolic side effects in SGA-treated children, illustrating the extent and depth of the problem; summarizes the potential long-term consequences of developing cardiometabolic risk during childhood and highlights genetic variants that may be useful in predicting cardiometabolic side effects in SGA-treated children.

Genomics and epigenomics in novel schizophrenia drug discovery: translating animal models to clinical research and back

INTRODUCTION

Schizophrenia is a major psychiatric disorder that afflicts about 1% of the world's population, falling into the top 10 medical disorders causing disability. Existing therapeutic strategies have had limited success; they have poor effects on core cognitive impairment and long-term disability. They are also burdened by relevant side effects. Although new antipsychotic medications have been launched in the past decades, there has been a general lack of significant innovation over the past 60 years. This lack of significant progress in the pharmacotherapy of schizophrenia is a reflection of the complexity and heterogeneity of its etiopathogenetic mechanisms.

AREAS COVERED

In this article, the authors briefly review genetic models of schizophrenia, focusing on examples of how new therapeutic strategies have been developed from them. They report on the evidence of epigenetic alterations in schizophrenia and their relevance to pharmacological studies. Further, they describe the implications of epigenetic mechanisms in the etiopathogenesis of the disease and the effects of current antipsychotic drugs on epigenetic processes. Finally, they provide their perspective of using epigenetic drugs for treating schizophrenia.

EXPERT OPINION

Current genetic and epigenetic studies are finally shedding light on the biomolecular mechanisms linked to the core pathogenetic alterations in schizophrenia, rather than just their symptoms. These advancements in the understanding of the physiopathology of schizophrenia provide exciting new perspectives for treatments. Indeed, the possibility of looking directly at the biomolecular level allows us to bypass the age-old issues of animal studies pertaining to their questionable validity as behavioral models.

Reverse microdialysis of a 5-HT2A receptor antagonist alters extracellular glutamate levels in the striatum of the MPTP mouse model of Parkinson's disease

Clinical observations have suggested that antagonism of 5-HT2A receptors may benefit patients with parkinsonian symptomatology. The mechanism of the antiparkinsonian effects of 5-HT2A receptor antagonists has not been fully elucidated. We have shown that the selective 5-HT2A receptor antagonist M100907 [R-(+)-alpha-(2,3-dimethoxyphenyl)-1-[2-(4-fluorophenethyl)]-4-piperidinemethanol] improved motor impairments in mice treated with the parkinsonian neurotoxin, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). In Parkinson's disease (PD) patients and animal models of parkinsonism dopamine denervation is associated with increased cortico-striatal glutamatergic transmission. We hypothesized that 5-HT2A receptor antagonists may exert their antiparkinsonian effects by decreasing striatal glutamate. Here, using in vivo microdialysis, we have shown an increased basal level of extracellular striatal glutamate when measured 3weeks after MPTP administration. The local administration of M100907 to the striatum significantly decreased striatal extracellular glutamate levels in MPTP-treated and saline treated mice. Basal extracellular serotonin (5-HT) levels were also elevated, whereas dopamine (DA) levels were significantly reduced in the striatum of MPTP-treated mice. Infusion of M100907 into the striatum produced no effect on dopamine or 5-HT levels. Local application of tetrodotoxin suppressed glutamate, 5-HT and DA concentrations in striatal dialysates in the presence or absence of M100907. The striatal expression of the glutamate transporter GLT1 was unchanged. However, there was an upregulation of the expression of 5-HT2A receptors in the striatum of MPTP-treated animals. Our data provide further evidence of enhanced glutamatergic neurotransmission in parkinsonism and demonstrate that blocking 5-HT2A receptors in the striatum will normalize glutamatergic neurotransmission.

Cost-effectiveness of long-acting injectable risperidone versus flupentixol decanoate in the treatment of schizophrenia: a Markov model parameterized using administrative data

We use longitudinal patient-level data from a German sickness fund with 7.26 million insured in a Markov-simulation model to assess the cost-effectiveness of long-acting injectable risperidone (LAI-RIS) compared with long-acting injectable flupentixol (LAI-FLX) in the long-term management of schizophrenia. We simulate treatment costs from the payer's perspective, hospitalization, the probability to be prescribed co-medication, and treatment discontinuation over a 2-year time horizon. Model inputs were derived from 935 patients hospitalized with schizophrenia between 2005 and 2008 who received either LAI-RIS or LAI-FLX for at least 1 month. After 2 years, 89.4% (95.8%) of patients who were initiated on LAI-RIS (LAI-FLX) discontinued the initial regimen. The number of days spent in hospital per month and patient was slightly lower with LAI-RIS (1.08 vs. 1.28 days, p<0.001). The proportion of patients receiving side-effect co-medication was lower with LAI-RIS (8.3 vs. 15.0% per month, p<0.001). Mean total costs of treatment per patient and month were 1,015 € under LAI-RIS and 395 € under LAI-FLX, resulting in an ICER of 3,088 € (95% CI [-913 €; 3,551 €]) for an avoided hospital day per patient and month in the base case scenario with a 15.1% probability of LAI-FLX being the dominant treatment strategy. Cost differences were mainly attributable to the higher drug costs of LAI-RIS. The effectiveness of LAI-RIS in preventing hospital days appears to be similar to LAI-FLX, with a slight superiority in side-effect and switching rates. This comes at the cost of substantially higher treatment expenses. From a decision-maker's point of view, the use of health insurance data as a source of input for decision models appears to be a reasonable alternative to models driven by clinical data only.

Waist circumference is a sensitive screening tool for assessment of metabolic syndrome risk in children treated with second-generation antipsychotics

OBJECTIVE

To compare the prevalence of metabolic syndrome (MetS) and its components in second-generation antipsychotic (SGA)-treated and SGA-naive children; and to explore the utility of clinical markers, such as waist circumference (WC) and body mass index (BMI), as screening tools for MetS.

METHODS

Subjects were prospectively recruited from the Psychiatry Emergency Unit at British Columbia Children's Hospital. As part of a quality-assurance project, a metabolic monitoring protocol was implemented, including collection of anthropomorphic and laboratory data.

RESULTS

From January 2008 to February 2010, there were 117 SGA-treated and 217 SGA-naive children recruited. The overall prevalence of MetS was 19.0% (16/84; median treatment duration = 14 months) in SGA-treated and 0.8% (1/127) in SGA-naive children (OR 29.7; 95% CI 3.85 to 228.40, P < 0.001), with an increased prevalence of all components except high-density lipoprotein cholesterol (HDL-C), respectively: elevated WC (40.7% and 10.1%; P < 0.001); hypertriglyceridemia (33.7% and 18.8%; P = 0.01); impaired fasting glucose (12.5% and 0.7%; P = 0.005); and elevated blood pressure (41.2% and 16.5%; P < 0.001). SGA treatment was the strongest predictor of MetS (OR 19.2; 95% CI 2.30 to 160.44, P = 0.006) followed by male sex (OR 5.7; 95% CI 1.08 to 30.62, P = 0.04). Presence of abdominal obesity was more sensitive (92.9%) than BMI (68.8%), while fasting glucose of 5.6 mmol/L or more and HDL-C of 1.03 mmol/L or less were most specific (94.1%) in correctly identifying MetS.

