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Mishra A, Maiti R, Mishra BR, Srinivasan A. Augmentation Strategies for Partial or Non-responders to Clozapine in Patients with Schizophrenia: A Bayesian Network Meta-analysis of Randomized Controlled Trials. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2024; 22:232-252. [PMID: 38627071 PMCID: PMC11024692 DOI: 10.9758/cpn.23.1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/03/2023] [Accepted: 10/19/2023] [Indexed: 04/20/2024]
Abstract
Clozapine is the only approved drug for treatment-resistant schizophrenia, but the response to the drug is often inadequate. Augmentation with other antipsychotics, anticonvulsants, and antidepressants is recommended for such patients, but there is a lack of evidence regarding the most effective therapy. This network meta-analysis was conducted to evaluate the efficacy of pharmacological agents used in the augmentation strategies in patients who were partial/ non-responders to clozapine. Relevant data were extracted from 30 randomized controlled trials through searches of electronic databases (MEDLINE/PubMed, Embase, Cochrane, clinical trial registries). PRISMA guidelines were followed for the extraction, management, analysis, and reporting of the data. The outcome measure in this study was a reduction in symptom severity according to total PANSS/BPRS and was reported as the standardized mean difference with a 95% credible interval. Bayesian network meta-analysis with random effects model and uninformative priors was conducted, and the ranking probability of each intervention was done. Meta-regression was done to assess the effect of duration on the reduction in symptom severity scores. Mirtazapine (-5.2 [95%CrI: -7.7, -2.7]) and memantine (-2.1 [95%CrI: -4.0, -0.19]] were more efficacious than placebo for augmentation of clozapine in partial/non-responders and were the most effective adjunctive agents as per SUCRA scores. Both drugs did not cause a significant increase in frequency of adverse events compared to placebo. There was a significant effect of duration on the reduction in symptom severity. There was no evident publication bias. Mirtazapine and memantine may prove beneficial for augmentation of clozapine in non/partial responders to monotherapy.
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Affiliation(s)
- Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Biswa Ranjan Mishra
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Abstract
BACKGROUND Several augmentation strategies have been used to improve symptomatology in patients not adequately responding to clozapine. Several randomised controlled trials (RCTs) have evaluated the efficacy of different strategies to augment clozapine. This systematic review and meta-analysis reviewed the available RCTs that have evaluated the clinical efficacy of various pharmacological agents, non-pharmacological strategies (occupational therapy, cognitive behaviour therapy), and somatic treatment [electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation, etc.)] as augmenting agents to clozapine. METHODS Data were extracted using standard procedures, and risk of bias was evaluated. Effect sizes were computed for the individual studies. RESULTS Forty-five clinical trials were evaluated. The pooled effect size for various antipsychotic medications was 0.103 (95% CI: 0.288-0.493, p < 0.001); when the effect size was evaluated for specific antipsychotics for which more than one trial was available, the effect size for risperidone was -0.27 and that for aripiprazole was 0.57. The effect size for lamotrigine was 0.145, and that for topiramate was 0.392. The effect size for ECT was 0.743 (CI: 0.094-1.392). Risk of bias was low (mean Jadad score - 3.93). Largest effect sizes were seen for mirtazapine (effect size of 5.265). Most of the studies can be considered underpowered and limited by small sample sizes. CONCLUSIONS To conclude, based on the findings of the present systematic review and meta-analysis, it can be said that compared to other treatment strategies, clozapine non-responsive patients respond maximum to mirtazapine followed by ECT.
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Campana M, Falkai P, Siskind D, Hasan A, Wagner E. Characteristics and definitions of ultra-treatment-resistant schizophrenia - A systematic review and meta-analysis. Schizophr Res 2021; 228:218-226. [PMID: 33454644 DOI: 10.1016/j.schres.2020.12.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/17/2020] [Accepted: 12/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to characterize ultra-treatment-resistant Schizophrenia also known as clozapine-resistant schizophrenia (CRS) patients across clozapine combination and augmentation trials through demographic and clinical baseline data. Furthermore, we investigated the variability and consistency in CRS definitions between studies. METHODS Systematic searches of articles indexed in PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO were conducted in March 2020. 1541 randomized and non-randomized clinical trials investigating pharmacological and non-pharmacological clozapine add-on strategies were screened and a total of 71 studies were included. The primary outcome was the overall symptom score at baseline, measured with Positive and Negative Syndrome Scale (PANSS) total or Brief Psychiatric Rating Scale (BPRS) total scores. RESULTS Data from 2731 patients were extracted. Patients were overall moderately ill with a mean PANSS total score at baseline of 79.16 (±7.52), a mean duration of illness of 14.64 (±4.14) years with a mean clozapine dose of 436.94 (±87.47) mg/day. Illness severity data were relatively homogenous among patients independently of the augmentation strategy involved, although stark geographical differences were found. Overall, studies showed a large heterogeneity of CRS definitions and insufficient guidelines implementation. CONCLUSIONS This first meta-analysis characterizing CRS patients and comparing CRS definitions revealed a lack of consistent implementation of a CRS definition from guidelines into clinical trials, compromising the replicability of the results and their applicability in clinical practice. We offer a new score modeled on a best practice definition to help future trials increase their reliability.
