An anti-tardive-dyskinesia effect of verapamil

Calcium channel blockers for antipsychotic-induced tardive dyskinesia

BACKGROUND

Schizophrenia and related disorders affect a sizable proportion of any population. Antipsychotic medications are the primary treatment for these disorders. Antipsychotic medications are associated with a variety of adverse effects including tardive dyskinesia. Dyskinesia is a disfiguring movement disorder of the orofacial region that can be tardive (having a slow or belated onset). Tardive dyskinesia is difficult to treat, despite experimentation with several treatments. Calcium channel blockers (diltiazem, nifedipine, nimodipine, verapamil, flunarizine) have been among these experimental treatments.

OBJECTIVES

To determine the effects of calcium channel blocker drugs (diltiazem, nifedipine, nimodipine, verapamil) for treatment of neuroleptic-induced tardive dyskinesia in people with schizophrenia, schizoaffective disorder or other chronic mental illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (July 2015 and April 2017), inspected references of all identified studies for further trials and contacted authors of trials for additional information.

SELECTION CRITERIA

We selected randomised controlled trials comparing calcium channel blockers with placebo, no intervention or any other intervention for people with both tardive dyskinesia and schizophrenia or serious mental illness who remained on their antipsychotic medication.

DATA COLLECTION AND ANALYSIS

We independently extracted data and estimated risk ratios of dichotomous data or mean differences (MD) of continuous data, with 95% confidence intervals (CI). We assumed that people who left the trials early had no improvement. We also created a 'Summary of findings' table using GRADE.

MAIN RESULTS

Previous versions of this review included no trials. From the 2015 search, we identified three cross-over trials that could be included. The 2017 search found no new studies relevant to this review. The included trials randomised 47 inpatients with chronic mental illnesses in the USA and China. Trials were published in the 1990s and were of short duration (six to 10 weeks). Overall, the risk of bias was unclear, mainly due to poor reporting; allocation concealment was not described, generation of the sequence was not explicit, studies were not clearly blinded, and attrition and outcome data were not fully reported. Findings were sparse, no study reported on the primary outcome 'no clinically important improvement in tardive dyskinesia symptoms,' but two small studies (37 participants) found no difference on the tardive dyskinesia symptoms scale Abnormal Involuntary Movement Scale (AIMS) scores between diltiazem or flunarizine and placebo after three to four weeks' treatment (MD -0.71, 95% CI -2.68 to 1.26, very low quality evidence). Only one study randomising 20 participants reported on adverse events, and reported that there were no adverse events with flunarizine or with placebo (very low quality evidence). One study with 18 participants reported no events of deterioration in mental state with diltiazem or with placebo (very low quality evidence). No studies reported on acceptability of treatment or on social confidence, social inclusion, social networks or personalised quality of life outcomes designated important to patients.

AUTHORS' CONCLUSIONS

Available evidence from randomised controlled trials is extremely limited and very low quality, conclusions cannot be drawn. The effects of calcium channel blockers for antipsychotic-induced tardive dyskinesia are unknown. Their use is experimental and should only be given in the context of well-designed randomised trials.

The Dystonias

Dystonia is a difficult problem for both the clinician and the scientist. It is sufficiently common to be seen by almost all physicians, yet uncommon enough to prevent any physician from gaining broad experience in its diagnosis and treatment. Each case represents a difficult challenge even to the specialist. The basic scientist is faced with investigating a disorder that is without relevant animal models and which is so rare that obtaining suitable tissue for study is a major obstacle. Dystonia may be idiopathic, or associated with lesions from many sources, including a variety of rare diseases. If idiopathic, it may be genetically transmitted or sporadic. If genetically transmitted, it may be generalized or focal, with symptoms varying in different members of the same family. It may be refractory to treatment, or it may respond to any one of a number of individual drugs that have very different mechanisms of action. For idiopathic dystonias, no clear method of genetic transmission has been established and no consistent pathology identified.

Calcium channel blockers for neuroleptic-induced tardive dyskinesia

BACKGROUND

Schizophrenia and related disorders affect a sizable proportion of any population. Neuroleptic (antipsychotic) medications are the primary treatment for these disorders. Neuroleptic medications are associated with a variety of side effects including tardive dyskinesia. Dyskinesia is a disfiguring movement disorder of the orofacial region that can be tardive (having a slow or belated onset). Tardive dyskinesia is difficult to treat, despite experimentation with several treatments. Calcium channel blockers (diltiazem, nifedipine, nimodipine, verapamil) have been among these experimental treatments.