CONCLUSIONS

SGA treatment confers a significantly increased risk for MetS over the long term. WC measurement is a simple and sensitive screening tool for determining MetS risk in SGA-treated children. These data highlight the dangers of SGA treatment and the importance of standardized metabolic monitoring using sex- and age-adjusted tables in this population.

Drug-induced movement disorders

This comprehensive review covers approaches for both the recognition and management of drug-induced movement disorders. Pharmacotherapeutic approaches for treating akathisia, dystonia, Parkinsonism and tardive dyskinesia are explored. The importance of early detection via periodic assessment is discussed.

An open trial of aripiprazole for the treatment of delirium in hospitalized cancer patients

Objective:

The purpose of this study was to examine the efficacy and safety of aripiprazole in the treatment of delirium in hospitalized cancer patients, and to examine differential responses based on delirium subtypes.

Method:

We conducted an analysis of 21 hospitalized cancer patients at Memorial Sloan-Kettering Cancer Center (MSKCC) who had been evaluated and treated for delirium with aripiprazole, using an MSKCC Institutional Review Board (IRB) approved Clinical Delirium Database. Measures used were the Memorial Delirium Assessment Scale (MDAS), the Karnofsky Scale of Performance Status (KPS), and side effect rating at baseline (T1), 2–3 days (T2), and 4–7 days (T3). All measurements were integrated into the routine clinical care of patients. Doses of aripiprazole were adjusted based on clinical response.

Results:

Patients treated for delirium with aripiprazole experienced significant improvement and resolution of delirium, with MDAS scores declining from a mean of 18.0 at baseline (T1) to mean of 10.8 at T2 and a mean of 8.3 at T3. KPS scores improved from 28.1 at baseline (T1) to 35.2 at T2 and 41 at T3. Delirium resolved (based on MDAS < 10) in 52.4% of cases at T2 and in 76.2% at T3. The mean dosage of aripiprazole required was 18.3 mg (range of 5–30) daily at T3. In our cohort of patients with hypoactive delirium, we observed a delirium resolution rate of 100% compared to the cohort of patients with hyperactive delirium (58.3% rate of delirium resolution). MDAS scores improved from 15.6 at T1 to 5.7 at T3 in hypoactive delirium and from 19.9 at T1 to 10.2 at T3 in hyperactive delirium. In patients with pre-morbid cognitive deficits and the hyperactive subtype of delirium, we observed a more limited treatment response to aripiprazole treatment for delirium. There were no clinically significant side effects noted.

Significance of results:

Aripiprazole is effective and safe in the treatment of delirium in hospitalized cancer patients. These preliminary finding suggest that aripiprazole may be most effective in resolving delirium of the hypoactive subtype.

Concomitant medication of psychoses in a lifetime perspective

OBJECTIVE

Patients treated with antipsychotic drugs often receive concomitant psychotropic compounds. Few studies address this issue from a lifetime perspective. Here, an analysis is presented of the prescription pattern of such concomitant medication from the first contact with psychiatry until the last written note in the case history documents, in patients with a diagnosis of psychotic illness.

METHODS

A retrospective descriptive analysis of all case history data of 66 patients diagnosed with schizophrenia or schizophrenia-like psychotic disorders.

RESULTS

Benzodiazepines and benzodiazepine-related anxiolytic drugs had been prescribed to 95% of the patients, other anxiolytics, sedatives or hypnotic drugs to 61%, anti-parkinsonism drugs to 86%, and antidepressants to 56% of the patients. However, lifetime doses were small and most of the time patients had no concomitant medication. The prescribed lifetime dose of anti-parkinsonism drugs was associated with that of prescribed first-generation but not second-generation antipsychotics.

CONCLUSIONS

Most psychosis patients are sometimes treated with concomitant drugs but mainly over short periods. Lifetime concomitant add-on medication at the individual patient level is variable and complex but not extensive.

Drug-emergent metabolic syndrome in patients with schizophrenia receiving atypical (second-generation) antipsychotics

BACKGROUND

Persons with schizophrenia are reported to be more likely to die from cardiovascular illness than those in the general population, and are at a greater risk of developing obesity, diabetes type 2, hypertension and dyslipidemias. Antipsychotic drugs used in the treatment of schizophrenia and other psychotic illnesses can induce weight gain, with some agents having a greater propensity to do so than others. These adverse effects associated with second-generation antipsychotics are also part of the metabolic syndrome.

AIMS

The aim of this study was to evaluate the emergence of metabolic syndrome due to second-generation antipsychotics as compared with conventional (typical) antipsychotics.

SETTINGS AND DESIGN

A prospective interventional study was conducted at the Psychiatric Centre, Jaipur. The study included 120 patients, both indoor and outdoor, suffering from schizophrenia diagnosed using the ICD-10 criteria. The patients were grouped into four categories, i.e. control group and three study groups, each group having 30 patients.

MATERIALS AND METHODS

Thirty patients were given conventional antipsychotics and 90 were given second-generation antipsychotics, including risperidone, olanzapine and clozapine. Metabolic parameters were taken before onset of drug treatment therapy and after 4 months. The changes in metabolic parameters were compared using appropriate statistical tools.

STATISTICAL ANALYSIS

Chi square chart and Unpaired t-test were used for statistical analysis using a computer.

RESULTS

11.66% of the patients developed metabolic syndrome after 4 months of antipsychotic medication.

CONCLUSIONS

Second-generation antipsychotics cause significantly more changes in the metabolic parameters, increasing the chances of developing metabolic syndrome and associated disorders like diabetes mellitus type-II and cerebrovascular accidents. Olanzapine is the antipsychotic drug that has the maximum potential to cause metabolic syndrome.

