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de Bartolomeis A, Ciccarelli M, Vellucci L, Fornaro M, Iasevoli F, Barone A. Update on novel antipsychotics and pharmacological strategies for treatment resistant schizophrenia. Expert Opin Pharmacother 2022; 23:2035-2052. [DOI: 10.1080/14656566.2022.2145884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Andrea de Bartolomeis
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Mariateresa Ciccarelli
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Licia Vellucci
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Michele Fornaro
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Felice Iasevoli
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Annarita Barone
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
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Zhu MH, Liu ZJ, Hu QY, Yang JY, Jin Y, Zhu N, Huang Y, Shi DH, Liu MJ, Tan HY, Zhao L, Lv QY, Yi ZH, Wu FC, Li ZZ. Amisulpride augmentation therapy improves cognitive performance and psychopathology in clozapine-resistant treatment-refractory schizophrenia: a 12-week randomized, double-blind, placebo-controlled trial. Mil Med Res 2022; 9:59. [PMID: 36253804 PMCID: PMC9578180 DOI: 10.1186/s40779-022-00420-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 09/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although clozapine is an effective option for treatment-resistant schizophrenia (TRS), there are still 1/3 to 1/2 of TRS patients who do not respond to clozapine. The main purpose of this randomized, double-blind, placebo-controlled trial was to explore the amisulpride augmentation efficacy on the psychopathological symptoms and cognitive function of clozapine-resistant treatment-refractory schizophrenia (CTRS) patients. METHODS A total of 80 patients were recruited and randomly assigned to receive initial clozapine plus amisulpride (amisulpride group) or clozapine plus placebo (placebo group). Positive and Negative Syndrome Scale (PANSS), Scale for the Assessment of Negative Symptoms (SANS), Clinical Global Impression (CGI) scale scores, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Treatment Emergent Symptom Scale (TESS), laboratory measurements, and electrocardiograms (ECG) were performed at baseline, at week 6, and week 12. RESULTS Compared with the placebo group, amisulpride group had a lower PANSS total score, positive subscore, and general psychopathology subscore at week 6 and week 12 (PBonferroni < 0.01). Furthermore, compared with the placebo group, the amisulpride group showed an improved RBANS language score at week 12 (PBonferroni < 0.001). Amisulpride group had a higher treatment response rate (P = 0.04), lower scores of CGI severity and CGI efficacy at week 6 and week 12 than placebo group (PBonferroni < 0.05). There were no differences between the groups in body mass index (BMI), corrected QT (QTc) intervals, and laboratory measurements. This study demonstrates that amisulpride augmentation therapy can safely improve the psychiatric symptoms and cognitive performance of CTRS patients. CONCLUSION This study indicates that amisulpride augmentation therapy has important clinical significance for treating CTRS to improve clinical symptoms and cognitive function with tolerability and safety. Trial registration Clinicaltrials.gov identifier- NCT03652974. Registered August 31, 2018, https://clinicaltrials.gov/ct2/show/NCT03652974.
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Affiliation(s)
- Ming-Huan Zhu
- Clinical Research Center for Mental Disorders, School of Medicine, Shanghai Pudong New Area Mental Health Center, Tongji University, Shanghai, 200124, China
| | - Zhen-Jing Liu
- Qingdao Mental Health Center, Qingdao, 266034, Shandong, China
| | - Qiong-Yue Hu
- Qingdao Mental Health Center, Qingdao, 266034, Shandong, China
| | - Jia-Yu Yang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Ying Jin
- Clinical Research Center for Mental Disorders, School of Medicine, Shanghai Pudong New Area Mental Health Center, Tongji University, Shanghai, 200124, China
| | - Na Zhu
- Clinical Research Center for Mental Disorders, School of Medicine, Shanghai Pudong New Area Mental Health Center, Tongji University, Shanghai, 200124, China
| | - Ying Huang
- Clinical Research Center for Mental Disorders, School of Medicine, Shanghai Pudong New Area Mental Health Center, Tongji University, Shanghai, 200124, China
| | - Dian-Hong Shi
- Clinical Research Center for Mental Disorders, School of Medicine, Shanghai Pudong New Area Mental Health Center, Tongji University, Shanghai, 200124, China
| | - Min-Jia Liu
- Clinical Research Center for Mental Disorders, School of Medicine, Shanghai Pudong New Area Mental Health Center, Tongji University, Shanghai, 200124, China
| | - Hong-Yang Tan
- Clinical Research Center for Mental Disorders, School of Medicine, Shanghai Pudong New Area Mental Health Center, Tongji University, Shanghai, 200124, China
| | - Lei Zhao
- Qingdao Mental Health Center, Qingdao, 266034, Shandong, China
| | - Qin-Yu Lv
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Zheng-Hui Yi
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Feng-Chun Wu
- Department of Psychiatry, the Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, 510370, China. .,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China.
| | - Ze-Zhi Li
- Department of Psychiatry, the Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, 510370, China. .,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China.
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Kim JJ, Pae CU, Han C, Bahk WM, Lee SJ, Patkar AA, Masand PS. Exploring Hidden Issues in the Use of Antipsychotic Polypharmacy in the Treatment of Schizophrenia. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:600-609. [PMID: 34690115 PMCID: PMC8553537 DOI: 10.9758/cpn.2021.19.4.600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 12/23/2022]
Abstract
The mainstay of schizophrenia treatment is pharmacological therapy using various antipsychotics including first- and second-generation antipsychotics which have different pharmacokinetic and pharmacodynamic property leading to differential presentation of adverse events (AEs) and treatment effects such as negative symptoms, cognitive symptoms and cormorbid symptoms. Major treatment guidelines suggest the use of antipsychotic monotherapy (APM) as a gold standard in the treatment of schizophrenia. However, the effects of APM is inadequate and less potent to achieve symptom remission as well as functional recovery in real practice which has been consistently reported in numerous controlled clinical trials, large practical trials, independent small studies and systematic reviews till today. Therefore anti-psychotic polypharmacy (APP) regardless of the class of antipsychotics has been also commonly utilized for many reasons in real world practice. However, APP has also crucial pitfalls including increase of total psychotics including antipsychotics, high-doses of antipsychotics used, poor compliance, drug-drug interaction and risks for developing AEs, all of which are paradoxically related to poor clinical outcomes, whereas APP has also substantial advantages in reduction of re-hospitalization, severe psychopathology and targeted control of concurrent symptoms. Given currently limited therapeutic options, it is also important to properly utilize APP in order to maximize its clinical utility and minimize its risk for better treatment outcomes for patients with schizophrenia, based on risk/benefit with full understanding of pharmacological and clinical issues on APP. The present paper intends to address intriguing and important issues in the use of APP in real world practice.
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Affiliation(s)
- Jung-Jin Kim
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Changsu Han
- Department of Psychiatry, Korea University College of Medicine, Seoul, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Jung Lee
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ashwin A Patkar
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
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Seppälä A, Pylvänäinen J, Lehtiniemi H, Hirvonen N, Corripio I, Koponen H, Seppälä J, Ahmed A, Isohanni M, Miettunen J, Jääskeläinen E. Predictors of response to pharmacological treatments in treatment-resistant schizophrenia - A systematic review and meta-analysis. Schizophr Res 2021; 236:123-134. [PMID: 34496316 DOI: 10.1016/j.schres.2021.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/30/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND As the burden of treatment-resistant schizophrenia (TRS) on patients and society is high it is important to identify predictors of response to medications in TRS. The aim was to analyse whether baseline patient and study characteristics predict treatment response in TRS in drug trials. METHODS A comprehensive search strategy completed in PubMed, Cochrane and Web of Science helped identify relevant studies. The studies had to meet the following criteria: English language clinical trial of pharmacological treatment of TRS, clear definition of TRS and response, percentage of response reported, at least one baseline characteristic presented, and total sample size of at least 15. Meta-regression techniques served to explore whether baseline characteristics predict response to medication in TRS. RESULTS 77 articles were included in the systematic review. The overall sample included 7546 patients, of which 41% achieved response. Higher positive symptom score at baseline predicted higher response percentage. None of the other baseline patient or study characteristics achieved statistical significance at predicting response. When analysed in groups divided by antipsychotic drugs, studies of clozapine and other atypical antipsychotics produced the highest response rate. CONCLUSIONS This meta-analytic review identified surprisingly few baseline characteristics that predicted treatment response. However, higher positive symptoms and the use of atypical antipsychotics - particularly clozapine -was associated with the greatest likelihood of response. The difficulty involved in the prediction of medication response in TRS necessitates careful monitoring and personalised medication management. There is a need for more investigations of the predictors of treatment response in TRS.