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Affiliation(s)
- Mattia Campana
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Dan Siskind
- School of Medicine, University of Queensland, Brisbane, Australia; Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Augsburg, Germany
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
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Schmidt-Kraepelin C, Feyerabend S, Engelke C, Riesbeck M, Meisenzahl-Lechner E, Gaebel W, Verde PE, Kolbe H, Correll CU, Leucht S, Heres S, Kluge M, Makiol C, Neff A, Lange C, Englisch S, Zink M, Langguth B, Poeppl T, Reske D, Gouzoulis-Mayfrank E, Gründer G, Hasan A, Brockhaus-Dumke A, Jäger M, Baumgärtner J, Wobrock T, Cordes J. A randomized double-blind controlled trial to assess the benefits of amisulpride and olanzapine combination treatment versus each monotherapy in acutely ill schizophrenia patients (COMBINE): methods and design. Eur Arch Psychiatry Clin Neurosci 2020; 270:83-94. [PMID: 31486890 DOI: 10.1007/s00406-019-01063-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
This report presents the rationale and design of a multi-center clinical trial that examines the efficacy and safety of antipsychotic combination treatment in acutely ill schizophrenia patients compared to antipsychotic monotherapy. Antipsychotic combination treatment is common in clinical practice worldwide, despite clinical guidelines generally not recommending such practice due to lacking evidence for its efficacy and safety. Olanzapine has a related chemical structure and comparable receptor-binding profile as clozapine, which demonstrated superior efficacy in combination studies, but has a more unfavorable side-effect profile compared to olanzapine. Amisulpride and olanzapine have shown promising therapeutic efficacy in meta-analyses in monotherapy for people with schizophrenia. Combining amisulpride and olanzapine, complementary receptor-binding properties may enhance efficacy and possibly reduce (or at least not augment) side effects due to the different receptor profiles and metabolization pathways. Accordingly, we hypothesize that patients treated with amisulpride plus olanzapine show greater improvement on the Positive and Negative Syndrome Scale total score after 8 weeks versus either monotherapy. A randomized, double-blind controlled trial is performed at 16 German centers comparing flexibly dosed monotherapy of oral amisulpride (400-800 mg/day), and olanzapine (10-20 mg/day) and amisulpride-olanzapine co-treatment. Sample size was calculated to be n = 101 per treatment arm, assuming an effect size of 0.500 and a two-sided alpha = 0.025 and beta = 0.90. Recruitment for this trial started in June 2012. Until December 2018, 328 patients have been randomized. Trial conduct has been extended to reach the projected sample size. Publication of the study results is expected in 2019 informing an evidence-based recommendation regarding specific antipsychotic combination treatment.
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Affiliation(s)
- Christian Schmidt-Kraepelin
- Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Clinic Düsseldorf, Heinrich-Heine-University Duesseldorf, Bergische Landstraße 2, 40629, Duesseldorf, Germany.
| | - Sandra Feyerabend
- Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Clinic Düsseldorf, Heinrich-Heine-University Duesseldorf, Bergische Landstraße 2, 40629, Duesseldorf, Germany
| | - Christina Engelke
- Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Clinic Düsseldorf, Heinrich-Heine-University Duesseldorf, Bergische Landstraße 2, 40629, Duesseldorf, Germany
| | - Mathias Riesbeck
- Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Clinic Düsseldorf, Heinrich-Heine-University Duesseldorf, Bergische Landstraße 2, 40629, Duesseldorf, Germany
| | - Eva Meisenzahl-Lechner
- Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Clinic Düsseldorf, Heinrich-Heine-University Duesseldorf, Bergische Landstraße 2, 40629, Duesseldorf, Germany
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Clinic Düsseldorf, Heinrich-Heine-University Duesseldorf, Bergische Landstraße 2, 40629, Duesseldorf, Germany
| | - Pablo-Emilio Verde
- Coordination Center for Clinical Trials, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Henrike Kolbe
- Coordination Center for Clinical Trials, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Christoph U Correll
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Northwell Health, The Zucker Hillside Hospital, Psychiatry Research, Glen Oaks, NY, USA
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany
| | - Stephan Heres
- Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany
- kbo-Isar-Amper-Klinikum München-Ost, Munich, Germany
| | - Michael Kluge
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Christian Makiol
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Andrea Neff
- LVR-Klinikum Langenfeld, Langenfeld, Germany
| | | | - Susanne Englisch
- Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Mathias Zink
- Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Timm Poeppl
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
| | | | | | - Gerhard Gründer
- Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany
| | - Anke Brockhaus-Dumke
- Department of Psychiatry and Psychotherapy 1 und 2, Rheinhessen-Fachklinik Alzey, Academic Hospital of the University of Mainz, Alzey, Germany
| | - Markus Jäger
- Department of Psychiatry II, Bezirkskrankenhaus Günzburg, Ulm University, Günzburg, Germany
| | - Jessica Baumgärtner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Bezirkskrankenhaus Augsburg, University Augsburg, Augsburg, Germany
| | - Thomas Wobrock
- Department of Psychiatry and Psychotherapy, County Hospitals Darmstadt-Dieburg, Groß-Umstadt, Germany
- Department of Psychiatry and Psychotherapy, Georg-August-University Göttingen, Göttingen, Germany
| | - Joachim Cordes
- Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Clinic Düsseldorf, Heinrich-Heine-University Duesseldorf, Bergische Landstraße 2, 40629, Duesseldorf, Germany
- Department of Psychiatry and Psychotherapy, Kaiserswerther Diakonie, Florence Nightingale Hospital, Düsseldorf, Germany
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Kinzler MN, Zielke S, Kardo S, Meyer N, Kögel D, van Wijk SJL, Fulda S. STF-62247 and pimozide induce autophagy and autophagic cell death in mouse embryonic fibroblasts. Sci Rep 2020; 10:687. [PMID: 31959760 PMCID: PMC6971264 DOI: 10.1038/s41598-019-56990-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 12/20/2019] [Indexed: 01/14/2023] Open
Abstract
Induction of autophagy can have beneficial effects in several human diseases, e.g. cancer and neurodegenerative diseases (ND). Here, we therefore evaluated the potential of two novel autophagy-inducing compounds, i.e. STF-62247 and pimozide, to stimulate autophagy as well as autophagic cell death (ACD) using mouse embryonic fibroblasts (MEFs) as a cellular model. Importantly, both STF-62247 and pimozide triggered several hallmarks of autophagy in MEFs, i.e. enhanced levels of LC3B-II protein, its accumulation at distinct cytosolic sites and increase of the autophagic flux. Intriguingly, autophagy induction by STF-62247 and pimozide resulted in cell death that was significantly reduced in ATG5- or ATG7-deficient MEFs. Consistent with ACD induction, pharmacological inhibitors of apoptosis, necroptosis or ferroptosis failed to protect MEFs from STF-62247- or pimozide-triggered cell death. Interestingly, at subtoxic concentrations, pimozide stimulated fragmentation of the mitochondrial network, degradation of mitochondrial proteins (i.e. mitofusin-2 and cytochrome c oxidase IV (COXIV)) as well as a decrease of the mitochondrial mass, indicative of autophagic degradation of mitochondria by pimozide. In conclusion, this study provides novel insights into the induction of selective autophagy as well as ACD by STF-62247 and pimozide in MEFs.
