Adjunctive use of atypical antipsychotics and anticholinergic drugs among patients with schizophrenia

Comparison of Extrapyramidal Symptoms Among Outpatients With Schizophrenia on Long-Acting Injectable Antipsychotics

BACKGROUND

Extrapyramidal symptoms (EPSs) are adverse effects of antipsychotics. Different risks of EPSs have been attributed to the 3 classes of antipsychotics. This study aimed to assess EPS in a clinical sample of schizophrenia patients who are on LAI and compare the severity of EPSs among the following 3 antipsychotic groups: (1) partial agonist, (2) second-generation antipsychotics, and (3) first-generation antipsychotics.

METHODS

Ninety-two patients were recruited from the Schizophrenia Program Injection Clinic. Using the Extrapyramidal Symptom Rating Scale (ESRS), severity of EPS was assessed and information regarding factors associated with risk of EPS, including coprescriptions, comorbidities, and demographics, was obtained from medical charts. Group differences in ESRS scores and subscores were analyzed using 1-way analyses of variances.

RESULTS

Among the 3 groups, there was no significant difference in total ESRS scores and subscores. Risperidone was associated with higher ESRS scores when compared with paliperidone, aripiprazole, and flupenthixol. Doses above maximum were commonly used in the paliperidone group, and there was no significant difference in total ESRS scores between the low, average, or above-maximum doses of paliperidone.

CONCLUSIONS

Our results demonstrated a comparative risk of EPS across all 3 antipsychotic classes. Risperidone was associated with more EPS compared with other medications. A higher threshold for the "maximum dose" of paliperidone could be considered and higher doses used with the same cautions as low-average doses.

Prescribing patterns of psychotropic medications in psychiatric disorders: a descriptive study from Palestine

Background The practice patterns of psychiatrists have changed over the last two decades. Objectives This study describes the pattern of prescribing psychotropic drugs in treating common psychiatric disorders, and investigates the rate of polypharmacy and potential drug-drug interactions. Setting Psychiatry governmental outpatient clinic in the north of West Bank, Palestine. Methods Cross-sectional study that included all prescriptions which were issued over the period October 2018 to January 2019, for patients diagnosed with schizophrenia, depression, anxiety, bipolar disorder and schizoaffective disorders, and checked for the presence and the grade of potential drug-drug interactions using "Medscape drug interactions checker". Main outcome measure Prescribing patterns of psychotropic drugs. Results A total of 1045 prescriptions were examined. The mean age of the patients was 47.3 years (SD = 13.6), two-thirds of the patients (64.5%) were males. Fifty-two percent of the patients were diagnosed with schizophrenia while 15.2% were diagnosed with depression. The later third was diagnosed with bipolar disorder, schizoaffective and anxiety disorders (15.8%, 11.1% and 5.1% respectively). The most commonly prescribed drugs were typical antipsychotics for schizophrenia, bipolar and schizoaffective disorders, selective serotonin reuptake inhibitors for depression and tricyclic anti-depressants for anxiety. Polypharmacy was found in 877 prescriptions (84%), and drug-drug interactions (DDIs) were identified in 823 (94%) prescriptions. The DDIs were classified as minor (4, 0.5%), significant (418, 50.8%) and serious (401, 48.7%). Conclusions Our results suggest that the pharmacotherapy of psychiatric disorders in Palestine may not be in accordance to international guidelines and the incidence of polypharmacy and DDIs is high.

Anticholinergic use trends in 14,013 patients with schizophrenia from three national surveys on the use of psychotropic medications in China (2002-2012)

Our previous study demonstrated that there have been changes in the patterns of prescription antipsychotic use in China over the period from 2002 to 2012. The aim of this study was to evaluate whether time trends were present for the prescription of anticholinergic medications (ACMs) during the observation period. A total of 14,013 patients with schizophrenia treated in 45 psychiatric hospitals/centers nationwide were surveyed in 2002, 2006 and 2012. Basic socio-demographic and clinical characteristics and the prescription of psychotropic drugs were recorded using a standardized protocol and data collection procedure. The frequency of ACM prescription was 25.9% in the whole sample (29.5%, 21.6%, and 27.4% in 2002, 2006 and 2012, respectively). In addition, different temporal trends were observed across age groups. Multiple logistic regression analysis of the entire sample showed that ACM prescriptions were predicted by females, outpatients, patients receiving high doses of antipsychotic medication, select study years, benzodiazepine users, patients displaying extrapyramidal side effects, as well as antipsychotic prescription patterns. Although there was more widespread use of second-generation antipsychotics over the past decade, the frequency of ACM use only slightly decreased. How to use ACM appropriately is still a therapeutic issue that needs to foster evidence-based prescription practice.

Extrapyramidal motor side-effects of first- and second-generation antipsychotic drugs

BACKGROUND

Second-generation antipsychotics have been thought to cause fewer extrapyramidal side-effects (EPS) than first-generation antipsychotics, but recent pragmatic trials have indicated equivalence.