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Affiliation(s)
- Annika Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Jenni Pylvänäinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Heli Lehtiniemi
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Noora Hirvonen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Information Studies, Faculty of Humanities, University of Oulu, Oulu, Finland
| | - Iluminada Corripio
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, CIBERSAM G21, U.A.B (Autonomous University of Barcelona), Barcelona, Spain
| | - Hannu Koponen
- University of Helsinki and Helsinki University Hospital, Psychiatry, Helsinki, Finland
| | - Jussi Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Department of Mental Health and Substance Use Disorders, South Carelia Social and Health Care District, Lappeenranta, Finland
| | - Anthony Ahmed
- Department of Psychiatry, Weill Cornell Medicine, Cornell University, White Plains, USA
| | - Matti Isohanni
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jouko Miettunen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Erika Jääskeläinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of Psychiatry, University Hospital of Oulu, Finland
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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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6
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Cognitive Effects of Combined Amisulpride and Quetiapine Treatment in Patients With Refractory Schizophrenia: A Naturalistic, Prospective Study. Am J Ther 2020; 27:e346-e355. [DOI: 10.1097/mjt.0000000000000956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kontaxakis VP, Havaki-Kontaxaki BJ, Ferentinos PP, Paplos KG, Soldatos CR. Switching to amisulpride monotherapy for treatment-resistant schizophrenia. Eur Psychiatry 2020; 21:214-7. [PMID: 16531015 DOI: 10.1016/j.eurpsy.2006.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractThe objective of this study was to assess switching to amisulpride (AMS) in treatment-resistant schizophrenia. Seven male subjects were switched to AMS and followed for 8 weeks. PANSS scores improved from 123 to 66 over this period. We conclude that AMS is of interest in the treatment of refractory schizophrenia.
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Affiliation(s)
- V P Kontaxakis
- Department of Psychiatry, University of Athens, Eginition Hospital, 74 Vas. Sophias Avenue, 11528 Athens, Greece.
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9
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Barnes TR, Leeson VC, Paton C, Marston L, Davies L, Whittaker W, Osborn D, Kumar R, Keown P, Zafar R, Iqbal K, Singh V, Fridrich P, Fitzgerald Z, Bagalkote H, Haddad PM, Husni M, Amos T. Amisulpride augmentation in clozapine-unresponsive schizophrenia (AMICUS): a double-blind, placebo-controlled, randomised trial of clinical effectiveness and cost-effectiveness. Health Technol Assess 2018; 21:1-56. [PMID: 28869006 DOI: 10.3310/hta21490] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND When treatment-refractory schizophrenia shows an insufficient response to a trial of clozapine, clinicians commonly add a second antipsychotic, despite the lack of robust evidence to justify this practice. OBJECTIVES The main objectives of the study were to establish the clinical effectiveness and cost-effectiveness of augmentation of clozapine medication with a second antipsychotic, amisulpride, for the management of treatment-resistant schizophrenia. DESIGN The study was a multicentre, double-blind, individually randomised, placebo-controlled trial with follow-up at 12 weeks. SETTINGS The study was set in NHS multidisciplinary teams in adult psychiatry. PARTICIPANTS Eligible participants were people aged 18-65 years with treatment-resistant schizophrenia unresponsive, at a criterion level of persistent symptom severity and impaired social function, to an adequate trial of clozapine monotherapy. INTERVENTIONS Interventions comprised clozapine augmentation over 12 weeks with amisulpride or placebo. Participants received 400 mg of amisulpride or two matching placebo capsules for the first 4 weeks, after which there was a clinical option to titrate the dosage of amisulpride up to 800 mg or four matching placebo capsules for the remaining 8 weeks. MAIN OUTCOME MEASURES The primary outcome measure was the proportion of 'responders', using a criterion response threshold of a 20% reduction in total score on the Positive and Negative Syndrome Scale. RESULTS A total of 68 participants were randomised. Compared with the participants assigned to placebo, those receiving amisulpride had a greater chance of being a responder by the 12-week follow-up (odds ratio 1.17, 95% confidence interval 0.40 to 3.42) and a greater improvement in negative symptoms, although neither finding had been present at 6-week follow-up and neither was statistically significant. Amisulpride was associated with a greater side effect burden, including cardiac side effects. Economic analyses indicated that amisulpride augmentation has the potential to be cost-effective in the short term [net saving of between £329 and £2011; no difference in quality-adjusted life-years (QALYs)] and possibly in the longer term. LIMITATIONS The trial under-recruited and, therefore, the power of statistical analysis to detect significant differences between the active and placebo groups was limited. The economic analyses indicated high uncertainty because of the short duration and relatively small number of participants. CONCLUSIONS The risk-benefit of amisulpride augmentation of clozapine for schizophrenia that has shown an insufficient response to a trial of clozapine monotherapy is worthy of further investigation in larger studies. The size and extent of the side effect burden identified for the amisulpride-clozapine combination may partly reflect the comprehensive assessment of side effects in this study. The design of future trials of such a treatment strategy should take into account that a clinical response may be not be evident within the 4- to 6-week follow-up period usually considered adequate in studies of antipsychotic treatment of acute psychotic episodes. Economic evaluation indicated the need for larger, longer-term studies to address uncertainty about the extent of savings because of amisulpride and impact on QALYs. The extent and nature of the side effect burden identified for the amisulpride-clozapine combination has implications for the nature and frequency of safety and tolerability monitoring of clozapine augmentation with a second antipsychotic in both clinical and research settings. TRIAL REGISTRATION EudraCT number 2010-018963-40 and Current Controlled Trials ISRCTN68824876. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 49. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Thomas Re Barnes
- Centre for Mental Health, Imperial College London, London, UK.,West London Mental Health NHS Trust, London, UK
| | - Verity C Leeson
- Centre for Mental Health, Imperial College London, London, UK
| | - Carol Paton
- Centre for Mental Health, Imperial College London, London, UK.,Oxleas NHS Foundation Trust, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Linda Davies
- Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
| | - William Whittaker
- Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
| | - David Osborn
- Division of Psychiatry, University College London, London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Raj Kumar
- Tees, Esk and Wear Valley NHS Foundation Trust, Billingham, UK
| | - Patrick Keown
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Rameez Zafar
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | | | - Vineet Singh
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Pavel Fridrich
- North Essex Partnership University NHS Foundation Trust, Chelmsford, UK
| | | | | | - Peter M Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK.,Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Mariwan Husni
- Central and North West London NHS Foundation Trust, London, UK.,Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Tim Amos
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK.,School of Social and Community Medicine, University of Bristol, Bristol, UK
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Lung SLM, Lee HME, Chen YHE, Chan KWS, Chang WC, Hui LMC. Prevalence and correlates of antipsychotic polypharmacy in Hong Kong. Asian J Psychiatr 2018; 33:113-120. [PMID: 29574303 DOI: 10.1016/j.ajp.2018.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 01/08/2018] [Accepted: 03/01/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Antipsychotic polypharmacy (APP) remains a common practice despite inconclusive empirical evidence of additional efficacy and potential exacerbation of side effects. Previous studies suggest APP rate is notably high in East Asia. This paper aims to investigate the prevalence and correlates of APP in Hong Kong. METHOD This was a cross-sectional study of 728 patients with psychosis. The demographics and clinical information, including age, gender, diagnosis, hospitalization history, and medication were collected. Chi-square tests and logistic regression analyses were used to study correlates of APP. RESULTS The APP rate for psychosis was 24.2% (n = 728) and that for schizophrenia was 26.0% (n = 611), both considerably lower than our previous local data and that from East Asian regions. The most widely used APP prescription fell within the atypical/atypical combination (i.e., Amisulpride/Clozapine and Paliperidone/Olanzapine), and Olanzapine was the most commonly prescribed antipsychotic. At least 75% of APP patients with psychosis took at least one type of atypical antipsychotics in their medical regimen. Typical/typical polypharmacy was associated with older age and use of antiparkinson drugs. Typical/atypical polypharmacy was associated with the use of antiparkinson drugs and anxiolytics, as well as inpatient status. Atypical/atypical polypharmacy was associated with younger age, inpatient status, and the use of mood stabilizers. CONCLUSION Overall, our study highlights a relatively low APP rate in Hong Kong when compared to other countries in East Asia. Age, inpatient status and use of antiparkinson drugs, anxiolytics and mood stabilizers were associated with use of APP.