Pharmacologic treatment of schizophrenia

Despite pharmacologic advances, the treatment of schizophrenia remains a challenge, and suboptimal outcomes are still all too frequent. Although treatment goals of response, remission, and recovery have been defined more uniformly, a good “effectiveness” measure mapping onto functional outcomes is still lacking. Moreover, the field has to advance in transferring measurement-based approaches from research to clinical practice. There is an ongoing debate whether, and which, first- or second-generation antipsychotics should be used. However, an individualized treatment approach needs to consider current symptoms, comorbid conditions, past therapeutic response, and adverse effects, as well as patient choice and expectations. Moreover, acute and long-term goals and effects of medication treatment need to be balanced. While the acute response to appropriately dosed first-generation antipsychotics may not differ much from second-generation antipsychotics, advantages of lower rates of extrapyramidal side effects, tardive dyskinesia, and, possibly, relapse may favor second-generation antipsychotics. However, when considering individual adverse effect prof iles, the differentiation into first- and second-generation antipsychotics as unified classes can not be upheld, and a more differentiated view and treatment selection is required. To date, clozapine is the only evidence-based treatment for refractory patients, and the role of antipsychotic polypharmacy and other augmentation strategies remains unclear, at best. To improve the treatment outcomes in schizophrenia, research efforts are needed that elucidate biomarkers of the illness and of treatment response (both therapeutic and adverse effects). Moreover, new treatment options are needed that affect nondopaminergic targets with relevance for symptom reduction, relapse prevention, enhanced efficacy for nonresponders, and reduced key adverse effects.

Patient adherence and efficacy of quetiapine treatment in schizophrenia: results of a multicentre, naturalistic 6-month follow-up study

The aim of the study was to evaluate the adherence and efficacy of quetiapine treatment in a 6-month, multicentre, noninterventional naturalistic design. Overall, 710 schizophrenia patients using quetiapine or who had switched to quetiapine were included. The continuation rate for quetiapine treatment during 6-month follow-up period was 69%. Adherence improved with each subsequent visit for continued patients, 92.9% at the second visit to 96.1% at the last. Treatment adherence was correlated to improvement of symptoms, though not significantly. Patients having lower clinical global impression severity scores at the beginning were twice as likely to improve compared with patients with higher clinical global impression scores. Schizophrenia patients with antisocial behaviour problems had two and a half times higher drop-out rates. In conclusion, this naturalistic study showed that adherence to quetiapine treatment was high, and treatment was effective in schizophrenia patients during long-term treatment. Remission of symptoms in schizophrenia is much related to severity of symptoms at baseline, treatment adherence and characteristics of patients such as antisocial behavioural patterns.

In Silico Receptorome Screening of Antipsychotic Drugs

The recent availability of a complete interaction matrix between 13 antipsychotic drugs and 34 protein targets (Roth et al. Nat. Rev. Drug Discov. 2004, 3, 353-359) allows to assess the performance of computational methods on their ability to anticipate the entire affinity profile of drugs across multiple targets. The analyses reveal that our current implementations, based on the similarity of drugs against a reference set of small molecules for which pharmacological data is available in the public domain, are able to predict 65 % of the 442 affinities within 1-log unit error, with a level of precision above 92 %. In spite of the relatively small scale of this validation study, the results are indicative that in silico receptorome screening of drugs offers an efficient and cost-effective complement to in vitro screening.

Evaluation of akathisia in patients with schizophrenia, schizoaffective disorder, or bipolar I disorder: a post hoc analysis of pooled data from short- and long-term aripiprazole trials

The objective of this article is to assess the clinical characteristics of akathisia in patients with schizophrenia, schizoaffective disorder, or bipolar I disorder receiving aripiprazole, haloperidol, olanzapine, or placebo. We conducted post hoc analyses of pooled safety data from trials in patients with schizophrenia, schizoaffective disorder, and bipolar I disorder. Outcome measures included the incidence of akathisia, time to onset, duration, severity, and discontinuation due to akathisia, concomitant use of benzodiazepines and/or anticholinergics, Barnes Akathisia Rating Scale (BARS) scores, and the correlation between antipsychotic efficacy and akathisia. The results for schizophrenia and schizoaffective disorder were as follows: akathisia in 9% of aripiprazole- and 6% of placebo-treated patients; 12.5% of aripiprazole- versus 24% of haloperidol-treated patients; 11% of aripiprazole- versus 6% of olanzapine-treated patients. Bipolar I disorder: akathisia in 18% of aripiprazole- and 5% of placebo-treated patients. The clinical characteristics of akathisia were similar between each data set, regardless of disease. Akathisia was generally mild-to-moderate in severity. Discontinuation due to akathisia was low in both the schizophrenia trials (aripiprazole 0.3%; placebo 0%; aripiprazole 0.9%; haloperidol 2.3%; aripiprazole 1.2%; olanzapine 0.2%) and the bipolar trials (aripiprazole 2.3%; placebo 0%). Treatment-emergent akathisia was not associated with a poorer clinical response. In conclusion, akathisia with aripiprazole occurred early in treatment, was mild-to-moderate in severity, led to few study discontinuations, and did not compromise therapeutic efficacy.

Fluvoxamine for blonanserin-associated akathisia in patients with schizophrenia: report of five cases

BACKGROUND

Atypical antipsychotic drugs have been reported to cause fewer incidences of extrapyramidal side effects (EPS) than typical antipsychotic drugs, but adverse events such as akathisia have been observed even with atypical antipsychotic drugs. Although understanding of the pathophysiology of akathisia remains limited, it seems that a complex interaction of several neurotransmitter systems plays a role in its pathophysiology. The endoplasmic reticulum protein sigma-1 receptors have been shown to regulate a number of neurotransmitter systems in the brain.

METHODS

We report on five cases in which monotherapy of the selective serotonin reuptake inhibitor and sigma-1 receptor agonist fluvoxamine was effective in ameliorating the akathisia of patients with schizophrenia treated with the new atypical antipsychotic drug blonanserin.

RESULTS

The global score on the Barnes Akathisia Scale in five patients with schizophrenia treated with blonanserin rapidly decreased after fluvoxamine treatment.

CONCLUSION

Doctors should consider that fluvoxamine may be an alternative approach in treating akathisia associated with atypical antipsychotic drugs.

Fluvoxamine for aripiprazole-associated akathisia in patients with schizophrenia: a potential role of sigma-1 receptors

BACKGROUND

Second-generation antipsychotic drugs have been reported to cause fewer incidences of extrapyramidal side effects (EPSs) than typical antipsychotic drugs, but adverse events such as akathisia have been observed even with atypical antipsychotic drugs. Although understanding of the pathophysiology of akathisia remains limited, it seems that a complex interplay of several neurotransmitter systems might play a role in its pathophysiology. The endoplasmic reticulum protein sigma-1 receptors are shown to regulate a number of neurotransmitter systems in the brain.

METHODS

We report on two cases in which monotherapy of the selective serotonin reuptake inhibitor and sigma-1 receptor agonist fluvoxamine was effective in ameliorating the akathisia of patients with schizophrenia treated with the antipsychotic drug aripiprazole.