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Affiliation(s)
- Maximilian N Kinzler
- Institute for Experimental Cancer Research in Pediatrics, Goethe-University Frankfurt, Komturstr. 3a, 60528, Frankfurt, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt, Frankfurt, Germany
| | - Svenja Zielke
- Institute for Experimental Cancer Research in Pediatrics, Goethe-University Frankfurt, Komturstr. 3a, 60528, Frankfurt, Germany
| | - Simon Kardo
- Institute for Experimental Cancer Research in Pediatrics, Goethe-University Frankfurt, Komturstr. 3a, 60528, Frankfurt, Germany
| | - Nina Meyer
- Experimental Neurosurgery, Goethe-University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Donat Kögel
- Experimental Neurosurgery, Goethe-University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Sjoerd J L van Wijk
- Institute for Experimental Cancer Research in Pediatrics, Goethe-University Frankfurt, Komturstr. 3a, 60528, Frankfurt, Germany
| | - Simone Fulda
- Institute for Experimental Cancer Research in Pediatrics, Goethe-University Frankfurt, Komturstr. 3a, 60528, Frankfurt, Germany.
- German Cancer Consortium (DKTK), Partner Site Frankfurt, Frankfurt, Germany.
- German Cancer Research Centre (DKFZ), Heidelberg, Germany.
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Faden J, Citrome L. Resistance is not futile: treatment-refractory schizophrenia - overview, evaluation and treatment. Expert Opin Pharmacother 2018; 20:11-24. [PMID: 30407873 DOI: 10.1080/14656566.2018.1543409] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Schizophrenia is a debilitating condition with three main symptom domains: positive, negative, and cognitive. Approximately one-third of persons with schizophrenia will fail to respond to treatment. Growing evidence suggests that treatment-resistant (refractory) schizophrenia (TRS) may be a distinct condition from treatment-respondent schizophrenia. There is limited evidence on effective treatments for TRS, and a lack of standardized diagnostic criteria for TRS has hampered research. Areas covered: A literature search was conducted using Pubmed.gov and the EMBASE literature database. The authors discuss the pragmatic definitions of TRS and review treatments consisting of antipsychotic monotherapy and augmentation strategies. Expert opinion: Currently available first-line antipsychotic medications are generally effective at treating the positive symptoms of schizophrenia, leaving residual negative and cognitive symptoms. Before diagnosing TRS, rule out any pharmacodynamic or pharmacokinetic failures. Most evidence supports clozapine as having the most efficacy for TRS. If clozapine is used, it should be optimized, and serum levels should be at least 350-420 ng/ml. If clozapine is unable to be tolerated, some evidence suggests olanzapine at dosages up to 40mg/day can be useful. Augmentation strategies have weak evidence. Tailoring treatment to the specific domain is the preferred approach, and the use of a structured assessment/outcome measure is encouraged.
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Affiliation(s)
- Justin Faden
- a Psychiatry , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Leslie Citrome
- b Psychiatry & Behavioral Sciences , New York Medical College , Valhalla , NY , USA
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Loperamide, pimozide, and STF-62247 trigger autophagy-dependent cell death in glioblastoma cells. Cell Death Dis 2018; 9:994. [PMID: 30250198 PMCID: PMC6155211 DOI: 10.1038/s41419-018-1003-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 12/11/2022]
Abstract
Autophagy is a well-described degradation mechanism that promotes cell survival upon nutrient starvation and other forms of cellular stresses. In addition, there is growing evidence showing that autophagy can exert a lethal function via autophagic cell death (ACD). As ACD has been implicated in apoptosis-resistant glioblastoma (GBM), there is a high medical need for identifying novel ACD-inducing drugs. Therefore, we screened a library containing 70 autophagy-inducing compounds to induce ATG5-dependent cell death in human MZ-54 GBM cells. Here, we identified three compounds, i.e. loperamide, pimozide, and STF-62247 that significantly induce cell death in several GBM cell lines compared to CRISPR/Cas9-generated ATG5- or ATG7-deficient cells, pointing to a death-promoting role of autophagy. Further cell death analyses conducted using pharmacological inhibitors revealed that apoptosis, ferroptosis, and necroptosis only play minor roles in loperamide-, pimozide- or STF-62247-induced cell death. Intriguingly, these three compounds induce massive lipidation of the autophagy marker protein LC3B as well as the formation of LC3B puncta, which are characteristic of autophagy. Furthermore, loperamide, pimozide, and STF-62247 enhance the autophagic flux in parental MZ-54 cells, but not in ATG5 or ATG7 knockout (KO) MZ-54 cells. In addition, loperamide- and pimozide-treated cells display a massive formation of autophagosomes and autolysosomes at the ultrastructural level. Finally, stimulation of autophagy by all three compounds is accompanied by dephosphorylation of mammalian target of rapamycin complex 1 (mTORC1), a well-known negative regulator of autophagy. In summary, our results indicate that loperamide, pimozide, and STF-62247 induce ATG5- and ATG7-dependent cell death in GBM cells, which is preceded by a massive induction of autophagy. These findings emphasize the lethal function and potential clinical relevance of hyperactivated autophagy in GBM.
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Siskind DJ, Lee M, Ravindran A, Zhang Q, Ma E, Motamarri B, Kisely S. Augmentation strategies for clozapine refractory schizophrenia: A systematic review and meta-analysis. Aust N Z J Psychiatry 2018; 52:751-767. [PMID: 29732913 DOI: 10.1177/0004867418772351] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although clozapine is the most effective medication for treatment refractory schizophrenia, only 40% of people will meet response criteria. We therefore undertook a systematic review and meta-analysis of global literature on clozapine augmentation strategies. METHODS We systematically reviewed PubMed, PsycInfo, Embase, Cochrane Database, Chinese Biomedical Literature Service System and China Knowledge Resource Integrated Database for randomised control trials of augmentation strategies for clozapine resistant schizophrenia. We undertook pairwise meta-analyses of within-class interventions and, where possible, frequentist mixed treatment comparisons to differentiate treatment effectiveness Results: We identified 46 studies of 25 interventions. On pairwise meta-analyses, the most effective augmentation agents for total psychosis symptoms were aripiprazole (standardised mean difference: 0.48; 95% confidence interval: -0.89 to -0.07) fluoxetine (standardised mean difference: 0.73; 95% confidence interval: -0.97 to -0.50) and, sodium valproate (standardised mean difference: 2.36 95% confidence interval: -3.96 to -0.75). Memantine was effective for negative symptoms (standardised mean difference: -0.56 95% confidence interval: -0.93 to -0.20). However, many of these results included poor-quality studies. Single studies of certain antipsychotics (penfluridol), antidepressants (paroxetine, duloxetine), lithium and Ginkgo biloba showed potential, while electroconvulsive therapy was highly promising. Mixed treatment comparisons were only possible for antipsychotics, and these gave similar results to the pairwise meta-analyses. CONCLUSIONS On the basis of the limited data available, the best evidence is for the use of aripiprazole, fluoxetine and sodium valproate as augmentation agents for total psychosis symptoms and memantine for negative symptoms. However, these conclusions are tempered by generally short follow-up periods and poor study quality.