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Affiliation(s)
- Stephanie Lock Man Lung
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
| | - Ho Ming Edwin Lee
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
| | - Yu Hai Eric Chen
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
| | - Kit Wa Sherry Chan
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
| | - Wing Chung Chang
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
| | - Lai Ming Christy Hui
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
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11
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Abstract
The incidence of treatment resistance in schizophrenia (failure to respond to antipsychotic therapy) is about 20%. Factors that may contribute to it include non-adherence (non-compliance) to treatment, comorbid conditions and medication side-effects. The National Institute for Clinical Excellence recommends that clozapine be used for schizophrenia resistant to another atypical antipsychotic. Here we focus on patients who are also resistant to clozapine given in adequate dosage for sufficient duration. Switching from clozapine to a previously untried atypical (e.g. olanzapine, risperidone, quetiapine) might be of benefit in partial treatment resistance. In more difficult cases, augmentation of clozapine with benzamides (sulpiride, amisulpride) and anti-epileptics (lamotrigine) shows some success. In extreme treatment resistance, a strategy is recommended that combines the proven best drug for the particular patient and psychosocial treatments.
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12
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Wilson S, Hamilton R, Callender J, MacManus A, Howitt S, Okpo B. Clozapine antipsychotic polypharmacy: audit of use and patient monitoring. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/pb.bp.112.040352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Aims and methodWe audited prescribing within our area to ascertain how widespread the practice of antipsychotic polypharmacy using clozapine was, and whether it was being carried out within existing standards, including those of high-dose monitoring when required.ResultsData on 169 patients were reviewed in year one, rising to 193 in year three. Around 30% of patients on clozapine received additional antipsychotic medication. A disturbingly low proportion of patients on clozapine whose antipsychotic polypharmacy brought them into the high-dose range were being monitored appropriately after three audit cycles (the proportion rose from 10% in cycle 1 to 28% in cycle 3). A wide range of additional antipsychotic medications was used.Clinical implicationsClozapine antipsychotic polypharmacy was prevalent at just below a third of all patients in this review. Prescribers should be alert to the fact that clozapine antipsychotic polypharmacy can push patients into the high-dose range and ensure appropriate monitoring.
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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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Affiliation(s)
| | | | - Oriana Bianchini
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy Institute of Psychiatry, University of Catania, Catania, Italy
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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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Augmentation of clozapine with amisulpride: an effective therapeutic strategy for violent treatment-resistant schizophrenia patients in a UK high-security hospital. CNS Spectr 2014; 19:403-10. [PMID: 24284256 DOI: 10.1017/s1092852913000874] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Clozapine is used in the management of treatment-resistant schizophrenia and is effective in reducing aggression; however a subgroup of patients is poorly responsive. For violent patients in this group, there is limited literature on the use of strategies to augment clozapine with other agents. Here we present a case series of 6 schizophrenia patients, within a high-security hospital, who have a history of serious violence and who were treated with clozapine augmented with amisulpride. METHODS We reviewed case notes and health records for evidence of violence/aggression and positive factors such as engagement in activities, and Clinical Global Impression (CGI) scores were formulated. We also examined metabolic parameters before and after augmentation. RESULTS All 6 of the patients showed clinical improvement in symptoms and a reduction in their risk of violence to others. Five patients had a reduction in number of violent/aggressive incidents, and all patients showed improvement in engagement in occupational, vocational, and/or psychological work. Metabolic parameters were largely unchanged except for 1 patient whose Body Mass Index (BMI) increased. Five patients reported side effects as unchanged or improved. CONCLUSION These schizophrenia patients with a history of violence showed clinical improvement and reduced aggression and violence with amisulpride augmentation of clozapine. To our knowledge, this is the first report of an antiaggressive benefit of this combination in forensic psychiatric patients. Further studies are warranted to establish the efficacy and anti-aggressive effects of amisulpride augmentation of clozapine.
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Reboxetine adjuvant therapy in patients with schizophrenia showing a suboptimal response to clozapine: a 12-week, open-label, pilot study. J Clin Psychopharmacol 2014; 34:620-3. [PMID: 25118083 DOI: 10.1097/jcp.0000000000000196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The present 12-week open-label uncontrolled trial was aimed to explore the efficacy of reboxetine add-on pharmacotherapy on clinical symptoms and cognitive functioning in 15 patients with schizophrenia with suboptimal response (mean [SD] Brief Psychiatric Rating Scale baseline total score, 32.2 [5.4]) despite receiving clozapine monotherapy at the highest tolerated dosage. The results obtained evidenced that reboxetine at a dosage of 4 mg/d mildly reduced only depressive symptoms (Calgary Depression Scale for Schizophrenia: P = 0.035, Cohen d = 0.7), whereas worsening of performances on phonemic fluency (P = 0.012, Cohen d = 0.5) was observed. After Bonferroni correction, changes at the Calgary Depression Scale for Schizophrenia and at the Verbal Fluency Task were not further confirmed.The results obtained indicate that reboxetine seemed to be scarcely effective for reducing clinical symptoms in patients with schizophrenia who have had an incomplete clinical response to clozapine. Regarding cognitive functioning, in our sample, a trend to experience cognitive impairment in the examined domains was observed, as confirmed by a mild worsening of performances on cognitive tasks.Schizophrenia is a heterogeneous disorder with regard to pathophysiology; therefore, data reflecting the mean response of a sample of patients may fail to reveal therapeutic effects. More research is needed to better identify subgroups of patients with peculiar features, which may account for responsivity to experimental medications and augmentation strategies.
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Augmentation of clozapine with agomelatine in partial-responder schizophrenia: a 16-week, open-label, uncontrolled pilot study. J Clin Psychopharmacol 2014; 34:491-4. [PMID: 24911437 DOI: 10.1097/jcp.0000000000000157] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The present 16-week open-label uncontrolled trial was aimed to explore the efficacy of adjunctive agomelatine on clinical symptoms and cognitive functioning in 20 schizophrenia patients showing partial response (Brief Psychiatric Rating Scale, mean [SD] baseline total score = 37.5 [6.6]) to clozapine monotherapy at the highest tolerated dosage. The results obtained evidenced that agomelatine at a dosage of 50 mg/d was associated with score reduction in all Positive and Negative Syndrome Scale domains (positive, P = 0.011 and Cohen d = 0.7; negative, P < 0.0001 and Cohen d = 1.1; psychopathology, P = 0.001 and Cohen d = 0.9) and total score (P = 0.001, Cohen d = 1.2), depressive (Calgary Depression Scale for Schizophrenia, P = 0.013 and Cohen d = 0.6), and overall clinical symptoms (Brief Psychiatric Rating Scale, P = 0.001 and Cohen d = 0.6 ); moreover, improved performances on Stroop task (P = 0.006, Cohen d = 0.7) and Wisconsin Card Sorting Test "perseverative errors" (P = 0.033, Cohen d = 0.3) were observed. The favorable effect of agomelatine on clinical and cognitive symptoms was encouraging, and more research is needed to better identify subgroups of patients who are partially responsive to clozapine monotherapy in which agomelatine augmentation may be of benefit.