AIMS

To determine whether second-generation antipsychotics had better outcomes in terms of EPS than first-generation drugs.

METHOD

We conducted an intention-to-treat, secondary analysis of data from an earlier randomised controlled trial (n = 227). A clinically significant difference was defined as double or half the symptoms in groups prescribed first- v. second-generation antipsychotics, represented by odds ratios greater than 2.0 (indicating advantage for first-generation drugs) or less than 0.5 (indicating advantage for the newer drugs). We also examined EPS in terms of symptoms emergent at 12 weeks and 52 weeks, and symptoms that had resolved at these time points.

RESULTS

At baseline those randomised to the first-generation antipsychotic group (n = 118) had similar EPS to the second-generation group (n = 109). Indications of resolved Parkinsonism (OR = 0.5) and akathisia (OR = 0.4) and increased tardive dyskinesia (OR = 2.2) in the second-generation drug group at 12 weeks were not statistically significant and the effects were not present by 52 weeks. Patients in the second-generation group were dramatically (30-fold) less likely to be prescribed adjunctive anticholinergic medication, despite equivalence in terms of EPS.

CONCLUSIONS

The expected improvement in EPS profiles for participants randomised to second-generation drugs was not found; the prognosis over 1 year of those in the first-generation arm was no worse in these terms. The place of careful prescription of first-generation drugs in contemporary practice remains to be defined, potentially improving clinical effectiveness and avoiding life-shortening metabolic disturbances in some patients currently treated with the narrow range of second-generation antipsychotics used in routine practice. This has educational implications because a generation of psychiatrists now has little or no experience with first-generation antipsychotic prescription.

Drug utilization study of psychotropic drugs in outdoor patients in a teaching hospital

BACKGROUND

Psychotropic drugs have had a remarkable impact in psychiatric practice. However, their utilization in actual clinical practice, effectiveness and safety in real life situation need continuous study.

MATERIALS AND METHODS

A prospective cross sectional study was carried out for 6 months. Patients of all ages and both sexes were included in the study while in-patients, referred patients and patients of epilepsy were excluded. Using World Health Organization basic drug indicators, the prescribing pattern was analyzed.

RESULTS

The numbers of psychotropic drugs prescribed per patient were 2.96. Anti-anxiety drugs (82.83%) were most frequently prescribed psychotropic drugs in various psychiatric disorders. Usage of antipsychotic drugs was in 70.15% cases. Atypical antipsychotic drugs (43.83%) were prescribed more frequently than the typical antipsychotic drugs (26.32%). Prescribing frequency of selective serotonin reuptake inhibitors (36.66%) was more than the tricyclic antidepressant (21.96%) and atypical antidepressant drugs (1.83%) in major depression. Use of mood stabilizers was restricted only to bipolar mood disorders. Central anticholinergic drug was co-prescribed in as many as 88.15% patients receiving antipsychotic drugs.

CONCLUSION

Anti-anxiety drug (Benzodiazepine (BZD)) usage was extensive in various psychiatry disorders. Rational use of BZD requires consideration/attention to dose and duration of usage as well as drug interactions with other psychotropic drugs. Routine use of central anticholinergic drug along with atypical antipsychotic drugs also, could not be justified.

Measurement of treatment adherence with antipsychotic agents in patients with schizophrenia

The importance of medication adherence in sustaining control of schizophrenic symptoms has generated a great deal of interest in comparing levels of treatment adherence with different antipsychotic agents. However, the bulk of the research has yielded results that are often inconsistent. In this prospective, observational study, we assessed the measurement properties of 3 commonly used, pharmacy-based measures of treatment adherence with antipsychotic agents in schizophrenia using data from the Veterans Health Administration during 2000 to 2005. Patients were selected if they were on antipsychotics and diagnosed with schizophrenia (N = 18,425). A gap of >/=30 days (with no filled index medication) was used to define discontinuation of treatment as well as medication "episodes," or the number of times a patient returned to the same index agent after discontinuation of treatment within a 1-year period. The study found that the 3 existing measures differed in their approaches in measuring treatment adherence, suggesting that studies using these different measures would generate different levels of treatment adherence across antipsychotic agents. Considering the measurement problems associated with each existing approach, we offered a new, medication episode-specific approach, which would provide a fairer comparison of the levels of treatment adherence across different antipsychotic agents.

An alternative approach to measuring treatment persistence with antipsychotic agents among patients with schizophrenia in the Veterans Health Administration

Prior studies have demonstrated the importance of treatment persistence with anti-psychotic agents in sustaining control of schizophrenic symptoms. However, the conventional approach in measuring treatment persistence tended to use only the first prescription episode even though some patients received multiple prescriptions (or multiple treatment episodes) of the same medication within one year following the initiation of the index drug. In this study, we used data from the Veterans Health Administration in the United States to assess the extent to which patients received multiple prescriptions. The study found that about a quarter of the patients had two or more treatment episodes and that levels of treatment persistence tended to vary across treatment episodes. Based on these results, we offered an alternative approach in which we calculated treatment persistence with typical and atypical antipsychotic agents separately for patients with one, two, or three treatment episodes. Considering that patients with different number of treatment episodes might differ in disease profiles, this treatment episode-specific approach offered a fair comparison of the levels of treatment persistence across patients with different number of treatment episodes. Future research needs to extend the analyses beyond two antipsychotic classes to individual antipsychotic agents. A more comprehensive assessment using appropriate analytic methods should help physicians make prescription choices that will ultimately improve the care of patients with schizophrenia.