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Affiliation(s)
- Dan J Siskind
- 1 Addiction and Mental Health Services and MIRT, Metro South Health, Brisbane, QLD, Australia.,2 MIRT, Woolloongabba Community Health Centre, Metro South Health, Woolloongabba, QLD, Australia.,3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Michael Lee
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Arul Ravindran
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Qichen Zhang
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Evelyn Ma
- 3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Balaji Motamarri
- 1 Addiction and Mental Health Services and MIRT, Metro South Health, Brisbane, QLD, Australia.,3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Steve Kisely
- 1 Addiction and Mental Health Services and MIRT, Metro South Health, Brisbane, QLD, Australia.,3 School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Ortiz‐Orendain J, Castiello‐de Obeso S, Colunga‐Lozano LE, Hu Y, Maayan N, Adams CE. Antipsychotic combinations for schizophrenia. Cochrane Database Syst Rev 2017; 6:CD009005. [PMID: 28658515 PMCID: PMC6481822 DOI: 10.1002/14651858.cd009005.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Many people with schizophrenia do not achieve a satisfactory treatment response with their initial antipsychotic drug treatment. Sometimes a second antipsychotic, in combination with the first, is used in these situations. OBJECTIVES To examine whether:1. treatment with antipsychotic combinations is effective for schizophrenia; and2. treatment with antipsychotic combinations is safe for the same illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group's register which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There are no language, time, document type, or publication status limitations for inclusion of records in the register. We ran searches in September 2010, August 2012 and January 2016. We checked for additional trials in the reference lists of included trials. SELECTION CRITERIA We included all randomised and quasi-randomised controlled trials comparing antipsychotic combinations with antipsychotic monotherapy for the treatment of schizophrenia and/or schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and the 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CIs. For the meta-analysis we used a random-effects model. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for included studies. MAIN RESULTS Sixty-two studies are included in the review, 31 of these compared clozapine monotherapy with clozapine combination. We considered the risk of bias in the included studies to be moderate to high. The majority of trials had unclear allocation concealment, method of randomisation and blinding, and were not free of selective reporting.There is some limited evidence that combination therapy is superior to monotherapy in improving clinical response (RR 0.73, 95% CI 0.63 to 0.85; participants = 2364; studies = 29, very low-quality evidence), although subgroup analyses show that the positive result was due to the studies with clozapine in both the monotherapy and combination groups (RR 0.66, 95% CI 0.53 to 0.83; participants = 1127; studies = 17). Few studies reported on rate of relapse, most likely due to the short length of the studies. Overall, a combination of antipsychotics was not superior or inferior to antipsychotic monotherapy in preventing relapse (RR 0.63, 95% CI 0.31 to 1.29; participants = 512; studies = 3, very low-quality evidence), but the pooled data showed high heterogeneity (I² = 82%). A combination of antipsychotics was not superior or inferior to antipsychotic monotherapy in reducing the number of participants discontinuing treatment early (RR 0.89, 95% CI 0.73 to 1.07; participants = 3103; studies = 43, low-quality evidence). No difference was found between treatment groups in the number of participants hospitalised (RR 0.96, 95% CI 0.36 to 2.55; participants = 202; studies = 3, low-quality evidence) . We did not find evidence of a difference between treatment groups in serious adverse events or those requiring discontinuation (RR 1.05, 95% CI 0.65 to 1.69; participants = 2398; studies = 30, very low-quality evidence). There is as lack of evidence on clinically important change in quality of life, with only four studies reporting average endpoint or change data for this outcome on three different scales, none of which showed a difference between treatment groups. AUTHORS' CONCLUSIONS Currently, most evidence regarding the use of antipsychotic combinations comes from short-term trials, limiting the assessment of long-term efficacy and safety. We found very low-quality evidence that a combination of antipsychotics may improve the clinical response. We also found low-quality evidence that a combination of antipsychotics is may make no difference at preventing participants from leaving the study early, preventing relapse and/or causing more serious adverse events than monotherapy.