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Augmentation of clozapine with ziprasidone in refractory schizophrenia: a double-blind, placebo-controlled study. J Clin Psychopharmacol 2014; 34:129-33. [PMID: 24145221 DOI: 10.1097/jcp.0000000000000042] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present 16-week double-blind, randomized, placebo-controlled trial was aimed to explore the efficacy of ziprasidone add-on pharmacotherapy on clinical symptoms and cognitive functioning in 40 schizophrenic patients (active group, n = 20; placebo group, n = 20) with residual symptoms (Brief Psychiatric Rating Scale mean [SD] baseline total score in active group vs placebo, 40.4 [5.9] vs 37.9 [6.8]) despite receiving clozapine monotherapy at the highest tolerated dosage. The results obtained evidenced that ziprasidone augmentation of clozapine significantly reduced Positive and Negative Syndrome Scale "Negative" (P = 0.006, mean change [SD] in active group vs placebo, -2.7 [2.3] vs 1.1 [2.1], Cohen d = 1.7) and "General Psychopathology" (P = 0.009, mean change [SD] in active group vs placebo, -5.3 [3.8] vs -0.7 [2.0], Cohen d = 1.5). Regarding cognitive domains, ziprasidone was more effective than placebo in improving semantic fluency (P < 0.0001, mean change [SD] in active group vs placebo, 4.4 [3.5] vs -0.1 [4.1], Cohen d = 1.2). Ziprasidone had only a small effect on prolongation of heart-rate corrected QT interval (QTc) of the electrocardiogram, not significantly different from placebo (QTc milliseconds, mean [SD], week 16 in active group vs placebo, 408.17 [20.85] vs 405.45 [17.11], P = 0.321); within-group comparison revealed that QTc prolongation induced by ziprasidone was statistically significant (baseline vs week 16, P = 0.002). Ziprasidone added to clozapine was effective on negative and cognitive symptoms, although it may be proposed as a helpful treatment in schizophrenia, mainly for those patients who partially respond to clozapine monotherapy.
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Papoutsis I, Rizopoulou A, Nikolaou P, Pistos C, Spiliopoulou C, Athanaselis S. A validated GC/MS method for the determination of amisulpride in whole blood. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 947-948:111-6. [PMID: 24412693 DOI: 10.1016/j.jchromb.2013.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 11/26/2013] [Accepted: 12/18/2013] [Indexed: 11/17/2022]
Abstract
A sensitive GC/MS method for the determination of amisulpride in whole blood was developed, optimized and validated. Sample preparation included solid-phase extraction using HF Bond Elut C18 cartridges and further derivatization with heptafluorobutyric anhydride (HFBA). The limits of detection and quantification were 3.00 and 10.0 μg/L, respectively. The calibration curves were linear up to 1000 μg/L (R(2)≥0.991). Absolute recovery ranged from 94.2 to 101%. Accuracy was found to be between -8.7 and 1.9% and imprecision was less than 10.0%. The developed method covers the generally accepted therapeutic range but it can also cover levels above them. This makes our method suitable for the determination of amisulpride not only for clinical purposes on psychiatric patients, but also during the investigation of forensic cases where amisulpride is involved.
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Affiliation(s)
- Ioannis Papoutsis
- Department of Forensic Medicine and Toxicology, Faculty of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, Athens 115 27, Greece
| | - Anna Rizopoulou
- Department of Forensic Medicine and Toxicology, Faculty of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, Athens 115 27, Greece
| | - Panagiota Nikolaou
- Department of Forensic Medicine and Toxicology, Faculty of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, Athens 115 27, Greece.
| | - Constantinos Pistos
- Department of Forensic Medicine and Toxicology, Faculty of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, Athens 115 27, Greece
| | - Chara Spiliopoulou
- Department of Forensic Medicine and Toxicology, Faculty of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, Athens 115 27, Greece
| | - Sotiris Athanaselis
- Department of Forensic Medicine and Toxicology, Faculty of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, Athens 115 27, Greece
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Clozapine augmented with amisulpride in 3 cases of treatment-resistant early- and very early-onset schizophrenia. J Clin Psychopharmacol 2013; 33:572-4. [PMID: 23764685 DOI: 10.1097/jcp.0b013e3182946719] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gross G, Drescher K. The role of dopamine D(3) receptors in antipsychotic activity and cognitive functions. Handb Exp Pharmacol 2013:167-210. [PMID: 23027416 DOI: 10.1007/978-3-642-25758-2_7] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Dopamine D(3) receptors have a pre- and postsynaptic localization in brain stem nuclei, limbic parts of the striatum, and cortex. Their widespread influence on dopamine release, on dopaminergic function, and on several other neurotransmitters makes them attractive targets for therapeutic intervention. The signaling pathways of D(3) receptors are distinct from those of other members of the D(2)-like receptor family. There is increasing evidence that D(3) receptors can form heteromers with dopamine D(1), D(2), and probably other G-protein-coupled receptors. The functional consequences remain to be characterized in more detail but might open new interesting pharmacological insight and opportunities. In terms of behavioral function, D(3) receptors are involved in cognitive, social, and motor functions, as well as in filtering and sensitization processes. Although the role of D(3) receptor blockade for alleviating positive symptoms is still unsettled, selective D(3) receptor antagonism has therapeutic features for schizophrenia and beyond as demonstrated by several animal models: improved cognitive function, emotional processing, executive function, flexibility, and social behavior. D(3) receptor antagonism seems to contribute to atypicality of clinically used antipsychotics by reducing extrapyramidal motor symptoms; has no direct influence on prolactin release; and does not cause anhedonia, weight gain, or metabolic dysfunctions. Unfortunately, clinical data with new, selective D(3) antagonists are still incomplete; their cognitive effects have only been communicated in part. In vitro, virtually all clinically used antipsychotics are not D(2)-selective but also have affinity for D(3) receptors. The exact D(3) receptor occupancies achieved in patients, particularly in cortical areas, are largely unknown, mainly because only nonselective or agonist PET tracers are currently available. It is unlikely that a degree of D(3) receptor antagonism optimal for antipsychotic and cognitive function can be achieved with existing antipsychotics. Therefore, selective D(3) antagonism represents a promising mechanism still to be fully exploited for the treatment of schizophrenia, cognitive deficits in schizophrenia, and comorbid conditions such as substance abuse.
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Affiliation(s)
- Gerhard Gross
- Abbott, Neuroscience Research, Ludwigshafen, Germany.
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Bowskill SVJ, Patel MX, Handley SA, Flanagan RJ. Plasma amisulpride in relation to prescribed dose, clozapine augmentation, and other factors: data from a therapeutic drug monitoring service, 2002-2010. Hum Psychopharmacol 2012; 27:507-13. [PMID: 22996618 DOI: 10.1002/hup.2256] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE This study aimed to investigate the effect of dose and other factors on plasma amisulpride concentrations in clinical practice. METHOD Amisulpride therapeutic drug monitoring data 2002-2010 have been studied. RESULTS There were 296 samples (196 adult patients). Amisulpride was not detected in 10% of samples. In the remainder, the mean plasma amisulpride in relation to the prescribed dose (mg/day) was as follows: 100-200 (111 µg/L), 201-400 (254 µg/L), 400-800 (421 µg/L), and 800-1200 (494 µg/L). For prescribed doses up to 800 mg/day, only 51% of results were within 100-319 µg/L. There were no significant sex differences in mean plasma amisulpride or mean dose. The mean plasma amisulpride, but not the dose, was significantly higher in smokers. Linear regression analysis showed that dose explained only 42% of the variation in plasma amisulpride after log(10) transformation of both variables. There was no significant difference in the mean dose or mean plasma amisulpride in patients co-prescribed clozapine as compared with the remaining samples. CONCLUSION In practice, dose is a poor predictor of plasma amisulpride concentration. Therapeutic drug monitoring may not only help assess adherence, but also guide dosage.
