[Effectiveness and tolerance of zotepine in a double-blind comparison with perazine in schizophrenic patients]

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia and is reputed to have a low level of extrapyramidal adverse effects. As far as we are aware, its use is limited to Germany, Poland, the former Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medications.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register, which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile. We searched the references of all included studies for further trials. We contacted pharmaceutical companies and authors of trials. We updated this search on 16th July 2012.

SELECTION CRITERIA

We selected all randomised controlled trials that compared perazine with other treatments for people with schizophrenia or schizophrenia-like psychoses, or both.

DATA COLLECTION AND ANALYSIS

The review authors (SL, BH, BHe) independently inspected the citations and where possible abstracts and ordered papers for re-inspection and quality assessment. We independently extracted data. We calculated the risk ratio (RR) and 95% confidence interval (CI) using a random-effects model. For continuous data, we calculated mean differences (MD). We inspected all data for heterogeneity, assessed trials for risk of bias and created summary of findings tables using GRADE.

MAIN RESULTS

The review now includes seven trials with a total of 479 participants. In only one trial, with 95 participants, perazine appeared superior to 'active placebo' (trimipramine) at five weeks for the outcome of 'no important global improvement' (n = 95, RR 0.43 CI 0.2 to 0.8, low quality evidence), but there was no statistically significant difference in most measures of mental state. Perazine did not induce more general adverse events than placebo but more participants received at least one dose of antiparkinson medication (n = 95, RR 4.50 CI 1.0 to 19.5, very low quality evidence).Six small trials comparing perazine with other antipsychotics, including 384 participants in total, were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible on most occasions. In the six studies, a similar number of participants receiving perazine or comparator antipsychotics (amisulpride, haloperidol, olanzapine, ziprasidone, zotepine) left the studies early (n = 384, RR 0.97 CI 0.68 to 1.38, low quality evidence). The results on efficacy could not be meta-analysed because the authors presented their results in very different ways. No obvious differences in adverse events between perazine and other antipsychotics could be derived from the limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a way that was suitable for use in meta-analysis, but three small comparisons with the second-generation antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n = 111, RR 0.31 CI 0.1 to 1.1), dyskinesia (n = 111, RR 0.47 CI 0.1 to 3.5), parkinsonism (n = 81, RR 1.21 CI 0.5 2.8) or tremor (n = 40, RR 0.80 CI 0.3 to 2.6) with perazine.

AUTHORS' CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials are insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics but this is based on small comparisons. This should be clarified in larger, well-designed trials.

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

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.

Zotepine for schizophrenia

BACKGROUND

Zotepine is a relatively new antipsychotic often used for the treatment of people with schizophrenia. It is claimed to be particularly effective for negative symptoms.

OBJECTIVES

To determine the effects of zotepine compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

For the 2006 update we searched the Cochrane Schizophrenia Group's register of trials.

SELECTION CRITERIA

We included all randomised clinical trials comparing zotepine with other treatments for people with schizophrenia or other psychoses.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and abstracts, ordered papers, re-inspected these and assessed their quality. For homogenous dichotomous data we calculated the relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat/harm (NNT/H) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). We inspected all data for heterogeneity.

MAIN RESULTS

The review currently includes 11 studies with 966 participants. Most outcomes were short term (4-12 weeks). We found no data for outcomes such as relapse, time in hospital, satisfaction with care and day-to-day functioning. Compared with placebo, mental state ratings favoured zotepine (n=106, 1 RCT, RR No 20% decrease in BPRS 0.44 CI 0.3 to 0.7, NNT 3 CI 2 to 6) using the last observation carried forward method. For the comparison with typical drugs, limited data suggest that zotepine may be as effective as these older medications. Mental state measures of 'no clinically important improvement' favour zotepine when compared with other active drugs (n=356, 4 RCTs, RR 0.77 CI 0.7 to 0.9, NNT 7 CI 4 to 22). About one third of people in both the zotepine and control groups left the studies before trial completion. Zotepine may result in less movement disorder adverse effects than typical antipsychotic drugs. Trials have not highlighted clear differences between zotepine and other atypical drugs.

AUTHORS' CONCLUSIONS

Zotepine may be a valuable addition to the class of atypical antipsychotic drugs. However, more data from existing studies is urgently needed to increase confidence in the findings of this review. In addition to this, new data from well planned, conducted and reported long term pragmatic randomised trials are needed. Otherwise clinical use of zotepine will be based upon speculation of short explanatory trials for everyday practice.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia and is reputed to have a low level of extrapyramidal adverse effects. As far as we are aware, its use is limited to Germany, Poland, the former Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia, and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile (last update of the review March 2005). We searched references of all included studies for further trials. We contacted pharmaceutical companies and authors of trials.

SELECTION CRITERIA

We selected all randomised controlled trials that compared perazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We independently (SL, BH) inspected citations and where possible abstracts and ordered papers for re-inspection and quality assessment. We independently extracted data. We excluded data if loss to follow up was greater than 50%. For homogeneous dichotomous data we calculated the Relative Risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). We inspected all data for heterogeneity.