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Affiliation(s)
- Javier Ortiz‐Orendain
- University of GuadalajaraCentro Universitario de Ciencias de la SaludSierra Mojada 950Col. IndependenciaGuadalajaraJaliscoMexico44340
| | - Santiago Castiello‐de Obeso
- University of GuadalajaraCenter for Behavior Studies and Investigations180 Fco. de QuevedoCol. Arcos de VallartaGuadalajaraJaliscoMexico44130
| | - Luis Enrique Colunga‐Lozano
- McMaster UniversityDepartments of Health Research Methods, Evidence, and Impact and of Medicine1280 Main Street WestHamiltonOntarioCanadaL8S 4L8
| | - Yue Hu
- Tianjin University of Traditional Chinese MedicineGraduate School314 An Shan Xi RoadNan Kai DistrictTianjinChina300193
| | - Nicola Maayan
- CochraneCochrane ResponseSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Clive E Adams
- The University of NottinghamCochrane Schizophrenia GroupInstitute of Mental HealthInnovation Park, Triumph Road,NottinghamUKNG7 2TU
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Galling B, Roldán A, Hagi K, Rietschel L, Walyzada F, Zheng W, Cao X, Xiang Y, Zink M, Kane JM, Nielsen J, Leucht S, Correll CU. Antipsychotic augmentation vs. monotherapy in schizophrenia: systematic review, meta-analysis and meta-regression analysis. World Psychiatry 2017; 16:77-89. [PMID: 28127934 PMCID: PMC5269492 DOI: 10.1002/wps.20387] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Antipsychotic polypharmacy in schizophrenia is much debated, since it is common and costly with unclear evidence for its efficacy and safety. We conducted a systematic literature search and a random effects meta-analysis of randomized trials comparing augmentation with a second antipsychotic vs. continued antipsychotic monotherapy in schizophrenia. Co-primary outcomes were total symptom reduction and study-defined response. Antipsychotic augmentation was superior to monotherapy regarding total symptom reduction (16 studies, N=694, standardized mean difference, SMD=-0.53, 95% CI: -0.87 to -0.19, p=0.002). However, superiority was only apparent in open-label and low-quality trials (both p<0.001), but not in double-blind and high-quality ones (p=0.120 and 0.226, respectively). Study-defined response was similar between antipsychotic augmentation and monotherapy (14 studies, N=938, risk ratio = 1.19, 95% CI: 0.99 to 1.42, p=0.061), being clearly non-significant in double-blind and high-quality studies (both p=0.990). Findings were replicated in clozapine and non-clozapine augmentation studies. No differences emerged regarding all-cause/specific-cause discontinuation, global clinical impression, as well as positive, general and depressive symptoms. Negative symptoms improved more with augmentation treatment (18 studies, N=931, SMD=-0.38, 95% CI: -0.63 to -0.13, p<0.003), but only in studies augmenting with aripiprazole (8 studies, N=532, SMD=-0.41, 95% CI: -0.79 to -0.03, p=0.036). Few adverse effect differences emerged: D2 antagonist augmentation was associated with less insomnia (p=0.028), but more prolactin elevation (p=0.015), while aripiprazole augmentation was associated with reduced prolactin levels (p<0.001) and body weight (p=0.030). These data suggest that the common practice of antipsychotic augmentation in schizophrenia lacks double-blind/high-quality evidence for efficacy, except for negative symptom reduction with aripiprazole augmentation.
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Affiliation(s)
- Britta Galling
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité-Universitätsmedizin BerlinBerlinGermany,Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Hofstra Northwell School of MedicineHempsteadNYUSA
| | - Alexandra Roldán
- Department of PsychiatryInstitut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de BarcelonaBarcelonaSpain
| | - Katsuhiko Hagi
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Sumitomo Dainippon Pharma Co.TokyoJapan
| | - Liz Rietschel
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBernSwitzerland
| | - Frozan Walyzada
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA
| | - Wei Zheng
- Guangzhou Brain Hospital, Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Xiao‐Lan Cao
- Department of PsychiatryChinese University of Hong KongHong Kong SARChina
| | - Yu‐Tao Xiang
- Unit of Psychiatry, Faculty of Health Sciences, University of MacaoTaipa, MacaoSARChina
| | - Mathias Zink
- Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg UniversityMannheimGermany
| | - John M. Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Hofstra Northwell School of MedicineHempsteadNYUSA,Feinstein Institute for Medical ResearchManhassetNYUSA,Albert Einstein College of MedicineBronxNYUSA
| | - Jimmi Nielsen
- Department of PsychiatryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Stefan Leucht
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität MünchenMunichGermany
| | - Christoph U. Correll
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Hofstra Northwell School of MedicineHempsteadNYUSA,Feinstein Institute for Medical ResearchManhassetNYUSA,Albert Einstein College of MedicineBronxNYUSA
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Woo YS, Park JE, Kim DH, Sohn I, Hwang TY, Park YM, Jon DI, Jeong JH, Bahk WM. Blonanserin Augmentation of Atypical Antipsychotics in Patients with Schizophrenia-Who Benefits from Blonanserin Augmentation?: An Open-Label, Prospective, Multicenter Study. Psychiatry Investig 2016; 13:458-67. [PMID: 27482249 PMCID: PMC4965658 DOI: 10.4306/pi.2016.13.4.458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/12/2016] [Accepted: 03/07/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the efficacy and tolerability of atypical antipsychotics (AAPs) with augmentation by blonanserin in schizophrenic patients. METHODS aA total of 100 patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP were recruited in this 12-week, open-label, non-comparative, multicenter study. Blonanserin was added to their existing AAP regimen, which was maintained during the study period. Efficacy was primarily evaluated using the Positive and Negative Syndrome Scale (PANSS) at baseline and at weeks 2, 4, 8, and 12. Predictors for PANSS response (≥20% reduction) were investigated. RESULTS The PANSS total score was significantly decreased at 12 weeks of blonanserin augmentation (-21.0±18.1, F=105.849, p<0.001). Moreover, 51.0% of participants experienced a response at week 12. Premature discontinuation of blonanserin occurred in 17 patients (17.0%); 4 of these patients dropped out due to adverse events. The patients who benefited the most from blonanserin were those with severe symptoms despite a treatment with a higher dose of AAP. CONCLUSION Blonanserin augmentation could be an effective strategy for patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP.