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Affiliation(s)
- Sally V J Bowskill
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, UK
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Porcelli S, Balzarro B, Serretti A. Clozapine resistance: augmentation strategies. Eur Neuropsychopharmacol 2012; 22:165-82. [PMID: 21906915 DOI: 10.1016/j.euroneuro.2011.08.005] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/12/2011] [Accepted: 08/13/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clozapine (CLZ) is not effective in more than 50% of treatment-resistant schizophrenic patients. In these cases, several pharmacological strategies are used in clinical practice, with different levels of evidence for both safety and efficacy. OBJECTIVES In the present paper we critically reviewed literature data regarding the efficacy and safety of adjunctive agents in CLZ-resistant schizophrenics. The following classes of agents were considered: 1) antipsychotics, 2) antidepressants, 3) mood stabilizers, 4) other agents (e.g. fatty acid supplement and glutamatergic agents), 5) electroconvulsive therapy (ECT). For lamotrigine and risperidone sufficient data were available to perform a meta-analysis. METHODS A Medline literature search covering a 20-year period was performed. For the meta-analysis, data were entered and analyzed with the Cochrane Collaboration Review Manager Software (RevMan version 5). RESULTS 62 pertinent studies were identified, including 1556 schizophrenic or schizoaffective patients. Among treatments investigated, there is evidence for CLZ augmentation with 1) amisulpride and aripiprazole, 2) mirtazapine and 3) ethyl eicosapentaenoic acid (E-EPA). Although promising, ECT augmentation needs further validation. The meta-analyses did not support either the use of risperidone or lamotrigine as CLZ adjunct. CONCLUSION Overall, there is scarce evidence of efficacy and safety as regards adjunctive strategies for CLZ-resistant patients. However, several limitations do not allow to draw any definitive conclusion; among these we underline the small sample size of clinical trials, the variable definitions of CLZ resistance, the heterogeneity of outcome measures and methodological designs.
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Affiliation(s)
- Stefano Porcelli
- Institute of Psychiatry, University of Bologna, Viale Carlo Pepoli 5, 40123 Bologna, Italy
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Kreinin A, Miodownik C, Sokolik S, Shestakova D, Libov I, Bergman J, Lerner V. Amisulpride versus moclobemide in treatment of clozapine-induced hypersalivation. World J Biol Psychiatry 2011; 12:620-6. [PMID: 20964499 DOI: 10.3109/15622975.2010.527370] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Previous publications demonstrated substitute benzamides as effective agents in treatment of clozapine-induced sialorrhea (CIS). The aim of this study was to compare efficacy of amisulpride and moclobemide (both from the substitute benzamide group) in controlling, or at least minimizing, CIS. METHODS The study was designed as a 6-week, two-center, fixed-dose, comparison study of 400 mg/day of amisulpride versus 300 mg/day of moclobemide as an adjunctive treatment in 53 schizophrenia and schizoaffective disorder patients (diagnosed according to DSM-IV) suffering from CIS. The patients were treated with each medication during 2 weeks, followed by a washout period of 2 weeks. Primary outcome measures included the reduction in the five-point Nocturnal Hypersalivation Rating Scale (NHRS). Secondary outcomes included the Positive and Negative Syndrome Scale (PANSS), Manic State Assessment Scale, and Extrapyramidal Symptom Rating Scale (ESRS). RESULTS Both amisulpride and moclobemide were very effective in reducing CIS. Almost 74% of patients treated with amisulpride and 83% of patients treated with moclobemide showed some level of improvement on NHRS. Only in one patient treated with amisulpride, CIS worsened. CONCLUSIONS Both medications were safe and effective as treatment of CIS. Although moclobemide exceeded amisulpride in antisalivation activity, treatment of CIS with amisulpride leads to improvement in psychotic symptoms.
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Affiliation(s)
- Anatoly Kreinin
- Mental Health Center Tirat Carmel, Bruce Rapaport Faculty of Medicine Technion-Haifa, Israel
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Abstract
BACKGROUND The development of algorithms and guidelines in medicine is widespread. There are six major guidelines used and/or influencing the treatment of schizophrenia in the United States. The impact of these guidelines on clinical practice is difficult to evaluate. Many studies to date show poor adherence to schizophrenia guideline recommendations. OBJECTIVE The purpose of this article is to discuss the rationale for use of guidelines/algorithms in medicine, the importance of schizophrenia guidelines, barriers to using guidelines, and to review key aspects of schizophrenia guidelines most commonly used in the United States. RESULTS Schizophrenia guidelines/algorithms differ somewhat in scope, focus, goals, and recommendations. Each guideline/algorithm has its utility in clinical practice.
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Affiliation(s)
- Troy A Moore
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio South Texas Veterans Health Care System, San Antonio, TX, USA.
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Van Sant SP, Buckley PF. Pharmacotherapy for treatment-refractory schizophrenia. Expert Opin Pharmacother 2011; 12:411-34. [PMID: 21254948 DOI: 10.1517/14656566.2011.528200] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION despite advances in pharmacotherapy of schizophrenia-spectrum disorders, a large percentage of persons with schizophrenia remain at least partially nonresponsive to treatment, leading to increased morbidity/mortality, increased healthcare cost, and poor quality of life for affected individuals. AREAS COVERED this paper comprises a review of recent research in drug therapy for schizophrenia, particularly treatment-refractory schizophrenia, with a focus on research conducted between 2005 and June 2010. Databases that were searched include: Pubmed, CINAHL, Science Direct, Medline and Clinical Trials.gov. Primary search terms were 'treatment-refractory schizophrenia' and 'treatment-resistant schizophrenia', with cross reference to specific agents covered in this article. An objective perspective on current trends in pharmacotherapy for treatment-refractory schizophrenia. We review the available evidence and discuss the strengths and weaknesses of published data in this field. EXPERT OPINION although there have been many advances in pharmacotherapy for schizophrenia, more well-designed trials are required to establish true efficacy and safety of current prescribing trends in clinical practice.
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Affiliation(s)
- Scott P Van Sant
- Medical College of Georgia, Department of Psychiatry and Health Behavior, Augusta, GA 30912, USA.
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Muscatello MRA, Bruno A, Pandolfo G, Micò U, Scimeca G, Di Nardo F, Santoro V, Spina E, Zoccali RA. Effect of aripiprazole augmentation of clozapine in schizophrenia: a double-blind, placebo-controlled study. Schizophr Res 2011; 127:93-9. [PMID: 21262565 DOI: 10.1016/j.schres.2010.12.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 12/01/2010] [Accepted: 12/17/2010] [Indexed: 01/23/2023]
Abstract
The simultaneous prescription of two or more antipsychotic drugs in combination is a common treatment strategy for those patients who have demonstrated a suboptimal response to clozapine; nevertheless, evidence suggesting potential advantages of combination treatment with clozapine plus one antipsychotic in terms of efficacy and tolerability are still sparse. The present 24-week double-blind, randomized, placebo-controlled trial of adjunctive aripiprazole to clozapine therapy in schizophrenia was aimed to explore the efficacy of aripiprazole add-on pharmacotherapy on clinical symptomatology and cognitive functioning in a sample of patients with treatment-resistant schizophrenia receiving clozapine. After clinical and neurocognitive assessments patients were randomly allocated to receive, in a double-blind design, either up to 15 mg/day of aripiprazole or a placebo. A final sample of thirty-one patients completed the study. The results obtained indicate that aripiprazole added to stable clozapine treatment showed a beneficial effect on the positive and general psychopathological symptomatology in a sample of treatment-resistant schizophrenia patients. Regarding executive cognitive functions, aripiprazole augmentation of clozapine had no significant effects. The findings provide evidence that aripiprazole augmentation of clozapine treatment is well-tolerated and may be of benefit for patients who are partially responsive to clozapine monotherapy; further double-blind, placebo-controlled trials in a larger number of patients are required to evaluate the therapeutic potential of aripiprazole augmentation of clozapine.
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Affiliation(s)
- Maria Rosaria A Muscatello
- Section of Psychiatry, Department of Neurosciences, Psychiatric and Anaesthesiological Sciences, University of Messina, Messina, Italy
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O'Connell G, Lawrie SM, McIntosh AM, Hall J. Schizophrenia risk genes: Implications for future drug development and discovery. Biochem Pharmacol 2010; 81:1367-73. [PMID: 21093417 DOI: 10.1016/j.bcp.2010.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 11/07/2010] [Accepted: 11/08/2010] [Indexed: 02/04/2023]
Abstract
Present-day development of improved treatments for schizophrenia is hindered by uncertain models of disease, inter-individual response variability in clinical trials and a paucity of sensitive measures of treatment effects. Findings from genetic research emphasize the potential for schizophrenia risk genes to help develop focused treatments, discover new drug targets and provide markers of clinical subtypes. Advances in genetic technologies also provide novel modes of drug discovery in schizophrenia such as transcriptomics, epigenetics and transgenic animal models. In this review, we discuss proven and proposed ways risk genes can be used to enhance the development and discovery of treatments for schizophrenia and highlight key studies in these approaches.