MAIN RESULTS

We included six trials with a total of 288 participants. In only one trial with 95 participants, perazine appeared superior to 'active placebo' (trimipramine) at five weeks for the outcome of 'no important global improvement' (n=95, RR 0.43 CI 0.2 to 0.8, NNT 4 CI 2 to 13), but there was no statistically significant difference in most measures of mental state. Perazine did not induce more general adverse events than placebo, but more participants received at least one dose of antiparkinson medication (n=95, RR 4.50 CI 1.0 to 19.5, NNH 6 CI 4 to 33). Five small trials comparing perazine with other antipsychotics, including in total only 193 participants, were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible in most occasions. A similar number of participants receiving perazine or comparator antipsychotics left the studies early (n=193, RR 0.85, CI 0.5 to 1.4). The results on efficacy were controversial and need further assessment by randomised controlled trials. No obvious differences in adverse events between perazine and other antipsychotics could be derived from the limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a suitable way for use in meta-analysis, but three small comparisons with the atypical antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n=111, RR 0.31 CI 0.1 to 1.1), dyskinesia (n=111, RR 0.47 CI 0.1 to 3.5), parkinsonism (n=81, RR 1.21 CI 0.5 2.8) or tremor (n=40, RR 0.80 CI 0.3 to 2.6) with perazine.

AUTHORS' CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials is insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics, and this should be clarified in larger, well-designed trials.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia

These guide lines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBO). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

New generation antipsychotics versus low-potency conventional antipsychotics: a systematic review and meta-analysis

BACKGROUND

The clearest advantage of new generation, atypical antipsychotics is a reduced risk of extrapyramidal side-effects (EPS), compared with conventional compounds. These findings might have been biased by the use of the high-potency antipsychotic haloperidol as a comparator in most of the trials. We aimed to establish whether the new drugs induce fewer EPS than low-potency conventional antipsychotics.

METHODS

We did a meta-analysis of all randomised controlled trials in which new generation antipsychotics had been compared with low-potency (equivalent or less potent than chlorpromazine) conventional drugs. We included studies that met quality criteria A or B in the Cochrane Collaboration Handbook, and assessed quality with the Jadad scale. The primary outcome of interest was the number of patients who had at least one EPS. We used risk differences and 95% CIs as measures of effect size.

FINDINGS

We identified 31 studies with a total of 2320 participants. Of the new generation drugs, only clozapine was associated with significantly fewer EPS (RD=-0.15, 95% CI -0.26 to -0.4, p=0.008) and higher efficacy than low-potency conventional drugs. Reduced frequency of EPS seen with olanzapine was of borderline significance (-0.15, -0.31 to -0.01, p=0.07). Only one inconclusive trial of amisulpride, quetiapine, and risperidone and no investigations of ziprasidone and sertindole were identified, but some evidence indicates that zotepine and remoxipride do not lead to fewer EPS than low-potency antipsychotics. Mean doses less than 600 mg/day of chlorpromazine or its equivalent had no higher risk of EPS than new generation drugs. As a group, new generation drugs were moderately more efficacious than low-potency antipsychotics, largely irrespective of the comparator doses used.

INTERPRETATION

Optimum doses of low-potency conventional antipsychotics might not induce more EPS than new generation drugs. Potential advantages in efficacy of the new generation drugs should be a factor in clinical treatment decisions to use these rather than conventional drugs.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia which has a reputed low level of extrapyramidal side-effects. However, its use is restricted in the sense that - to the best knowledge of the reviewers - it is only marketed in Germany, Poland, Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia, and schizophrenia-like psychoses.

SEARCH STRATEGY

Electronic searches of the Cochrane Schizophrenia Group's register which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile were undertaken. References of all included studies were searched for further trials. Pharmaceutical companies and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared perazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by two reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the Relative Risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity.

MAIN RESULTS

Six trials with a total of 288 participants are included. According to only one trial with 95 participants perazine appeared superior to active placebo (trimipramine) at five weeks for the outcome of 'no important global improvement' (n=95, RR 0.6, CI 0.3-0.9, NNT 4, CI 2-17), but there was no difference in various measures of mental state. The side-effect risk of perazine compared to placebo could not be estimated because they were not reported. Five small trials including only 193 participants which compared perazine with other antipsychotics were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible in most occasions. A similar number of participants receiving perazine or comparator antipsychotics left the studies early (n=193, RR 0.9, CI 0.5-1.4). The results on efficacy were controversial and need further assessment by randomised controlled trials. No obvious differences in adverse events between perazine and other antipsychotics could be derived from these limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a way usable for meta-analysis, but three small comparisons with the atypical antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n=111, RR 0.3, CI 0.1-1.1), dyskinesia (n=111, RR 0.5, CI 0.1-3.5), parkinsonism (n=81, RR 1.2, CI 0.5-2.8) or tremor (n=40, RR 0.8, CI 0.3-2.3) with perazine.

REVIEWER'S CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials is insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics, and this should be clarified in larger, well-designed trials.