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Affiliation(s)
- Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joo Eon Park
- Department of Psychiatry, Keyo Hospital, Keyo Medical Foundation, Uiwang, Republic of Korea
| | - Do-Hoon Kim
- Department of Psychiatry, Hallym University Medical Center, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
| | - Inki Sohn
- Department of Psychiatry, Keyo Hospital, Keyo Medical Foundation, Uiwang, Republic of Korea
| | - Tae-Yeon Hwang
- WHO Collaborating Center of Yongin Mental Hospital, Yongin, Republic of Korea
| | - Young-Min Park
- Department of Psychiatry, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Republic of Korea
| | - Duk-In Jon
- Department of Psychiatry, College of Medicine, Hallym University, Anyang, Republic of Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Galling B, Roldán A, Rietschel L, Hagi K, Walyzada F, Zheng W, Cao XL, Xiang YT, Kane JM, Correll CU. Safety and tolerability of antipsychotic co-treatment in patients with schizophrenia: results from a systematic review and meta-analysis of randomized controlled trials. Expert Opin Drug Saf 2016; 15:591-612. [PMID: 26967126 DOI: 10.1517/14740338.2016.1165668] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Antipsychotic co-treatment is common in schizophrenia, despite lacking evidence for its efficacy and safety. Areas: We conducted a systematic search of PubMed/PsycInfo/CJN/WangFan/CBM without language restrictions from database inception until 05/25/2015 for randomized trials comparing antipsychotic monotherapy with antipsychotic co-treatment in ≥20 adults with schizophrenia reporting meta-analyzable adverse events (AEs) data. Meta-analyzing 67 studies (n=4,861, duration=10.3±5.2 weeks), antipsychotic co-treatment was similar to monotherapy regarding intolerability-related discontinuation (risk ratio (RR)=0.84, 95% confidence interval (CI)=0.53-1.33, p=0.455). While incidence of ≥1 AE was lower with antipsychotic co-treatment (RR=0.77, 95%CI=0.66-0.90, p=0.001), these results were solely driven by open-label and efficacy-focused studies. Adjunctive D2-antagonists lead to less nausea (RR=0.220, 95%CI=0.06-0.87, p=0.030) and insomnia (RR=0.26, 95%CI=0.08-0.86, p=0.028), but higher prolactin (SMD=2.20, 95%CI=0.43-3.96, p=0.015). Conversely, adjunctive partial D2-agonists (aripiprazole=100%) resulted in lower electrocardiogram abnormalities (RR=0.43, 95%CI=0.25-0.73, p=0.002), constipation (RR=0.45, 95%CI=0.25-0.79, p=0.006), drooling/hypersalivation (RR=0.14, 95%CI=0.07-0.29, p<0.001), prolactin (SMD=-1.77, 95%CI=-2.38, -1.15, p<0.001), total and LDL-cholesterol (SMD=-0.33, 95%CI=-0.55, -0.11, p=0.003; SMD=-0.33, 95%CI=-0.54, -0.10, p=0.004). EXPERT OPINION No double-blind evidence for altered AE burden associated with antipsychotic co-treatment was found. However, AEs were insufficiently and incompletely reported and follow-up duration was modest. Adjunctive partial D2-agonists might be beneficial for counteracting several AEs. High-quality, long-term studies that comprehensively assess AEs are needed.
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Affiliation(s)
- Britta Galling
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA
| | - Alexandra Roldán
- b Department of Psychiatry, Institut d'Investigació Biomédica-Sant Pau (IIB-SANT PAU) , Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB) , Barcelona , Spain
| | - Liz Rietschel
- c University Hospital of Child and Adolescent Psychiatry and Psychotherapy , University of Bern , Bern , Switzerland
| | - Katsuhiko Hagi
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA.,d Sumitomo Dainippon Pharma Co., Ltd., Medical Affairs , Tokyo , Japan
| | - Frozan Walyzada
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA
| | - Wei Zheng
- e Department of Psychiatry, Guangzhou Brain Hospital (Guangzhou Huiai Hospital), Affilated Hospital of Guangzhou Medical University , Guangzhou , China
| | - Xiao-Lan Cao
- f Department of Psychiatry , Chinese University of Hong Kong , Hong Kong , China
| | - Yu-Tao Xiang
- g Unit of Psychiatry, Faculty of Health Sciences , University of Macau , Macao , China
| | - John M Kane
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA.,h Hofstra North Shore LIJ School of Medicine , Hempstead , NY , USA.,i The Feinstein Institute for Medical Research , Manhasset , NY , USA.,j Albert Einstein College of Medicine , Bronx , NY , USA
| | - Christoph U Correll
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA.,h Hofstra North Shore LIJ School of Medicine , Hempstead , NY , USA.,i The Feinstein Institute for Medical Research , Manhasset , NY , USA.,j Albert Einstein College of Medicine , Bronx , NY , USA
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Takeuchi H, Suzuki T, Remington G, Uchida H. Antipsychotic Polypharmacy and Corrected QT Interval: A Systematic Review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:215-22. [PMID: 26174525 PMCID: PMC4484690 DOI: 10.1177/070674371506000503] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 02/01/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVE It remains unclear whether antipsychotic polypharmacy, a common clinical practice, is related to an increased risk of corrected time between start of Q wave and end of T wave (QTc) interval prolongation. We conducted a systematic review of the literature to address this important issue. METHOD A systematic literature search was conducted in October 2014, using MEDLINE, Embase, and PsycINFO. Studies and case reports were included if they reported QTc intervals or QTc interval changes before and after antipsychotic polypharmacy or QTc intervals in both antipsychotic polypharmacy and monotherapy groups. RESULTS A total of 21 articles (10 clinical trials, 4 observational studies, and 7 case reports) met inclusion criteria. The clinical trials have shown that a combination treatment with risperidone or pimozide is not obviously related to an increase in QTc interval, whereas ziprasidone or sertindole combined with clozapine may prolong QTc interval. Among the 4 observational studies, antipsychotic polypharmacy was not clearly associated with QTc prolongation in 3 studies, each cross-sectional. In contrast, one prospective study showed a significant increase in QTc interval following antipsychotic coadministration. The case reports indicated an increased risk of QTc prolongation in at least some patients receiving antipsychotic polypharmacy. CONCLUSIONS Currently available evidence fails to confirm that antipsychotic polypharmacy worsens QTc prolongation in general, although the evidence is scarce and inconsistent. Clinicians are advised to remain conservative in resorting to antipsychotic polypharmacy, as a combination of some QTc-prolongation liable antipsychotics may further prolong QTc interval, and efficacy supporting the clinical benefits of antipsychotic polypharmacy is equivocal, at best.
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Affiliation(s)
- Hiroyoshi Takeuchi
- Post-doctoral Fellow, Schizophrenia Division, Complex Mental Illness Program, Centre for Addiction and Mental Health, Toronto, Ontario; Clinical Fellow, Department of Psychiatry, University of Toronto, Toronto, Ontario; Collaborative Researcher, Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takefumi Suzuki
- Senior Lecturer, Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Gary Remington
- Lead, Schizophrenia Division, Complex Mental Illness Program, Centre for Addiction and Mental Health, Toronto, Ontario; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Professor, Institute of Medical Science, University of Toronto, Toronto, Ontario
| | - Hiroyuki Uchida
- Senior Lecturer, Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Research Scientist, Geriatric Mental Health Program, Centre for Addiction and Mental Health, Toronto, Ontario
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Wang Y, Lin HQ, Law WK, Liang WC, Zhang JF, Hu JS, Ip TM, Waye MMY, Wan DCC. Pimozide, a novel fatty acid binding protein 4 inhibitor, promotes adipogenesis of 3T3-L1 cells by activating PPARγ. ACS Chem Neurosci 2015; 6:211-8. [PMID: 25437245 DOI: 10.1021/cn5002107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pimozide is a conventional antipsychotic of the diphenylbutylpiperidine class that has been clinically used for over 30 years. The obvious side effect of this drug is weight gain. However, the mechanism of pimozide-induced weight gain is still unknown. In the present study, we identified pimozide as a novel fatty acid binding protein 4 (FABP4) inhibitor using molecular docking simulation as well as biochemical characterizations. BMS309403, a well-known FABP4 inhibitor, elevated the basal protein levels of PPARγ, therefore stimulating adipogenesis in adipocytes. The present study showed that the inhibitory effect of pimozide on FABP4 promoted adipocyte differentiation with the potency proportional to their propensities for weight gain. These effects in adipogenesis by pimozide may help to explain the weight gain that is frequently observed in patients treated with pimozide.