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Affiliation(s)
- Garret O'Connell
- Division of Psychiatry, University of Edinburgh, Scotland, United Kingdom.
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Elie D, Poirier M, Chianetta J, Durand M, Grégoire C, Grignon S. Cognitive effects of antipsychotic dosage and polypharmacy: a study with the BACS in patients with schizophrenia and schizoaffective disorder. J Psychopharmacol 2010; 24:1037-44. [PMID: 19164494 DOI: 10.1177/0269881108100777] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antipsychotic polypharmacy and high doses have been associated with poorer outcome, longer hospital stays, and increased side effects. The present naturalistic study assessed the cognitive effects of antipsychotics in 56 patients with a diagnosis of schizophrenia or schizoaffective disorder, using the Brief Assessment of Cognition in Schizophrenia (BACS). Antipsychotic daily dose (ADD) was expressed as mg risperidone equivalents/day (RIS eq), using a model based on drug doses from the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) study for second generation antipsychotics (SGA) and chlorpromazine equivalents for first generation antipsychotics (FGA), with a 1/1 equivalence between haloperidol and risperidone. Increasing age was associated with polypharmacy, FGA prescription and decreasing BACS score. FGA prescription, in turn, predicted a poorer cognitive functioning, independently of age, PANSS subscores and ADD. ADD was associated with decreasing cognitive scores, an effect that remained significant after controlling for age, PANSS or polypharmacy. The detrimental cognitive effects of polypharmacy, in turn, appeared to be mediated by ADD. Different methods of data fitting suggested that ADD above 5-6 mg RIS eq/day were associated with lower BACS scores. Overall, these results show that increasing antipsychotic daily dose is associated with poorer cognitive functioning at doses lower than previously thought, independently of the number of antipsychotic drugs.
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Affiliation(s)
- D Elie
- Department of Psychiatry, Sherbrooke University, Sherbrooke, QC, Canada, and Department of Psychiatry, CHUQ-Hôtel Dieu, Québec, QC, Canada
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Abstract
This article summarizes the current knowledge base on the diagnosis and management of treatment resistant schizophrenia. While the prevalence of treatment resistant schizophrenia is definition dependent, estimates have ranged from 30% to up to 60%. This article first looks into the various diagnostic criteria of treatment resistant schizophrenia. Then the literature is reviewed about the pharmacotherapeutics of its management. Clozapine emerges to be the gold standard. In addition risperidone and high dose olanzapine also emerge as clinically useful options. Other emerging adjunctive treatment options are equally addressed.
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Affiliation(s)
- R K Solanki
- Department of Psychiatry, Psychiatry Center, SMS Medical College, Jaipur, India
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Combined treatment with amisulpride in patients with schizophrenia discharged from a short-term hospitalization unit: a 1-year retrospective study. Clin Neuropharmacol 2009; 32:10-5. [PMID: 18978498 DOI: 10.1097/wnf.0b013e3181672213] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Antipsychotic monotherapy is considered as the reference standard in the pharmacological treatment of schizophrenia. Nonetheless, there is a large rate of studies showing polypharmacy with antipsychotics as more frequent than would be expected attending experts' recommendations. The objective of this study is to describe polypharmacy with antipsychotic regimen in patients with schizophrenia discharged with amisulpride from the short-term hospitalization unit. METHODS We have analyzed the prescription of psychotropic drugs upon discharge of 52 patients with schizophrenia or schizoaffective disorder who were discharged with amisulpride from January to December 2005. Variables were included to describe the following treatments: antipsychotic (drug and dose), benzodiazepine, and anticholinergic drugs. Sociodemographic and clinical variables were also collected. RESULTS In the group treated with 2 antipsychotics, the most frequently used common combination was with a classic antipsychotic in depot formulation. Patients (17.5%) were prescribed to another 2 antipsychotics in addition to amisulpride, being the most common combination with a second generation antipsychotic, and a classic or depot antipsychotic. CONCLUSIONS The results of our study show that the use of amisulpride as an adjuvant can be a suitable therapeutic strategy for patients with schizophrenia resistant to treatment and for the rapid control of symptoms in schizophrenic patients with acute episodes. However, its clinical use does not have to be reserved exclusively for patients with resistant schizophrenia to clozapine.
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Nielsen RE, Nielsen J. Antipsychotic Drug Treatment for Patients with Schizophrenia: Theoretical Background, Clinical Considerations and Patient Preferences. ACTA ACUST UNITED AC 2009. [DOI: 10.4137/cmt.s2175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The cornerstone in treatment of psychosis is antipsychotic drugs. Treatment options have increased over the years; newer antipsychotic drugs with a proposed increased efficacy regarding negative and cognitive symptoms, but also a shift in side-effects from neurological side-effects to metabolic side-effects have arisen as the new challenge. The basis of successful pharmacological treatment is a fundamental understanding of the mechanisms of action, the desired effects and side-effects of antipsychotic drugs, a good relationship with the patient and a thorough monitoring of the patient before and during treatment. The clinically relevant aspects of antipsychotic drug treatment are reviewed; mechanism of antipsychotic drug action, clinical considerations in treatment, switching antipsychotic drugs, polypharmacy, safety and patient preference.
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Affiliation(s)
- René Ernst Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Aalborg, Denmark
| | - Jimmi Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Aalborg, Denmark
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Abstract
OBJECTIVE To use structured implicit review following large-scale explicit audit of antipsychotic polyprescribing to: (1) determine the true rate of antipsychotic polytherapy that deviated from best practice for schizophrenia treatment; and (2) assess whether explicit antipsychotic polytherapy criterion was appropriate for identifying patients at risk for medication problems and assessing quality of care. METHODS Antipsychotic prescribing was reviewed for outpatients in four public health services in Auckland, New Zealand on 31 October 2004 (T1). Schizophrenia patients in one service (n = 794) prescribed antipsychotic polytherapy (n = 84, 10.6%) were followed up 10 months later (T2). Historical medication summaries were prepared for those remaining on polytherapy, including diagnosis, clinical problems and treatment plan. Criteria for structured implicit review and rating form for quality of antipsychotic management were piloted. All medication summaries were independently rated by two reviewers, and a third independent rater reviewed summaries where disagreement was found. RESULTS Forty-nine patients remained on long-term polytherapy at T2 (6.2% of original population). All but two cases included a second-generation antipsychotic. At T2, average polytherapy duration was 35.8 months, and average antipsychotic dose was 699 mg day(-1) chlorpromazine equivalents. Two raters achieved agreement for 24/49 summaries, and the remaining 25 were rated independently by a third reviewer. Consensus agreement of antipsychotic management (by two raters) was reached for 44/49 cases (89.8%). Polytherapy was rated 'well-justified' in 32.7%, 'some justification' in 10.2% and 'lacked justification' in 46.9% cases. The final rate of polytherapy deviating from best practice reduced from 10.6% to 3.5% when short-term polytherapy was excluded, and details of the clinical situation and care plan were included in implicit review. CONCLUSIONS Audit of prescribing in routine practice using explicit guideline-based criteria may be a useful baseline performance indicator. It does not provide an accurate measurement of quality of care because it overestimates the deviation rate from good practice. It may also identify complex patients at risk for poor treatment outcomes who may benefit from structured treatment review.