OBJECTIVES

To determine the effects of calcium-channel blocker drugs (diltiazem, nifedipine, nimodipine, verapamil) for treatment of neuroleptic-induced tardive dyskinesia in people with schizophrenia, schizoaffective disorder or other chronic mental illnesses.

SEARCH STRATEGY

We updated previous searches in May 2010 by searching the Cochrane Schizophrenia Group Register using the Cochrane Schizophrenia Group search strategy.

SELECTION CRITERIA

Randomised clinical trials comparing calcium-channel blockers with placebo, no intervention or any other intervention for people with both tardive dyskinesia and schizophrenia or serious mental illness.

DATA COLLECTION AND ANALYSIS

We planned to extract and analyse data on an intention-to-treat (ITT) basis. We intended to calculate the relative risk (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data using a random-effects model, and, where possible, calculate the number needed to treat. We planned to calculate mean differences (MD) for continuous data.

MAIN RESULTS

We did not include any trials in this review. We excluded 15 studies; eight were not randomised, one did not use calcium channel blockers, five small, randomised, studies reported no usable data and one did not include people with both tardive dyskinesia and schizophrenia.

AUTHORS' CONCLUSIONS

The effects of calcium-channel blockers for antipsychotic induced tardive dyskinesia are unknown. Their use is experimental and should only be given in the context of well designed randomised clinical trials.

L-type calcium channels and psychiatric disorders: A brief review

Emerging evidence from genome-wide association studies (GWAS) support the association of polymorphisms in the alpha 1C subunit of the L-type voltage-gated calcium channel gene (CACNA1C) with bipolar disorder. These studies extend a rich prior literature implicating dysfunction of L-type calcium channels (LTCCs) in the pathophysiology of neuropsychiatric disorders. Moreover, calcium channel blockers reduce Ca(2+) flux by binding to the α1 subunit of the LTCC and are used extensively for treating hypertension, preventing angina, cardiac arrhythmias and stroke. Calcium channel blockers have also been studied clinically in psychiatric conditions such as mood disorders and substance abuse/dependence, yielding conflicting results. In this review, we begin with a summary of LTCC pharmacology. For each category of disorder, this article then provides a review of animal and human data. In particular, we extensively focus on animal models of depression and clinical trials in mood disorders and substance abuse/dependence. Through examining rationale and study design of published clinical trials, we provide some of the possible reasons why we still do not have definitive evidence of efficacy of calcium-channel antagonists for mood disorders. Refinement of genetic results and target phenotypes, enrollment of adequate sample sizes in clinical trials and progress in physiologic and pharmacologic studies to synthesize tissue and isoform specific calcium channel antagonists, are all future challenges of research in this promising field. © 2010 Wiley-Liss, Inc.

Calcium channel blockers in psychiatric disorders: a review of the literature

OBJECTIVES

To review the published literature of the past 15 years regarding use of calcium channel blockers (CCBs) in psychiatric practice. These drugs, especially verapamil, have been recommended as possible treatments for mania and other disorders.

METHODS

The Cumulative Medical Index and other databases were searched and back-tracked to locate relevant articles. Sixty-one such articles were uncovered: 37 anecdotal reports, 7 partially controlled reports, and 17 controlled trials.

RESULTS

Most studies involved treatment of mania using verapamil. Although anecdotal reports were generally favourable, results from partially controlled reports or controlled clinical trials were mixed. Generally, verapamil was less effective than was lithium or placebo. Treatment of depression with CCBs was not very successful, regardless of the type of trial; the best trial was negative. The same was true for the treatment of schizophrenia, although the cases studied were extremely chronic and treatment-resistant. Evidence for efficacy in other illnesses, such as Alzheimer's disease or tardive dyskinesia was scanty but suggested that further trials might be in order.

CONCLUSIONS

CCBs do not at present have an established place in psychiatric treatment. Nonetheless, clinicians faced with a manic patient not responsive to other antimanic drugs, either alone or in combination, might consider adding verapamil as an adjunct. A study bearing on this specific issue is needed to determine whether or not such off-label use would really be justified.