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Affiliation(s)
- Yan Wang
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Huang-Quan Lin
- Division
of Life Science and Center for Chinese Medicine, The Hong Kong University of Science and Technology, Clear Water Bay Road, Hong
Kong SAR, China
| | - Wai-Kit Law
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Wei-Cheng Liang
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Department
of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Jin-Fang Zhang
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Department
of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Jian-Shu Hu
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Tsz-Ming Ip
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Mary Miu-Yee Waye
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - David Chi-Cheong Wan
- School
of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Muscatello MRA, Bruno A, De Fazio P, Segura-Garcia C, Pandolfo G, Zoccali R. Augmentation strategies in partial responder and/or treatment-resistant schizophrenia patients treated with clozapine. Expert Opin Pharmacother 2014; 15:2329-45. [PMID: 25284216 DOI: 10.1517/14656566.2014.956082] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although clozapine (CLZ) is considered the best evidence-based therapeutic option for treatment of resistant schizophrenia patients, a significant proportion of CLZ-treated patients show a partial or inadequate response to treatment, leading to increased healthcare cost and poor quality of life for affected individuals. AREAS COVERED This paper comprises a review of main research in CLZ augmentation strategies for treatment-refractory schizophrenia, with a focus on research conducted between 1990 and 2014. Databases that were searched include: PubMed, CINAHL, EMBASE PsychINFO, AgeLine and Cochrane Database of Systematic Reviews. Primary search terms were 'clozapine augmentation', 'clozapine and add-on' and 'treatment-resistant schizophrenia', with cross reference to specific agents covered in this article. We reviewed the available evidence on CLZ augmentation with antipsychotics, antidepressants, mood stabilizers and other agents. EXPERT OPINION Many drugs have been evaluated as CLZ add-on therapies without demonstrating convincing efficacy in treating refractory schizophrenia symptoms. More research is needed to better define outcomes in schizophrenia, the topic of treatment-resistance and more well-designed trials are required to establish true efficacy and safety of CLZ augmentation strategies.
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Affiliation(s)
- Maria Rosaria A Muscatello
- University of Messina, Department of Neurosciences , Policlinico Universitario Via Consolare Valeria - Messina 98125 , Italy +39 090 22212092 ; +39 090 695136 ;
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Abstract
BACKGROUND Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained death. Electrocardiogram monitoring is now required before and during use. OBJECTIVES To review the effects of pimozide for people with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medication.A secondary objective was to examine the effects of pimozide for people with delusional disorder. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Register (28 January 2013). SELECTION CRITERIA We sought all relevant randomised clinical trials (RCTs) comparing pimozide with other treatments. DATA COLLECTION AND ANALYSIS Working independently, we inspected citations, ordered papers and then re-inspected and assessed the quality of the studies and of extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and mean differences (MDs) for continuous data. We excluded data if loss to follow-up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence. MAIN RESULTS We included 32 studies in total: Among the five studies that compared pimozide versus placebo, only one study provided data for global state relapse, for which no difference between groups was noted at medium term (1 RCT n = 20, RR 0.22 CI 0.03 to 1.78, very low quality of evidence). None of the five studies provided data for no improvement or first-rank symptoms in mental state. Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (1 RCT, n = 19, RR 5.50 CI 0.30 to 101.28, very low quality of evidence) or at medium term (1 RCT n = 25, RR 1.33 CI 0.14 to 12.82, very low quality of evidence), or for Parkinsonism (tremor) at medium term (1 RCT n = 25, RR 1 CI 0.2 to 4.95, very low quality of evidence). No data were reported for quality of life at medium term.Of the 26 studies comparing pimozide versus any antipsychotic, seven studies provided data for global state relapse at medium term, for which no difference was noted (7 RCTs n = 227, RR 0.82 CI 0.57 to 1.17, moderate quality of evidence). Data from one study demonstrated no difference in mental state (no improvement) at medium term (1 RCT n = 23, RR 1.09 CI 0.08 to 15.41, very low quality evidence); another study demonstrated no difference in the presence of first-rank symptoms at medium term (1 RCT n = 44, RR 0.53 CI 0.25 to 1.11, low quality of evidence). Data for extrapyramidal symptoms demonstrate no difference between groups for Parkinsonism (rigidity) at short term (6 RCTs n = 186, RR 1.21 CI 0.71 to 2.05,low quality of evidence) or medium term (5 RCTs n = 219, RR 1.12 CI 0.24 to 5.25,low quality of evidence), or for Parkinsonism (tremor) at medium term (4 RCTs n = 174, RR 1.46 CI 0.68 to 3.11, very low quality of evidence). No data were reported for quality of life at medium term.In the one study that compared pimozide plus any antipsychotic versus the same antipsychotic, significantly fewer relapses were noted in the augmented pimozide group at medium term (1 RCT n = 69, RR 0.28 CI 0.15 to 0.50, low quality evidence). No data were reported for mental state outcomes or for extrapyramidal symptoms (EPS). Data were skewed for quality of life scores, which were not included in the meta-analysis but were presented separately.Two studies compared pimozide plus any antipsychotics versus antipsychotic plus placebo; neither study reported data for outcomes of interest, apart from Parkinsonism at medium term and quality of life using the Specific Level of Functioning scale (SLOF); however, data were skewed.Only one study compared pimozide plus any antipsychotic versus antipsychotics plus antipsychotic; no data were reported for global state and mental state outcomes of interest. Data were provided for Parkinsonism (rigidity and tremor) using the Extrapyramidal Symptom Rating Scale (ESRS); however, these data were skewed. AUTHORS' CONCLUSIONS Although shortcomings in the data are evident, enough overall consistency over different outcomes and time scales is present to confirm that pimozide is a drug with efficacy similar to that of other, more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. No data support or refute its use for those with delusional disorder.