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Affiliation(s)
- Amanda Wheeler
- Clinical Research and Resource Centre, Mental Health and Addiction Services, Waitakere Hospital, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Zink M, Kuwilsky A, Krumm B, Dressing H. Efficacy and tolerability of ziprasidone versus risperidone as augmentation in patients partially responsive to clozapine: a randomised controlled clinical trial. J Psychopharmacol 2009; 23:305-14. [PMID: 18562423 DOI: 10.1177/0269881108089593] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients suffering from schizophrenic psychoses sometimes insufficiently respond to antipsychotic monotherapy and then combination approaches are preferred. We aimed in validating the add-on of ziprasidone and risperidone to clozapine, and we performed a randomised head-to-head trial. Patients with partial response to clozapine were randomly attributed to augmentation with ziprasidone (n = 12) or risperidone (n = 12). Efficacy assessments included the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Negative Symptoms (SANS), the Hamilton Depression Scale (HAMD), the Clinical Global Impression (CGI) and the Global Assessment of Functioning (GAF). Furthermore, several safety and tolerability measures were obtained. After six weeks, both groups showed significant reductions of positive and negative symptoms. In addition, affective state, psychosocial functioning and clozapine side effects improved without significant differences between the groups. Both approaches were well tolerated. However, the ziprasidone group experienced a small elongation of the QTc interval and a reduction of extrapyramidal symptoms. Patients under clozapine-risperidone therapy developed a rise of serum prolactin levels. The clozapine augmentation with ziprasidone or risperidone resulted in significant psychopathological improvements. The side effects differed between the treatment groups. Further head-to-head comparisons of atypical antipsychotics as add-on to clozapine are necessary.
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Affiliation(s)
- Mathias Zink
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany.
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Costa E, Chen Y, Dong E, Grayson DR, Kundakovic M, Maloku E, Ruzicka W, Satta R, Veldic M, Zhubi A, Guidotti A. GABAergic promoter hypermethylation as a model to study the neurochemistry of schizophrenia vulnerability. Expert Rev Neurother 2009; 9:87-98. [PMID: 19102671 DOI: 10.1586/14737175.9.1.87] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The neuronal GABAergic mechanisms that mediate the symptomatic beneficial effects elicited by a combination of antipsychotics with valproate (a histone deacetylase inhibitor) in the treatment of psychosis (expressed by schizophrenia or bipolar disorder patients) are unknown. This prompted us to investigate whether the beneficial action of this combination results from a modification of histone tail covalent esterification or is secondary to specific chromatin remodeling. The results suggest that clozapine, or sulpiride associated with valproate, by increasing DNA demethylation with an unknown mechanism, causes a chromatin remodeling that brings about a beneficial change in the epigenetic GABAergic dysfunction typical of schizophrenia and bipolar disorder patients.
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Affiliation(s)
- Erminio Costa
- Psychiatric Institute, Department of Psychiatry, University of Illinois at Chicago, 1601 Taylor, Chicago, IL 60612, USA.
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Lerma-Carrillo I, de Pablo Brühlmann S, del Pozo ML, Pascual-Pinazo F, Molina JD, Baca-García E. Antipsychotic polypharmacy in patients with schizophrenia in a brief hospitalization unit. Clin Neuropharmacol 2009; 31:319-32. [PMID: 19050409 DOI: 10.1097/wnf.0b013e31815cba78] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Antipsychotic monotherapy is considered the gold standard in pharmacological treatment of schizophrenia and other psychotic disorders. Only 2 of the main clinical guides recommend the use of antipsychotic polypharmacy (AP) for those patients refractory to monotherapy. Nonetheless, there is a large rate of studies, conducted in many different settings, showing that AP is more frequent as would be expected attending experts' recommendations. METHODS In this retrospective study, we review all the psychotropic drugs dispensed to inpatients of a brief hospitalization psychiatric unit diagnosed as having schizophrenia or schizoaffective disorder (International Statistical Classification of Diseases, 10th Revision) at time of discharge in the year 2005. These included a total of 209 patients older than 18 years. RESULTS Of the 209 studied patients, 55.5% were discharged under AP treatment. Inpatients were given a mean of 3.06 psychotropic drugs and a mean of 1.61 antipsychotics at the time of hospital discharge. A total of 33.2% of the studied patients got anticholinergic drugs, and 66.2% were given benzodiazepines. The most prevalent combination of drugs was intramuscular long-acting risperidone plus an atypical antipsychotic. Amisulpride was the most used antipsychotic as adjuvant treatment. CONCLUSIONS Despite different clinical guidelines, AP is a common pharmacological strategy as it is shown in our study and in the reviewed literature. Data in our study indicate that the observed rates of AP cannot exclusively be attributed to the treatment of patients with clozapine-resistant schizophrenia.
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Characterization of the action of antipsychotic subtypes on valproate-induced chromatin remodeling. Trends Pharmacol Sci 2009; 30:55-60. [DOI: 10.1016/j.tips.2008.10.010] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 10/29/2008] [Accepted: 10/31/2008] [Indexed: 11/23/2022]
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Abstract
Amisulpride is an atypical antipsychotic drug with a unique receptor pharmacology which is dose dependent. It is a standard treatment in dysthymia as well as in psychosis. Amisulpride is efficacious, effective and well tolerated in positive symptoms of schizophrenia: there is extensive evidence that it treats negative symptoms when given in low doses, although relative lack of EPS and an antidepressant effect may contribute. In first-episode patients amisulpride is an option, although there is little comparative work available. Amisulpride has the best evidence as an effective adjunct to clozapine treatment. Regarding intellectual function, amisulpride appears cognitive sparing but the clinical relevance of this remains obscure. There is evidence that amisulpride can improve social function but again there is little comparative work to demonstrate any particular advantages. Regarding the current conventional versus atypical antipsychotic controversy, amisulpride did better in switching studies and meta-analyses than in the single large pragmatic randomized trial reported to date. It is a versatile drug, and may offer advantages over other atypical antipsychotic drugs in the treatment of negative and depressive symptoms, and tolerability advantages such as the avoidance of weight gain. Essentially it rests with the treating clinician to employ a rational psychopharmacological approach towards the individual patient: there will be few circumstances in which amisulpride will not be a likely contender as a treatment choice.
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Affiliation(s)
- Ann M Mortimer
- Department of Psychiatry, Hertford Building, The University of Hull, Cottingham Road, Hull HU6 7RX, United Kingdom.
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Brunoni AR, Kobuti Ferreira LR, Gallucci-Neto J, Elkis H, Velloso EDPR, Vinicius Zanetti M. Lithium as a treatment of clozapine-induced neutropenia: a case report. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:2006-7. [PMID: 18824055 DOI: 10.1016/j.pnpbp.2008.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 09/07/2008] [Accepted: 09/09/2008] [Indexed: 11/16/2022]
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Pani L, Villagrán JM, Kontaxakis VP, Alptekin K. Practical issues with amisulpride in the management of patients with schizophrenia. Clin Drug Investig 2008; 28:465-77. [PMID: 18598092 DOI: 10.2165/00044011-200828080-00001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Amisulpride is an atypical antipsychotic with a significantly greater effect size than first-generation, typical antipsychotics, and efficacy at least similar to that of olanzapine and risperidone in large-scale clinical trials in schizophrenia. Amisulpride provides greater improvement in positive and negative symptoms of schizophrenia, a better long-term outcome than typical antipsychotics, and distinct tolerability advantages over typical antipsychotics, which are reported to cause extrapyramidal symptoms (EPS) in 20-50% of patients. In addition, amisulpride is associated with significantly less weight gain than olanzapine and risperidone, does not increase body mass index, and favourably influences lipid profiles. In many patients with schizophrenia, adverse events impair adherence to treatment, and switching from typical or atypical antipsychotic therapy to amisulpride may be clinically appropriate. Observational drug-utilization studies suggest that many physicians switch to amisulpride because of fewer EPS and/or less weight gain and improved patient adherence. Cross-tapering (over 4 weeks), rather than abrupt cessation of pre-switch treatment, is preferred. Amisulpride has a low risk of drug-drug interactions, and, during cross-tapering, patients can remain on concurrent treatments (e.g. anticholinergics and antiparkinsonian agents) until the effective dosage has been reached. An appropriate amisulpride starting dose is 800 mg/day for patients with acute psychotic exacerbations, 400-800 mg/day for patients with predominantly positive symptoms, and 100-300 mg/day for predominantly negative symptoms. Amisulpride may be particularly suitable for clozapine-augmentation therapy in patients with refractory schizophrenia. Indeed, amisulpride is more effective than quetiapine as augmentation therapy in patients partially responsive to clozapine, and several prospective open-label studies and case series have reported promising results for amisulpride/clozapine combination therapy. In three prospective studies, addition of amisulpride 200-800 mg/day to clozapine significantly reduced mean scores on the Brief Psychiatric Rating Scale (BPRS) total (-33% to -35%), Clinical Global Impression (CGI)-Severity scale (-31%), Positive and Negative Syndrome Scale total (-22%), and Scale for the Assessment of Negative Symptoms (-34%). The proportion of responders (CGI score > or =3 or BPRS improvement >20%) was 71-86%. Retrospective case-series analyses have also reported improved psychopathological state, reduced adverse events, and lower clozapine dosage requirement with use of this combination. The pharmacological and clinical profiles of amisulpride suggest that this agent is a viable clinical option when a change of antipsychotic therapy is required in patients with schizophrenia because of lack of efficacy, adverse events and poor adherence to treatment, or for augmentation of clozapine in treatment-resistant illness.