RESULTS

The global score on the Barnes Akathisia Scale in the two patients with schizophrenia treated with aripiprazole decreased after fluvoxamine monotherapy.

CONCLUSION

Doctors may wish to consider fluvoxamine as an alternative approach in treating akathisia associated with antipsychotic drugs such as aripiprazole.

Systematic evaluation of rating scales for drug-induced parkinsonism and recommendations for future research

OBJECTIVE

Drug-induced parkinsonism (DIP) is one of the most common adverse effects of antipsychotic agents. The limited agreement about which rating scale should be used in clinical practice to assess DIP prompted us to review the feasibility and the psychometric qualities of the available instruments.

METHODS

The PubMed and EMBASE databases were searched in November 2008 using the terms "parkinsonism," "scale," and "drug induced" to identify instruments used to measure DIP. Then, the literature was searched for studies investigating the use and psychometric properties of each identified instrument. Outcome measures included feasibility, validity (including appropriateness of used reference test), and reliability (internal consistency and interrater and intrarater reliability).

RESULTS

Seventeen rating scales were identified, each with a different representation of the concept of parkinsonism. The Simpson Angus Scale (SAS) was used the most, followed by the Extrapyramidal Symptom Rating Scale. There were limited psychometric data, especially regarding validity, available for any scale. The SAS, the Drug-Induced Extrapyramidal Scale, and the parkinsonism subscale of the Schedule for the Assessment of Drug-Induced Movement Disorders, which is identical to the St Hans Rating Scale for Extrapyramidal Syndromes, seemed to have moderate to good reliability and acceptable validity. The time-consuming nature of the Schedule for the Assessment of Drug-Induced Movement Disorders would make it less useful in daily practice.

CONCLUSIONS

Although various scales are used to assess DIP, few have been evaluated for validity and reliability. The SAS, St Hans Rating Scale for Extrapyramidal Syndromes, and Drug-Induced Extrapyramidal Scale seem to be the most valid, reliable, and easy-to-use instruments to evaluate DIP in clinical practice.

Antipsychotic-induced gene regulation in multiple brain regions

The molecular mechanism of action of antipsychotic drugs is not well understood. Their complex receptor affinity profiles indicate that their action could extend beyond dopamine receptor blockade. Single gene expression studies and high-throughput gene profiling have shown the induction of genes from several molecular classes and functional categories. Using a focused microarray approach, we investigated gene regulation in rat striatum, frontal cortex, and hippocampus after chronic administration of haloperidol or olanzapine. Regulated genes were validated by in situ hybridization, real-time PCR, and immunohistochemistry. Only limited overlap was observed in genes regulated by haloperidol and olanzapine. Both drugs elicited maximal gene regulation in the striatum and least in the hippocampus. Striatal gene induction by haloperidol was predominantly in neurotransmitter signaling, G-protein coupled receptors, and transcription factors. Olanzapine prominently induced retinoic acid and trophic factor signaling genes in the frontal cortex. The data also revealed the induction of several genes that could be targeted in future drug development efforts. The study uncovered the induction of several novel genes, including somatostatin receptors and metabotropic glutamate receptors. The results demonstrating the regulation of multiple receptors and transcription factors suggests that both typical and atypical antipsychotics could possess a complex molecular mechanism of action.

Tardive dyskinesia in a patient treated with quetiapine

Quetiapine is an atypical antipsychotic that is believed to have a low D2 binding affinity in striatal and extrastriatal regions. We report the case of a female patient with the diagnosis of schizoaffective disorder (using DSM-IV-TR criteria) who initially received amisulpride for 3 months, discontinued gradually because of persistent and distressing extra-pyramidal symptoms, and who developed tardive dyskinesia 3 months later after the initiation of quetiapine. A trial with ziprasidone resulted in a further worsening of tardive dyskinesia symptoms. A further trial with aripiprazole, improved her tardive dyskinesia symptoms. Although, it is under consideration the possibility that the improvement could have been due to the discontinuation of quetiapine, we conclude that aripiprazole improved the TD symptoms.

No association of serotonin transporter polymorphism (5-HTTVNTR and 5-HTTLPR) with characteristics and treatment response to atypical antipsychotic agents in schizophrenic patients

BACKGROUND

Serotonin transporter is a candidate gene for the pathogenesis of some psychiatric disorders. The aim of this study was to examine the role of the serotonin transporter gene polymorphism in the clinical aspects of schizophrenia including symptomatology and therapeutic response.

METHODS

This study comprised 141 unrelated patients who strictly met the DSM-IV criteria for schizophrenia and 115 control subjects. All subjects were of Korean ethnicity. Serotonin transporter intron 2 VNTR polymorphism (5-HTTVNTR) and serotonin transporter linked polymorphic region polymorphism (5-HTTLPR) were analyzed in schizophrenia patients and control subjects. The Positive and Negative Symptom Scale (PANSS) was used at baseline and 6 weeks after atypical antipsychotic treatment to evaluate the clinical symptoms. Body mass index (BMI), the Barnes Akathisia Rating Scale (BARS), the Simpson-Angus Rating Scale (EPS) for adverse effect and the Calgary Depression rating Scale for Schizophrenia (CDSS) were measured.

RESULTS

There were no significant differences in the frequency of genotypes between schizophrenia patients and control subjects. There were no significant differences in PANSS scores before treatment according to the serotonin transporter genotypes. Treatment response after atypical antipsychotics did not differ among the genotypes. No difference was shown among the genotypes for the scales in adverse effects and depression (BMI, BARS, EPS, CDSS).

CONCLUSIONS

Our results suggest that the serotonin transporter polymorphism does not seem to be a susceptibility factor for schizophrenia. Similarly, the serotonin transporter polymorphism might not affect the therapeutic response and adverse effect to atypical antipsychotics in Korean patients with schizophrenia. Further studies with a larger number of subjects are required to better understand the role of the serotonin transporter polymorphism in schizophrenia.

Clinical consequences of switching antipsychotic drugs in outpatients with schizophrenia: 36-month results from the European Schizophrenia Outpatient Health Outcomes study

Data from the European Schizophrenia Outpatient Health Outcomes, a 3-year, prospective, observational study of health outcomes associated with antipsychotic treatment in outpatients with schizophrenia (n=10 972 enrolled), were used to assess the impact of the first switching of antipsychotic medications, with a focus on olanzapine, on clinical status and tolerability outcomes. Patients were defined as those who (1) started olanzapine at baseline and changed treatment; (2) started another antipsychotic at baseline and changed to olanzapine; and (3) changed from and to a non-olanzapine antipsychotic. A logistic regression model was used to analyse the impact of switching on treatment response and tolerability. Patients switching from olanzapine were less likely to respond than patients switching to olanzapine (OR: 0.59; 95% CI: 0.40, 0.87). Patients who switched from olanzapine and those who switched neither from nor to olanzapine were more likely to have extrapyramidal symptoms (OR: 3.79; 95% CI: 2.02, 7.10 and OR: 2.18; 95% CI: 1.23, 3.86, respectively) and loss of libido (OR: 1.89; 95% CI: 1.21, 2.96 and OR: 1.56; 95% CI: 1.04, 2.35, respectively) compared with patients who switched from another antipsychotic to olanzapine. Patients who switched to olanzapine experienced a higher weight gain. In conclusion, among patients switching antipsychotic medication, those who switched to olanzapine had better long-term outcomes.