Risk of Extrapyramidal Syndrome in Schizophrenic Patients Treated with Antipsychotics: A Population-based Study

To compare the prevalence of extrapyramidal syndrome (EPS) between the first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs), the co-prescribing rate of anti-Parkinson drugs (APDs) of each antipsychotic drug was analyzed using population database. Fourteen antipsychotics had been prescribed during the 5-year study period. Among the SGAs, quetiapine had the lowest crude co-prescribing rate of APDs (27.09%), whereas risperidone had the highest rate (66.50%). Among the FGAs, thioridazine and loxapine had the lowest (60.99%) and highest rates (96.35%), respectively. The rankings of the co-prescribing rate of APDs among antipsychotics, in increasing order, were quetiapine, clozapine, olanzapine, thioridazine, zotepine, chlorpromazine, risperidone, sulpiride, clotiapine, flupentixol, haloperidol, zuclopentixol, trifluoperazine, and loxapine. The results indicate that the risk of EPS appears to be lower in SGAs than in FGAs; however, the considerably high rate of EPS in some of the newer generation of antipsychotics warrants clinical attention.

Treatment persistence: a comparison among patients with schizophrenia who were initiated on atypical antipsychotic agents

BACKGROUND

Although clinical trials have demonstrated the efficacy of atypical antipsychotic agents in reducing symptoms of schizophrenia, the likelihood of sustaining control of schizophrenic symptoms may depend on treatment persistence.

OBJECTIVE

In this study, we compared treatment persistence between patients who were initiated on risperidone or olanzapine, the two most widely prescribed atypical antipsychotic agents.

METHOD

We identified patients with schizophrenia by ICD-9-CM codes (> or =1 inpatient or > or =2 outpatient ICD-9-CM codes > or =7 days apart) between 1 July 1998 and 30 June 1999. We further selected those who were prescribed the target drug during 1 April 1999 through 31 March 2000 provided that they were not on any antipsychotic agents during the prior 6 months. Using event history analysis, we compared the treatment persistence in terms of hazard ratio between olanzapine and risperidone initiators, adjusting for patient's sociodemographic and clinical characteristics.

RESULTS

Following the initiation of the target drug, more patients switched from risperidone to olanzapine than vice versa. However, among patients with schizophrenia who had comorbid diabetes, there were more patients who made a switch from olanzapine to risperidone; whereas among those who used anxiolytics, there were more patients who switched from risperidone to olanzapine. Finally, olanzapine initiators had decreased hazards of discontinuation by 14% (unadjusted; P < 0.001) and 12% (adjusted; P = 0.002), respectively, than risperidone initiators.

CONCLUSIONS

Compared with risperidone, olanzapine seems to be better tolerated by patients as indicated by better treatment persistence. As such, initiation of olanzapine may increase the likelihood of sustaining control of symptoms of schizophrenia. Future research needs to provide a more comprehensive assessment of treatment persistence by considering other antipsychotic agents in the study and developing models to assess treatment persistence and switching as two interdependent competing risks.

Patient characteristics and the likelihood of initiation on olanzapine or risperidone among patients with schizophrenia

Although pharmacologic treatments are available for patients with schizophrenia, little is known about how prescription patterns of atypical antipsychotic agents are related to patient characteristics. In this study, we examined the association between patient characteristics and the likelihood of being initiated on olanzapine or risperidone, two of the most frequently prescribed atypical agents for schizophrenia. We selected patients who were diagnosed with schizophrenia or schizoaffective disorder based on > or = 1 inpatient or > or = 2 outpatient ICD-9-CM codes (> or = 7 days apart) between 7/1/98 and 6/30/99 from the Veterans Health Administration (VA). We classified patients into one of three types of initiation: (a) not on olanzapine or risperidone, (b) not on any atypical agents, or (c) not on any antipsychotic agents for 6 months, and then subsequently being prescribed the target drugs. Using logistic regression, we examined whether the odds ratio of being initiated on olanzapine versus risperidone are related to patient sociodemographic and clinical characteristics. Compared to risperidone initiators, olanzapine initiators used more drugs for psychiatric conditions (including antiparkinsonian agents, typical antipsychotics, and mood stabilizers) than risperidone initiators. On the other hand, risperidone initiators had more medical comorbidities and more non-psychiatric hospitalizations. Olanzapine and risperidone appear to be prescribed to patients with different characteristics. Initiation of risperidone was more common among patients who presented with more medical comorbid conditions, whereas initiation of olanzapine was more common among patient who presented with more mental comorbid conditions. Future research needs to determine the reasons for those differences.