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Affiliation(s)
- Luca Pani
- Institute of Biomedical Technologies, National Research Council (CNR), Milan, ItalyPharmaNess Scarl, Sardegna Ricerche, Pula (Cagliari), Italy
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Gören JL, Parks JJ, Ghinassi FA, Milton CG, Oldham JM, Hernandez P, Chan J, Hermann RC. When Is Antipsychotic Polypharmacy Supported by Research Evidence? Implications for QI. Jt Comm J Qual Patient Saf 2008; 34:571-82. [DOI: 10.1016/s1553-7250(08)34072-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Combined antipsychotic treatment involving clozapine and aripiprazole. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:1386-92. [PMID: 18407391 DOI: 10.1016/j.pnpbp.2008.02.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Revised: 02/18/2008] [Accepted: 02/21/2008] [Indexed: 11/23/2022]
Abstract
Treatment resistance is considered a challenging problem of antipsychotic pharmacotherapy. In such cases, combination approaches are commonly used, for instance the add-on of aripiprazole to clozapine. This review aims at giving an overview of the present knowledge on this strategy. We performed a keyword-based screening of databases (including November 2007) and evaluated the data in a systematic manner. The courses of 94 patients were reported in 11 publications. At a mean dosage of 20.5 mg/day, aripiprazole achieved clinical improvement of psychotic symptoms and facilitated a dose reduction of clozapine from 476.7 to 425.1 mg/day. In parallel, clozapine serum levels decreased from 611 to 523 ng/ml. No pharmacokinetic interactions were reported, and clozapine-induced side effects ameliorated. However, single cases of extrapyramidal side effects occurred. The combination of clozapine and aripiprazole follows a neurobiological rationale and appears to be effective and tolerable. The results of placebo-controlled trials might allow further insight into the benefits and risks of this strategy.
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Tranulis C, Skalli L, Lalonde P, Nicole L, Stip E. Benefits and risks of antipsychotic polypharmacy: an evidence-based review of the literature. Drug Saf 2008; 31:7-20. [PMID: 18095743 DOI: 10.2165/00002018-200831010-00002] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Combination antipsychotic prescription is an increasingly common practice in clinical psychiatry. This clinical practice is at odds with clinical guidelines promoting antipsychotic monotherapy. Moreover, there has been increased concern over the safety profile of atypical antipsychotics in the last 10-15 years. We reviewed the literature on antipsychotic combinations with a focus on safety and efficacy. Multiple electronic database searches were complemented by relevant bibliography cross-checking and expert discussions. The review showed a literature that is dominated by case reports and uncontrolled studies. Polypharmacy was unequally studied, with some recent combinations (i.e. clozapine and risperidone) being extensively, albeit inconclusively, studied and other more commonly used combinations (first- with second-generation agents) receiving little attention. From an evidence-based perspective, further trials of antipsychotic association of sufficient power to address safety issues are needed before recommending any antipsychotic combination. Particular weaknesses of the present literature are low number of participants, lack of adequate control of confounding variables, short duration of experimental follow-up and inadequate monitoring of potential adverse effects.
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Gupta M. Clozapine and co-prescribed psychotropics: a short report. Clin Pract Epidemiol Ment Health 2008; 4:11. [PMID: 18439293 PMCID: PMC2386462 DOI: 10.1186/1745-0179-4-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Accepted: 04/25/2008] [Indexed: 11/30/2022]
Abstract
Clozapine is the drug of choice in treatment resistant schizophrenia. It reduces hospitalizations. Patients on clozapine are often co-prescribed other psychotropics. This report looks at a sample of twenty patients on clozapine. It finds that almost two thirds were on a psychotropic along with clozapine. Eight individuals were on an antidepressant; seven on an antipsychotic and five were on co-prescribed valproate. The clinical implications are discussed and a need to look at health services involving clozapine is suggested.
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Affiliation(s)
- Maneesh Gupta
- Lancashire Care NHS Foundation Trust, Parkwood Hospital, East Park Drive, Blackpool, FY3 8PW UK.
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Abstract
The management of early onset psychosis poses a significant challenge to professionals working in Child and Adolescent Mental Health Services. Young people with psychotic illness often present with a mixed clinical picture and a wide variety of attendant issues. Over the last decade there has been accumulating research, mainly based on work with adults, regarding the efficacy and effectiveness of medical and psychosocial interventions for patients with schizoaffective spectrum disorders. This article takes a symptoms-based approach, collating and summarising recent evidence, where it exists, regarding best practice when managing young people affected by schizophrenia, schizoaffective or bipolar affective disorder.
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Affiliation(s)
- Paul A Tiffin
- The Newberry Centre, West Lane Hospital, Middlesbrough, TS5 4EE, UK. E-mail:
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48
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Abstract
The author conducted a review of studies that compared the efficacy, tolerability and indication for the use of clozapine in current perspectives for the treatment of resistant schizophrenia/ partial responders.
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Affiliation(s)
- Ram K. Solanki
- Psychiatry Center, Department of Psychiatry, SMS Medical College, Jaipur, India
| | - Paramjeet Singh
- Psychiatry Center, Department of Psychiatry, SMS Medical College, Jaipur, India
| | - Mukesh K. Swami
- Psychiatry Center, Department of Psychiatry, SMS Medical College, Jaipur, India
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49
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Abstract
This article opens with a brief history of pharmacologic treatment of schizophrenia. It then discusses the definition and treatment of treatment-resistant schizophrenia, with particular attention to clinical, biological and neuroimaging correlates, as well as the best treatment options, including the use of clozapine in patients who meet the definition of treatment-resistant schizophrenia.
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Dratcu L, Grandison A, McKay G, Bamidele A, Vasudevan V. Clozapine-resistant psychosis, smoking, and caffeine: managing the neglected effects of substances that our patients consume every day. Am J Ther 2007; 14:314-8. [PMID: 17515710 DOI: 10.1097/01.pap.0000249958.96498.ce] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
More than 30% of patients with psychotic disorders who are refractory to antipsychotic treatment also fail to respond to clozapine. Despite the high prevalence of smoking and caffeine use in the psychiatric population, these habits are usually overlooked as factors contributing to antipsychotic treatment failure. We describe 2 male patients with severe treatment-resistant psychosis, one with schizophrenia and the other with bipolar affective disorder-both of whom smoked heavily, and the latter also consumed enormous amounts of caffeine-whose symptoms were refractory to clozapine. Both patients experienced a major, sustained amelioration of their psychotic symptoms when clozapine treatment was recommenced under supervision in the inpatient setting and the pharmacological interactions between clozapine, smoking, and caffeine were considered. Therapeutic strategies included gradual increases in daily doses of clozapine, monitoring clozapine plasma levels, using single daily doses of clozapine at night, and augmenting clozapine treatment with low doses of amisulpride, a selective antagonist at the dopamine D2 and D3 receptors. Smoking and excessive caffeine use are associated with poor therapeutic responses to clozapine and should be considered in the pharmacological management of treatment-refractory psychosis, regardless of the primary diagnosis.
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Affiliation(s)
- Luiz Dratcu
- York Clinic, Guy's Hospital, Southwark Division of Inpatient Psychiatry, South London and Maudsley NHS Trust, London, United Kingdom.
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