Long-term, naturalistic treatment with olanzapine, risperidone, quetiapine, or haloperidol monotherapy: 24-month results from the Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study

Objective. To compare the effectiveness of olanzapine, risperidone, quetiapine, or haloperidol monotherapy in patients with schizophrenia who were treated in routine clinical practice settings for a period of 2 years. The incidence and persistence of adverse events encountered during long-term therapy are also reported. Method. Outpatients with schizophrenia who entered this 3-year, prospective, observational study were classified according to their initially prescribed antipsychotic monotherapy: olanzapine (n=3222), risperidone (n=1116), quetiapine (n=189), or haloperidol (n=256). Patients were included in the analysis for as long as this treatment was maintained. Results. Over 2 years, olanzapine recipients had significantly (P≤0.001) greater reduction in overall CGI-S score (and the negative, depressive, and cognitive symptoms domains), lower incidence of sexual and motor dysfunction, and greater odds of response compared to risperidone or haloperidol-treated patients. However, olanzapine patients gained more weight than patients in other treatment groups. The incidence of motor dysfunction was significantly (P≤0.001) greater in haloperidol-treated patients, relative to the atypical treatment groups. Conclusion. The results of this observational study indicate that, in these patients with schizophrenia, long-term monotherapy with olanzapine may offer benefits over risperidone and haloperidol, but the potential for weight gain should be considered in the clinical management of these patients.

Serum BDNF levels and weight gain in schizophrenic patients on long-term treatment with antipsychotics

Several lines of evidence suggest that central brain-derived neurotrophic factor (BDNF) modulates food intake, metabolism, and increases in body weight. Reports have also shown that serum BDNF is altered in schizophrenic patients treated with antipsychotics. This study aimed to determine if there was a relationship between BDNF and antipsychotic-induced weight gain in patients with chronic schizophrenia. Serum BDNF was measured in 124 schizophrenia patients chronically treated with clozapine (n=57), risperidone (n=23) or typical antipsychotics (n=44) and 50 healthy control subjects. To further assess group differences in serum BDNF, additional analyses were performed in a subset of patients and controls individually matched for body mass index (BMI). BDNF levels were lower in patients with schizophrenia than normal controls. However, this difference was not present when controlling for current BMI. In the individually BMI-matched sample, no differences in serum BDNF levels were observed in schizophrenic patients compared to BMI-matched healthy controls. BDNF levels negatively correlated with BMI gain in female but not in male patients when gender was considered. Antipsychotic class exerted differential effects over BDNF levels and BMI gain. Our findings suggest that decreased BDNF levels may be associated with weight gain in female schizophrenic patients on long-term antipsychotic treatment.

Safety and tolerability of quetiapine in the treatment of acute mania in bipolar disorder

OBJECTIVE

To review the safety/tolerability of quetiapine in four placebo-controlled studies in patients with bipolar I disorder experiencing acute mania.

METHODS

Four double-blind, placebo-controlled studies evaluated quetiapine monotherapy (12 weeks) or quetiapine in combination with lithium (mean serum concentration 0.76 mEq/L) or divalproex (mean serum concentration 68.6 microg/mL) (Li/DVP) (3 and 6 weeks) in patients with acute mania. Pooled data from the two monotherapy studies and the two combination therapy studies have been evaluated in the analysis presented here. Adverse event reporting, Simpson Angus Scale (SAS), and Barnes Akathisia Rating Scale (BARS) scores were recorded.

RESULTS

Most adverse events were mild to moderate. Common adverse events (> or = 5% and at least twice the placebo rate) with quetiapine monotherapy and combination therapy were somnolence, dry mouth, weight gain, dizziness, asthenia, pharyngitis, and postural hypotension. Treatment-related discontinuations due to adverse events were not significantly different between quetiapine and placebo, nor was the incidence of extrapyramidal symptoms (including akathisia) (quetiapine monotherapy 12.9% vs placebo 13.1%; combination therapy 21.4% vs placebo 19.2%). Mean change from baseline to endpoint in SAS and BARS scores was not significantly different between groups. Mean weight change at treatment end with quetiapine compared with placebo was +1.8 vs -0.15 kg in monotherapy; and +1.97 vs +0.27 kg with combination therapy. No patients discontinued due to weight gain. The effect of quetiapine monotherapy on serum prolactin levels was no different from placebo.

CONCLUSIONS

Quetiapine monotherapy and combination therapy were well tolerated in the treatment of acute mania.

Decision analysis model evaluating the cost-effectiveness of risperidone, olanzapine and haloperidol in the treatment of schizophrenia

PURPOSE

To evaluate the cost-effectiveness of three antipsychotic medications (olanzapine, risperidone and haloperidol) in the treatment of schizophrenia using the Positive and Negative Symptom Scale.

STUDY DESIGN AND METHODS

A decision analysis model was created to evaluate the cost-effectiveness of two atypical antipsychotics (risperidone and olanzapine) and haloperidol. Outcome probabilities were determined from published clinical trials. The main dependent variable of interest was to compare the incremental cost-effectiveness ratios (ICER) of the atypical antipsychotic with haloperidol, and also to compare the ICER of olanzapine and risperidone. Sensitivity analyses were conducted for olanzapine and risperidone to determine the effects of altering drug cost, efficacy and re-hospitalization rate on total costs.

RESULTS

Risperidone and olanzapine were dominant strategies compared with haloperidol (less costly and more effective). Risperidone was also dominant when compared with olanzapine. A one-way sensitivity analysis for efficacy indicated that the efficacy of risperidone would need to decrease by approximately 3% from the base-case in order for olanzapine and risperidone to have equal total costs. In a two-way sensitivity analysis varying both the cost of olanzapine and risperidone, the difference in drug costs between them would have to increase from $2.12 per day to $4.12 per day in order to have equal total costs. In terms of varying re-hospitalization rates, the re-hospitalization rate for risperidone would have to increase from 3% to 33% greater than the re-hospitalization rate for olanzapine in order to have equal total direct costs.