Neuroleptic discontinuation syndromes

The existence of discontinuation syndromes following treatment with neuroleptic (antipsychotic) drugs was first outlined in the mid-1960s but the effects of such syndromes have been neglected since then. We have pursued evidence for the existence and nature of discontinuation syndromes following neuroleptics through reports of difficulties following the use of dopamine blocking anti-emetics, the use of chlorpromazine to treat tuberculosis, the use of antidepressant-neuroleptic combinations in affective disorders, the occurrence of tardive syndromes and studies designed to establish the existence of discontinuation syndromes in schizophrenia. Combined these bodies of data point strongly to the existence of discontinuation syndromes after cessation of treatment with neuroleptics which may involve features other than motor dyskinesias. There is at present little evidence on the relative frequency of such syndromes or predisposing factors. The area needs research input to establish the nature of the syndromes that may result, their frequency, predisposing factors and best methods of treatment.

Pharmacological options for the management of dyskinesias

Dyskinesias are abnormal involuntary movements characterised by an excessive amount of movement. Typically, these movements are choreiform in nature. They may be caused by systemic, metabolic, endocrinologic, structural, vascular, infectious or inherited degenerative conditions, or be toxin- or drug-induced. With many non-drug-induced dyskinesias, treatment of the underlying condition may be sufficient to eliminate the movements, although temporary treatment may be required to control the movements if they are severe. Drug-induced dyskinesias often resolve when the offending drug is discontinued. A notable exception is tardive dyskinesia, which is caused by exposure to dopamine receptor blocking drugs, the majority of which are antipsychotic agents. Tardive dyskinesias will persist, or may even develop after the causative agent has been stopped and may not spontaneously remit. Another commonly encountered form of drug-induced dyskinesia is seen in patients with Parkinson's disease who are receiving levodopa. Medications which deplete dopamine are most successful in treating choreiform dyskinesias, although anticholinergics, GABAergics, serotonergics, and calcium channel blocking agents have been reportedly beneficial in some cases. Treatment of levodopa-induced dyskinesias requires manipulation of the patient's antiparkinsonian drug regimen.

Are calcium-channel blockers effective in the treatment of tardive dyskinesia?

OBJECTIVE

To review the data describing the use of calcium-channel blockers in the treatment of tardive dyskinesia (TD).

DATA SOURCES

A MEDLINE search of the English-language literature and a bibliographic review of pertinent articles examining the use of calcium-channel blockers in the treatment of TD were performed. Medical Subject Headings (MESH) terms used were calcium-channel blockers, tardive dyskinesia, nifedipine, verapamil, and diltiazem.

STUDY SELECTION AND DATA EXTRACTION

Relevant case reports, open trials, and controlled studies reporting on the efficacy of calcium-channel blockers for treating TD are reviewed. Appropriate conclusions are drawn from the data and guidelines are suggested for the practitioner.

DATA SYNTHESIS

Studies addressing the efficacy of calcium-channel blockers in the palliative treatment of TD have yielded mixed results. Positive findings have been reported for nifedipine, verapamil, and diltiazem; nifedipine may be the most efficacious treatment and diltiazem the least. It appears that patients with TD who can tolerate higher doses of calcium-channel blockers may respond more favorably to treatment. Patient characteristics that may help determine a better response to treatment with calcium-channel blockers include advanced age and more-severe TD.

CONCLUSIONS

To determine the efficacy of calcium-channel blockers in the treatment of TD, additional data are needed from double-blind, placebo-controlled studies with larger sample sizes and longer durations of treatment. Until these data are available, calcium-channel blockers should be considered potentially useful therapy for the heretofore unresponsive TD.

Smithkline Beecham Prize for Young Psychopharmacologists: A review of the relationship between calcium channels and psychiatric disorders

The symptoms and etiology of most major psychiatric disorders probably represent an underlying disturbance of neurotransmitter function. Understanding the mechanisms which control neurotransmitter function, and in particular neurotransmitter release, is therefore of considerable importance in determining the appropriate pharmacological treatment for these disorders. Calcium entry into neurons triggers the release of a wide range of neurotransmitters and recently our understanding of the mechanisms which control neuronal calcium entry has increased considerably. Neuronal calcium entry occurs through either voltage-sensitive or receptor-operated calcium channels. This article reviews the different subtypes of calcium channel, with particular reference to their structure; drugs which act upon them; and the possible function of the subtypes identified to date. In addition, it reviews the potential role of calcium channel antagonists in the treatment of a wide range of psychiatric disorders, and concludes that these drugs may have an increasing therapeutic role particularly in the treatment of drug dependence, mood disorders and Alzheimer's disease.