Zotepine in the treatment of acute hospitalized schizophrenic episodes

The atypical antipsychotic zotepine was studied in an open, multicentre uncontrolled, post-marketing surveillance study in 108 schizophrenic patients hospitalized in 12 trial centres in Austria. Within the dosage range of 50-450 mg (mean at the end of the study, 207 +/- 125 mg/day), a significant reduction of positive as well as negative symptoms was noted. There was no increase in extrapyramidal side-effects during the study and a significant decrease in akathisia scores. The medication was well tolerated during the 42-day observation period. Zotepine improved both positive and negative symptoms and was not accompanied by extrapyramidal side-effects, justifying its classification as an atypical antipsychotic.

Definition, psychopharmacological basis and clinical evaluation of novel/atypical neuroleptics: methodological issues and clinical consequences

High expectations have been put into new/atypical neuroleptics for the treatment of schizophrenia: the higher extrapyramidal-motor tolerability and better efficacy in treating negative symptoms supposedly result in a more favourable influencing of the overall course of the disease and in a higher quality of life for the patients. This article will report about the state of evaluation and therapeutic advantages of new/atypical neuroleptics, and thereby deal with problems of definition and methodology. It also describes differences in the unwanted adverse events profile of the different new/atypical antipsychotics.

Zotepine for schizophrenia

BACKGROUND

Typical antipsychotic drugs are widely used as first line treatment for people with schizophrenia. The atypical class of antipsychotic drugs, however, is making important inroads into this approach and zotepine is one such compound. It is a dopamine antagonist and claimed to be to be particularly effective for negative symptoms

OBJECTIVES

To determine the effects of zotepine compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), CINAHL (1982-1999), The Cochrane Library (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), EMBASE (1980-1999), Dialog Corporation Datastar service (1999), MEDLINE (1966-1999), and PsycLIT (1974-1999) were undertaken. References of all identified studies were searched for further trials. Knoll Pharmaceuticals and authors of trials were contacted.

SELECTION CRITERIA

All randomised clinical trials that compared zotepine to other treatments for people with schizophrenia or other psychoses were included.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the relative risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) and numbers needed to harm (NNH), were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity.

MAIN RESULTS

All outcomes were short term (4-12 weeks). Limited data suggest that zotepine is an antipsychotic, at least as effective as typical drugs. Mental state measures of 'no clinically important improvement' favour zotepine when compared to other active drugs (n=356, RR 0.8 CI 0.7-0.9, NNT 7 CI 4-22). About one third of people in both zotepine and control groups left the studies before trial completion. Zotepine may result in less movement disorder adverse effects than typical antipsychotic drugs. Trials have not highlighted clear differences between zotepine and other atypical drugs.

REVIEWER'S CONCLUSIONS

Zotepine may be a valuable addition to the increasing ranks of atypical antipsychotic drugs. More data from already existing studies is urgently needed to increase the confidence in the findings of this review. New data from well planned, conducted and reported long term pragmatic randomised trials are necessary. Otherwise clinical use of zotepine will be based on speculation on the meaning of the findings of short explanatory trials for everyday practice.

Drug treatment of the negative symptoms of schizophrenia

The traditional antipsychotics are generally poorly effective or ineffective against the negative symptoms of schizophrenia and are also associated with extensive side effects which can themselves cause or exacerbate secondary negative symptomatology. As well as having a low propensity to cause extrapyramidal side effects (EPS), the currently available, putative, atypical antipsychotics (clozapine, risperidone, sertindole, and olanzapine), developmental antipsychotics (zotepine, quetiapine and ziprasidone) and low doses of certain traditional antipsychotics, such as amisulpride and fluphenazine, have been reported to ameliorate negative symptoms in comparison with placebo or standard antipsychotics such as fluphenazine, haloperidol or perphenazine. To date, few trials have specifically examined primary negative symptomatology and it has been suggested that the improvements observed with these drugs may be related to decreases in positive symptoms and/or reduced sedation or extrapyramidal side effects. Although atypicality has been ascribed to 5-HT2/D2 antagonism, the exact pharmacological mechanism(s) underlying the efficacy of the atypical antipsychotics have not been elucidated. Many of these drugs bind to multiple other receptors and/or inhibit neurotransmitter uptake and it seems probable that some of these other pharmacological properties may also contribute to their clinical features.

New drugs for the treatment of schizophrenic patients

Conventional neuroleptics are widely accepted as being effective against the positive symptoms of schizophrenia, but do not benefit all patients. Furthermore, they are relatively ineffective against negative symptoms and cognitive disorders, and most have unpleasant side effect profiles. New strategies for treating schizophrenia include the development of dopamine antagonists with high selectivity for different subtypes of dopamine receptors, dopamine partial agonists, antagonists at different serotonin (5-hydroxytryptamine; 5-HT) receptor subtypes, drugs with mixed pharmacological profiles and drugs which modify transmission via amino acids or peptides in the brain. The prospect is that some of these strategies will lead to the introduction of new drugs and that some of these will become the standards against which future drugs will be compared. The search for new drugs and their use in clinical practice will also lead to developments in our knowledge and understanding of schizophrenia.