CONCLUSION

Based on this decision model, atypical antipsychotics were a dominant strategy over haloperidol primarily because of increased efficacy and lower re-hospitalizations. The ICER indicated that risperidone was dominant over olanzapine because of lower drug costs and increased number of responders, which leads to decreased total costs.

The effects of olanzapine and fluphenazine on plasma cortisol, prolactin and muscle rigidity in schizophrenic patients: a double blind study

Pharmacotherapy of schizophrenia is associated with the stressful side effects. Muscle rigidity causes distress, discomfort and poor compliance. The aim of the study was to determine the relationship between plasma hormones (cortisol and prolactin/PRL) and muscle rigidity in female schizophrenic patients treated with olanzapine or fluphenazine. In a randomized, double-blind 22-weeks study, 12 patients were treated with olanzapine (5-20 mg/day) and 10 patients received fluphenazine (6-21 mg/day). Treatment with olanzapine moderately decreased, while treatment with fluphenazine significantly increased plasma cortisol levels and muscle rigidity. The marked and moderate increase in plasma PRL levels were found in patients treated with fluphenazine and olanzapine, respectively. The results suggested that olanzapine induced moderate neuroendocrine effects and a reduction in rigidity as compared to fluphenazine treatment.

Quetiapine demonstrates good tolerability and is associated with improvements in extrapyramidal symptoms in patients with schizophrenia switched from other antipsychotics: results of a naturalistic study

Objectives. Compared with conventional agents, atypical antipsychotics such as quetiapine (Seroquel®; AstraZeneca) show improved tolerability and a lower liability to cause extrapyramidal symptoms (EPS). In the routine treatment of schizophrenia, it is usual practice to consider a change of medication when the current treatment is ineffective or poorly tolerated, although few studies are available to guide clinicians. This paper reports the results from the Seroquel Method. Patient Evaluation on Changing Treatment Relative to Usual Medication (SPECTRUM) trial, a 12-week, open-label, noncomparative study that evaluated clinical benefit and tolerability of switching patients with schizophrenia from their existing antipsychotic to quetiapine. Patients were switched because of intolerance to, or lack of efficacy with, their previous antipsychotic. Quetiapine was titrated to 400 mg/day over 7 days, then dosed flexibly up to 750 mg/day over the remaining weeks (mean modal dose 505 mg/day). Results. In the overall population of 506 evaluable patients, quetiapine was well tolerated, with a low incidence of adverse events and minimal requirement for anticholinergic medication. Significant improvements in EPS, including parkinsonism and akathisia, were observed, irrespective of reason for switching, although greatest improvements were observed in patients switching because of EPS. Conclusions. This study provides further evidence for the utility and tolerability of quetiapine, in patients with schizophrenia who had been switched from a previous antipsychotic, following problems with efficacy or tolerability.

Second-generation antipsychotics: is there evidence for sex differences in pharmacokinetic and adverse effect profiles?

Six second-generation antipsychotics (SGAs), aripiprazole, clozapine, olanzapine, quetiapine, risperidone and ziprasidone, are currently US FDA approved. The aim of this review is to investigate whether sex differences exist for efficacy and adverse effects of these drugs.Sex-related differences have been shown in the pharmacokinetics of cytochrome P450 (CYP), with a higher activity in females for CYP3A4 and CYP2D6. However, even if there are pharmacokinetic differences between females and males, significantly higher plasma concentrations in women have been demonstrated only for olanzapine and clozapine. To date, sex differences in adverse effects have not been well studied, but some adverse effects such as weight gain, hyperprolactinaemia and cardiac effects are reported to be particularly problematic for women. Most of the studies reviewed indicate that clozapine and olanzapine are associated with greater bodyweight gain than the other atypical antipsychotics, and that serious adverse effects such as metabolic syndrome, which includes increased visceral adiposity, hyperglycaemia, hypertension and dyslipidaemia induced by SGAs, are more frequent in females. According to most studies, the risk for cardiac adverse effects induced by SGAs is the same in male and female patients. Although women are at a lower risk of sudden cardiac death, they have a higher risk of induced long QT syndrome from antiarrhythmic and, probably, antipsychotic drugs. The propensity of sexual dysfunctions is higher with conventional antipsychotics than with SGAs. Additionally, there is some evidence that female sexual dysfunction is associated with high prolactin levels; however, whether the degree of prolactin level elevation is different between female and male patients remains controversial. There is no evidence for sex differences for any of the SGAs to cause a higher rate of extrapyramidal symptoms, acute dystonia or any other movement disturbance. Knowledge of the risks and benefits associated with the use of SGAs during pregnancy and lactation is limited, although the direction of dose adjustments during pregnancy depends on the drug and the enzyme that is responsible for its metabolism. In general, data on sex differences were mostly obtained by posthoc analysis and, therefore, the conclusions that can be drawn are limited. For a better understanding of the basic mechanisms of sex differences, future studies with a primary focus on this topic are required. Data that are more specific will help determine the extent to which these differences will have implications for clinical management.

Placebo-level incidence of extrapyramidal symptoms (EPS) with quetiapine in controlled studies of patients with bipolar mania

OBJECTIVES

To evaluate extrapyramidal symptoms (EPS), including akathisia, with quetiapine in patients with bipolar mania.

METHODS

Data were analyzed from four similarly designed, randomized, double-blind, 3- to 12-week studies. Two studies evaluated quetiapine monotherapy (up to 800 mg/day) (n = 209) versus placebo (n = 198), with lithium or haloperidol monotherapy as respective active controls. Two studies evaluated quetiapine (up to 800 mg/day) in combination with a mood stabilizer (lithium or divalproex, QTP + Li/DVP) (n = 196) compared to placebo and mood stabilizer (PBO + Li/DVP) (n = 203). Extrapyramidal symptoms were evaluated using the Simpson-Angus Scale (SAS), the Barnes Akathisia Rating Scale (BARS), adverse event reports and anticholinergic drug usage.

RESULTS

The incidence of EPS-related adverse events, including akathisia, was no different with quetiapine monotherapy (12.9%) than with placebo (13.1%). Similarly, EPS-related adverse events with QTP + Li/DVP (21.4%) were no different than with PBO + Li/DVP (19.2%). Adverse events related to EPS occurred in 59.6% of patients treated with haloperidol (n = 99) monotherapy, whereas 26.5% of patients treated with lithium (n = 98) monotherapy experienced adverse events related to EPS. The incidence of akathisia was low and similar with quetiapine monotherapy (3.3%) and placebo (6.1%), and with QTP + Li/DVP (3.6%) and PBO + Li/DVP (4.9%). Lithium was associated with a significantly higher incidence (p < 0.05) of tremor (18.4%) than quetiapine (5.6%); cerebellar tremor, which is a known adverse effect of lithium, may have contributed to the elevated rate of tremor in patients receiving lithium therapy. Haloperidol induced a significantly higher incidence (p < 0.001) of akathisia (33.3% versus 5.9%), tremor (30.3% versus 7.8%), and extrapyramidal syndrome (35.4% versus 5.9%) than quetiapine. No significant differences were observed between quetiapine and placebo on SAS and BARS scores. Anticholinergic use was low and similar with quetiapine or placebo.