A clinical trial of nifedipine in schizophrenia and tardive dyskinesia

Effects of the dihydropyridine calcium channel inhibitor nifedipine on chronic schizophrenia and tardive dyskinesia were studied in an 8-week double-blind crossover trial. Four of the ten patients had tardive dyskinesia, and three of these were not receiving neuroleptics. No effects on symptoms of chronic schizophrenia were found using Psychiatric Symptom Assessment Scale ratings. In the four patients with tardive dyskinesia, an average improvement in total Abnormal Involuntary Movement Scale scores of 57% was observed. These data suggest that dihydropyridine calcium channel inhibitors may be effective in the treatment of tardive dyskinesia in schizophrenic patients.

The marketing of 5-hydroxytryptamine: depression or anxiety?

The discovery that tricyclic antidepressants blocked the re-uptake of both noradrenaline and 5-hydroxytryptamine (5-HT) was a significant step on the road to the development of the monoamine hypotheses of depression (Healy, 1987). The subsequent demonstration that the de-aminated metabolites of amitriptyline and imipramine, nortriptyline and desipramine, were antidepressants tilted the balance toward noradrenaline as the pertinent neurotransmitter, as these latter drugs were clearly inhibitors of noradrenergic rather than 5-HT uptake.

Possible involvement of dopaminergic mechanisms in the antimigraine action of flunarizine

Flunarizine, a calcium antagonist widely used in the prophylactic treatment of migraine, may interfere with dopaminergic systems. Flunarizine therapy can in fact induce extrapyramidal side effects and can increase basal as well as stimulated prolactin levels. To better define the mechanism of flunarizine action in migraine, we studied prolactin and growth hormone responses to thyrotropin releasing hormone and sulpiride in 13 female migraineurs before and after 60 days of flunarizine therapy. The treatment did not modify basal prolactin and growth hormone levels, but prolactin response to thyrotropin releasing hormone was enhanced. A paradoxical increase of growth hormone to thyrotropin releasing hormone observed before therapy was blunted after flunarizine treatment. These data indicate a modulatory action of flunarizine on dopaminergic systems which might to some extent explain the antimigraine action of this drug.

The psychopharmacological era: notes toward a history

Cultural and economic influences on the psychopharmacological era are reviewed, in an attempt to bring into focus what has been happening in psychopharmacology for the past thirty years. It is argued that the belief that clinical advances are made through the heroic achievements of disinterested scientists is a simplistic view that may militate against future significant discoveries. Such discoveries, it is argued, still come about for the most part serendipitously, despite a widespread belief that psychopharmacology has become a rational science.

Clinical neuropharmacology of calcium antagonists

Experimental and clinical data clearly demonstrate that calcium antagonists (CA) may have an action on the central nervous system (CNS). The cerebrovascular action of CA justifies their use in cerebral ischaemia, vasospasm and hypoxia. Several clinical trials have demonstrated such beneficial effects. On the other hand a number of reports indicate that CA may have a direct neuronal effect, although most of such trials have not been verified or are mere case reports. In addition, the large number of conditions susceptible to being corrected by CA is impressive: epilepsy, pain, dystonia, dyskinesia, psychiatric conditions, etc. Other papers are disconcerting that report extrapyramidal disorders induced by flunarizine and cinnarizine in the elderly, whereas nicardipine does not produce such side effects and may even alleviate some parkinsonian symptoms. In various experimental models (e.g. stroke, oedema), pharmacological effects have been shown to vary from one compound to the other. Two main questions are yet to be answered: 1) has the direct neuronal effect of CA been clearly established? 2) are the multiple clinical effects on the CNS really linked to calcium antagonism?

Pharmacotherapy of schizophrenia

Numerous advances in our understanding of schizophrenia and its pharmacotherapy have occurred over the last forty years, reflected in basic research endeavours exploring the pathophysiology of schizophrenia, as well as efforts to establish new medications with a more selective psychotropic action and fewer side effects. Ongoing clinical research has, at the same time, provided valuable information regarding the applicability of the various agents, appropriate dosing, symptom response patterns and side effect profiles. This growth in knowledge also has served to underscore the limitations and drawbacks of currently available drugs, leading to a more cautious approach in their use. Newer technologies, such as positron emission tomography, hold considerable promise in our efforts to further clarify the precise mechanisms mediating schizophrenia, and to establish treatment alternatives.