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Affiliation(s)
- Meghana Mothi
- General Adult Psychiatry, Newsam Centre, Seacroft Hospital, Leeds and York NHS Foundation Trust, York Road, Leeds, UK, LS14 6WB
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Vieira ML, dos Santos AH, Silva LS, Fernandes GSA, Kiss ACI, Moreira EG, Mesquita SDFP, Gerardin DCC. Lactational exposure to sulpiride: Assessment of maternal care and reproductive and behavioral parameters of male rat pups. Physiol Behav 2013; 122:76-83. [DOI: 10.1016/j.physbeh.2013.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 06/27/2013] [Accepted: 08/30/2013] [Indexed: 11/26/2022]
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Lochmann van Bennekom MWH, Gijsman HJ, Zitman FG. Antipsychotic polypharmacy in psychotic disorders: a critical review of neurobiology, efficacy, tolerability and cost effectiveness. J Psychopharmacol 2013; 27:327-36. [PMID: 23413275 DOI: 10.1177/0269881113477709] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study was to review the scientific evidence for neurobiological rationale, efficacy, tolerability and cost effectiveness of antipsychotic polypharmacy (APP). DATA SOURCES A systematic literature search of Medline, Embase, Ovid and the Cochrane Database of Systematic Reviews until April 2012 was carried out. RESULTS Theories behind APP have only modest pre-clinical and clinical evidence. We found limited statistical evidence supporting modest efficacy of APP in patients with psychotic symptoms refractory to clozapine. APP is associated with increased mortality, metabolic syndrome, decreased cognitive functioning, high dose prescription and non-adherence. It brings up extra costs, lacking evidence for cost-effectiveness. CONCLUSIONS Pre-clinical studies underpinning neurobiological hypotheses in APP are lacking. Evidence supporting efficacy of APP is limited with modest beneficial clinical relevance. APP is associated with several serious adverse effects and increased health costs. In the absence of more convincing pre-clinical support and clinical evidence we advise adherence to existing guidelines and limiting combinations of antipsychotics (in consideration with other pharmacotherapeutic, somatic and psychotherapeutic options) to patients with clozapine-refractory psychosis in well-evaluated individual trials that might need 10 weeks or more.
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Gunduz-Bruce H, Oliver S, Gueorguieva R, Forselius-Bielen K, D'Souza DC, Zimolo Z, Tek C, Kaliora S, Ray S, Petrides G. Efficacy of pimozide augmentation for clozapine partial responders with schizophrenia. Schizophr Res 2013; 143:344-7. [PMID: 23219861 DOI: 10.1016/j.schres.2012.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 11/03/2012] [Accepted: 11/06/2012] [Indexed: 11/17/2022]
Abstract
INTRODUCTION A substantial number of patients with treatment-resistant schizophrenia respond only partially to clozapine. Therefore, it has been common practice to use augmentation strategies to maximize clozapine's effect. But the efficacy of this strategy remains poorly established. We have conducted a randomized double-blind placebo controlled clinical trial in patients with schizophrenia currently receiving clozapine with partial response, and tested the efficacy of pimozide augmentation on positive and negative symptoms and also on neurocognitive measures. METHODS Thirty-two outpatients enrolled in the clinical trial and 28 completed. Patients with adequate blood levels of clozapine were randomized to pimozide vs placebo and participated in the trial for 12 weeks receiving monthly assessments for Brief Psychiatric Rating Scale (BPRS) and Schedule for Assessment of Negative Symptoms (SANS), and weekly assessments for electrocardiogram (EKG), and side effects. Neurocognitive tests measuring verbal fluency, working memory, motor and attention/executive function were obtained at study entry and end of the trial. RESULTS We found no significant effect of pimozide on BPRS total, psychosis and depression subscale items, SANS scores or QTc interval. Neurocognitive measures did not show significant improvement either. DISCUSSION In this well controlled clinical trial of patients with treatment-resistant schizophrenia currently receiving clozapine, pimozide augmentation was not an effective strategy to maximize the benefit for better control of positive and negative symptoms or improving neurocognitive function.
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Affiliation(s)
- Handan Gunduz-Bruce
- Yale School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06510, United States.
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Hasan A, Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Thibaut F, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry 2012; 13:318-78. [PMID: 22834451 DOI: 10.3109/15622975.2012.696143] [Citation(s) in RCA: 382] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This first part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia.
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Affiliation(s)
- Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University of Goettingen, Goettingen, Germany.
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Taylor DM, Smith L, Gee SH, Nielsen J. Augmentation of clozapine with a second antipsychotic - a meta-analysis. Acta Psychiatr Scand 2012; 125:15-24. [PMID: 22077319 DOI: 10.1111/j.1600-0447.2011.01792.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine using meta-analysis the effect of adding a second antipsychotic to established clozapine monotherapy. METHOD A literature search was conducted in April 2011, and randomised placebo-controlled double-blind studies were identified. We performed a meta-analysis of efficacy (as standardised mean difference) and tolerability (withdrawals from trials) and a regression analysis of duration of study versus effect size. We also examined publication bias using funnel-plot analysis. RESULTS Overall, 14 studies were included (734 subjects). Individual study numbers ranged from 10 to 207 (mean 52.6, median 40). Augmentation of clozapine with a second antipsychotic conferred a small benefit over placebo (effect size -0.239 (95% CI: -0.452, -0.026); P = 0.028). Meta-regression of the effect of length of treatment on effect size showed no relationship (P = 0.254). The risk of discontinuing antipsychotic augmentation was no greater than the risk of discontinuing placebo (RR = 1.20, 95% CI 0.80-1.82). There was no evidence of publication bias. CONCLUSION Augmentation with a second antipsychotic is modestly beneficial in patients not responding fully to clozapine. Tolerability seems not to be adversely affected, at least in the short term. Longer studies do not appear to increase the probability of showing positive effects for augmentation.
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Affiliation(s)
- D M Taylor
- Pharmacy Department, Maudsley Hospital, London, UK.
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