CONCLUSIONS

In bipolar mania, the incidence of EPS, including akathisia, with quetiapine therapy is similar to that with placebo.

Pharmacological aspects of the treatment of conduct disorder in children and adolescents

In recent years, the rates of psychosocial disorders in children and adolescents have increased, with behavioural manifestations of conduct disorder being one of the most common reasons for referrals to community psychiatrists. Childhood conduct problems are associated with a variety of psychiatric disorders in adult life that extend beyond antisocial behaviour. An increased awareness of the costs of conduct disorder to individuals, families and society has led to advancements in the pharmacological and nonpharmacological therapeutic modalities for this disorder. Despite this, patients with conduct disorder are difficult to treat as the patterns of maladaptive behaviours they exhibit are diverse and can vary as a function of age and sex. A multidisciplinary approach to the treatment of conduct disorder, which includes behavioural parent training, interpersonal skills training, family therapy and the use of psychotropic agents targeted at a particular cluster of symptoms, can increase the overall effectiveness of each of the applied interventions. Aggression, hyperactivity, impulsivity and mood symptoms are the most sensitive proximal targets. Evidence suggests that antipsychotics, antidepressants, mood stabilisers, antiepileptic drugs, stimulants and adrenergic drugs can be well tolerated and effective therapeutic options for individuals with conduct disorder and comorbid psychiatric conditions. However, the most successful therapeutic outcomes are likely to be achieved by combining the current advances in psychopharmacology with behavioural and psychosocial interventions, aimed at modifying the excessive patterns of maladaptive behaviours observed in conduct disorder.

The SOHO (Schizophrenia Outpatient Health Outcome) study: implications for the treatment of schizophrenia

The European SOHO (Schizophrenia Outpatient Health Outcome) study is an observational, naturalistic study of the outpatient treatment of schizophrenia. The patient recruitment and assessment began in September 2000 and finished in early 2005. A total of 10 972 adult patients from ten European countries who were initiating or changing antipsychotic medication for the treatment of schizophrenia within the normal course of care have been enrolled. The patients have been followed at regular intervals over the 3-year timeframe of the study. Evaluation includes clinical severity, measured with the Clinical Global Impression (CGI) scale; health-related quality of life; social functioning; and medication tolerability. The 6- and 12-month results have been published so far and have demonstrated that the patients in whom treatment was initiated with olanzapine or clozapine or who were started on more than one antipsychotic of any class at baseline tended to have somewhat greater improvement than patients treated with other atypical or typical antipsychotics, both in terms of symptoms measured with the CGI and quality of life. Numbers of social contacts increased with the treatment, but other aspects of social functioning did not show any significant change. Atypical antipsychotics as a class were associated with a lower frequency of extrapyramidal symptoms (EPS) and anticholinergic use than typical antipsychotics. The frequency of EPS was lowest in the clozapine-, quetiapine- and olanzapine-treated patients, at around 10%. The atypical antipsychotics also conferred a lower risk for tardive dyskinesia than the typical antipsychotics. Weight gain occurred in all treatment cohorts over the first 12 months of treatment and was statistically significantly greater in the patients who started treatment with olanzapine and clozapine. Prolactin- and sexually-related adverse events were frequent at baseline assessment: amenorrhoea was present in around one- third of women, impotence in around 40% of men, and loss of libido in 50% of both male and female patients. Patients treated with olanzapine, clozapine and quetiapine were significantly less likely to have sexual/endocrine-related dysfunctions after 6 months of treatment (the 12-month results of this parameter are yet to be published) than those in the other treatment cohorts (typical antipsychotics, risperidone and amisulpride). Concomitant medication use during the study has been high, ranging from 5% to 29% for anticholinergics, 8% to 23% for antidepressants, 22% to 37% for anxiolytics and 7% to 19% for mood stabilisers, depending on the type of antipsychotic prescribed. Fewer olanzapine-, quetiapine- and clozapine-treated patients used concomitant anticholinergics or anxiolytics/hypnotics. The current results from the SOHO study indicate that differences in effectiveness and tolerability do exist between the antipsychotics. Future results from the study will be published during the coming months and years, and will allow patterns of antipsychotic use in routine clinical practice (including how often and why changes are made) to be determined. This important information is likely to impact on the future use of antipsychotics and will assist clinicians in refining the use of these drugs and improving the outcome of patients to whom they are prescribed.

Endocrine and metabolic adverse effects of psychotropic medications in children and adolescents

OBJECTIVE

Despite increasing use of psychotropic medications in children and adolescents, data regarding their efficacy and safety are limited. Endocrine and metabolic adverse effects are among the most concerning adverse effects of commonly used psychotropic medications.

METHOD

Selective review of endocrine and metabolic effects of psychotropic medications in pediatric populations, with a focus on monitoring and management strategies.

RESULTS

Because youth are still developing at the time of psychotropic drug exposure, most reference values need to be adjusted for gender and age. As in adults, youngsters receiving lithium require monitoring for thyroid dysfunction. Psychostimulants appear to cause mild reversible growth retardation in some patients, most likely because of decreased weight or slowing of expected weight gain; some patients may experience clinically significant reductions in adult height. Although still controversial, valproate use has been associated with an increased risk for polycystic ovary syndrome, in addition to causing weight gain. Although more data are required, children and adolescents appear to be at higher risk than adults for antipsychotic-induced hyperprolactinemia, weight gain, and possibly, associated metabolic abnormalities, which is of particular concern.

CONCLUSIONS

Clinicians and caregivers need to be aware of potential endocrine and metabolic adverse effects of psychiatric medications. A careful selection of patients, choice of agents with potentially lesser risk for these adverse events, healthy lifestyle counseling, as well as close health monitoring are warranted to maximize effectiveness and safety.

Translocation of AIF in the human and rat striatum following protracted haloperidol, but not clozapine treatment

Loss of mitochondrial membrane integrity and consequent release of apoptogenic factors may be involved in mediating striatal neurodegeneration after prolonged treatment with the typical antipsychotic drug haloperidol. Apoptosis-inducing factor (AIF), an intramitochondrial protein, may have a large influence on mediating haloperidol-induced striatal neuron destruction. Translocation of this protein from mitochondria to the nucleus promotes cell death independently of the caspase cascade. To examine how AIF may contribute to haloperidol-induced apoptosis, AIF translocation was observed in three haloperidol treatment paradigms. SH-SY5Y cells were treated with both haloperidol and clozapine and examined for AIF immunofluorescence. Immunohistochemistry was also performed on human striatal sections obtained from the Stanley Foundation Neuropathology Consortium and on rat brain sections following 28 days of antipsychotic drug treatment. In the cellular model haloperidol, but not clozapine treatment increased the nuclear AIF immunofluorescent signal and decreased cell viability. Corollary to these findings, striatal sections from patients who had taken haloperidol and rats who were administered haloperidol both had an elevated nuclear AIF signal. The results provide novel evidence implicating the involvement of AIF in haloperidol-associated apoptosis and its relevance to the development of typical antipsychotic drug-related adverse effects such as tardive dyskinesia.

Tardive Dyskinesia: analysis of outpatients with schizophrenia from Africa and the Middle East, Asia, Central and Eastern Europe, and Latin America

The point prevalence of Tardive Dyskinesia (TD) in schizophrenia outpatients (n=6981) participating in a study of health outcomes was 8.9%. Duration of diagnosis, age, and prior use of typical antipsychotics were diagnostic indicators of TD in this population, with male sex further increasing risk. This study provides new data in a non-Western population with a unique regional geography comparison.

Focus on lower risk of tardive dyskinesia with atypical antipsychotics

BACKGROUND

Tardive dyskinesia (TD) is one of the most serious iatrogenic neurological complications of the first-generation antipsychotics. Identifying the risk factors for TD is important to minimize the risk of this potentially irreversible movement disorder in susceptible populations.

METHODS

A Medline search was conducted for the literature on risk factors for TD with the first-generation antipsychotics, as well as the emerging literature of the lower risk of TD with the second-generation antipsychotics.

RESULTS

Several demographic, phenomenological, comorbidities and treatment variables have been reported to be associated with higher risk of TD. On the other hand, significantly lower rates of TD have been reported with the second-generation atypical antipsychotics, even in high risk groups such as the elderly.

CONCLUSIONS

The use of the second-generation antipsychotics as first-line treatment of psychosis appears to have lowered the overall prevalence of acute movement disorders as well as TD, and have led them to become the standard of care in part because of their safer extrapyramidal profiles.

Switching antipsychotics: an updated review with a focus on quetiapine

Atypical antipsychotics offer broader efficacy and improved tolerability compared with conventional agents. Many patients currently treated with conventional antipsychotics continue to experience persistent symptoms or troublesome side effects and may benefit from a change to one of the newer atypical agents. There are also significant differences in the side-effect profiles of the atypicals, such that a switch from one atypical agent to another could offer advantages to many patients. Unfortunately, many clinicians remain uncertain about the switching process and are reluctant to initiate change. The aim of this review is to identify the indications for a switch in antipsychotic therapy with a focus on recent switching data for the atypical antipsychotic, quetiapine. The clinical aspects of quetiapine's receptor binding characteristics are reviewed including the implications of the low D(2) antagonist properties that make quetiapine the treatment of choice when EPS persists with other atypical antipsychotics. Practical guidelines are given for managing the process of changeover, for avoiding pitfalls and for maximizing the chances of a successful switch. For example, when managing the antipsychotic crossover, it is important to consider the psychological effects of switching arising from symptom and side-effect changes. Finally, advice is provided on the assessments necessary when evaluating the success of a change in therapy, together with guidance on the optimal duration of treatment trials.

Remission in schizophrenia: Results from a 1-year study of long-acting risperidone injection

PURPOSE

Although treatment advances have improved outcomes in schizophrenia, definitions of remission and recovery are still evolving. Recently proposed criteria for remission (mild or less on multiple core-symptom ratings for at least 6 months) have been applied to a 1-year study of long-acting risperidone injection.

METHODS

In a 50-week, open-label trial, stable patients with schizophrenia or schizoaffective disorder who received long-acting risperidone injection every 2 weeks were assessed using the Positive and Negative Syndrome Scale (PANSS). Remission criteria for the PANSS were applied; global illness severity (Clinical Global Impressions) and patient-rated health status (36-Item Short-form Health Survey) were measured.

RESULTS

Groups were identified by initial remission status (excluding the time component). Although considered clinically "stable," 68.2% (394/578) did not meet the symptom-severity component of remission criteria at baseline. Following long-acting, injectable risperidone treatment, 20.8% (82) of nonremitted patients achieved symptom remission for at least 6 months, with significant decreases in mean PANSS total and cluster scores (P < 0.0001) and significantly improved patient-rated health status (P < 0.0001). Percentages rated as not ill, very mild, or mild increased from 39% to 88%. Among 31.8% (184/578) of patients meeting the symptom-severity component of remission criteria at baseline, 84.8% (156) maintained these criteria at endpoint.

CONCLUSIONS

Among previously "stable," nonremitted patients, many achieved symptom remission after long-acting, injectable risperidone treatment, with significant improvements in multiple symptom domains and patient-rated health status. These results warrant further study as these remission criteria may represent a meaningful clinical endpoint and an important step towards functional recovery.

Validation of the Investigator's Assessment Questionnaire, a new clinical tool for relative assessment of response to antipsychotics in patients with schizophrenia and schizoaffective disorder

The success of long-term therapy in schizophrenia is contingent upon real-world effectiveness or improvements in several domains, including efficacy, safety and tolerability. This report describes the Investigator's Assessment Questionnaire (IAQ), a new 10-item instrument designed to assess relative effectiveness (efficacy, safety and tolerability) of antipsychotic medications in patients with schizophrenia or schizoaffective disorder. To measure content validity, 300 psychiatrists rated the importance of the IAQ items. Efficacy (i.e., positive and negative symptoms) was considered most important, but importance scores relative to the mean ranged only from 0.87 to 1.18, suggesting similar importance of the items. Cronbach's coefficient alpha values showed that the items were internally consistent. Factor analyses indicated that all IAQ items belong to a single domain. Data from the US Broad Effectiveness Trial of Aripiprazole were used for construct validation. Total IAQ score correlated significantly with time to treatment discontinuation (r=-0.50), Clinical Global Impressions-Improvement (CGI-I) score (r=0.76) and medication preference of patients (r=0.71) or caregivers (r=0.70). A one-unit decrease in IAQ score corresponded to an additional 1.35 days in the study and a decrease in CGI-I of 0.21 units. These results provide initial validation of the IAQ as a tool for evaluating antipsychotic response in patients with schizophrenia or schizoaffective disorder.