Weight changes during treatment with olanzapine in older adult patients with dementia and behavioral disturbances

Efficacy and Safety of Brexpiprazole for the Treatment of Agitation in Alzheimer's Dementia: Two 12-Week, Randomized, Double-Blind, Placebo-Controlled Trials

OBJECTIVE

To assess the efficacy, safety, and tolerability of brexpiprazole in patients with agitation in Alzheimer's dementia (AAD).

DESIGN

Two 12-week, randomized, double-blind, placebo-controlled, parallel-arm studies (NCT01862640; NCT01922258).

SETTING

Study 1: 81 sites in 7 countries. Study 2: 62 sites in 9 countries.

PARTICIPANTS

Patients with AAD (Study 1: 433 randomized; Study 2: 270 randomized) in a care facility or community-based setting. Stable Alzheimer disease medications were permitted.

INTERVENTION

Study 1 (fixed dose): brexpiprazole 2 mg/day, brexpiprazole 1 mg/day, or placebo (1:1:1) for 12 weeks. Study 2 (flexible dose): brexpiprazole 0.5-2 mg/day or placebo (1:1) for 12 weeks.

MEASUREMENTS

Cohen-Mansfield Agitation Inventory (CMAI) (Total score range: 29-203; higher scores indicate more frequent agitated behaviors), and Clinical Global Impression - Severity of illness (CGI-S) as related to agitation. Safety was also assessed.

RESULTS

In Study 1, brexpiprazole 2 mg/day demonstrated statistically significantly greater improvement in CMAI Total score from baseline to Week 12 than placebo (adjusted mean difference, -3.77; confidence limits, -7.38, -0.17; t₍₃₁₆₎ = -2.06; p = 0.040; MMRM). Brexpiprazole 1 mg/day did not show meaningful separation from placebo (0.23; -3.40, 3.86; t₍₃₁₄₎ = 0.12; p = 0.90; MMRM). In Study 2, brexpiprazole 0.5-2 mg/day did not achieve statistical superiority over placebo (-2.34; -5.49, 0.82; t₍₂₃₀₎ = -1.46; p = 0.15; MMRM). However, a benefit was observed in post hoc analyses among patients titrated to the maximum brexpiprazole dose of 2 mg/day compared with similarly titrated placebo patients (-5.06; -8.99, -1.13; t₍₁₄₄₎ = -2.54; p = 0.012; MMRM). On the CGI-S, a greater numerical improvement than placebo was demonstrated for brexpiprazole 2 mg/day in Study 1 (-0.16; -0.39, 0.06; t₍₃₃₇₎ = -1.42; nominal p = 0.16; MMRM), and a greater improvement for brexpiprazole 0.5-2 mg/day in Study 2 (-0.31; -0.55, -0.06; t₍₂₂₂₎ = -2.42; nominal p = 0.016; MMRM). In Study 1, treatment-emergent adverse events (TEAEs) with incidence ≥5% among patients receiving brexpiprazole 2 mg/day were headache (9.3% versus 8.1% with placebo), insomnia (5.7% versus 4.4%), dizziness (5.7% versus 3.0%), and urinary tract infection (5.0% versus 1.5%). In Study 2, TEAEs with incidence ≥5% among patients receiving brexpiprazole 0.5-2 mg/day were headache (7.6% versus 12.4% with placebo) and somnolence (6.1% versus 3.6%). In both studies, the majority of TEAEs were mild or moderate in severity.

CONCLUSIONS

Brexpiprazole 2 mg/day has the potential to be efficacious, safe, and well tolerated in the treatment of AAD.

Atypical antipsychotic-induced metabolic disturbances in the elderly

The metabolic side effects of atypical antipsychotics (AAPs) have been widely studied in younger populations, but research investigating these sequelae in the elderly is lacking. This article reviews the available literature examining the use of AAPs in the elderly, evaluating their association with weight gain and changes in blood glucose and lipid parameters. We find a relative paucity of studies in this area; while some data highlight significant, collective changes in metabolic parameters, the majority suggests an apparent low vulnerability to these side effects. We conclude that the risk and clinical implications of unfavorable metabolic changes in the elderly being treated with AAP medications remain largely undetermined, and we caution against drawing firm conclusions based on the available data. The conflicting evidence leaves us recommending that metabolic monitoring be implemented, with regular follow-up as advocated in other populations.

A systematic review of metabolic side effects related to the use of antipsychotic drugs in dementia

BACKGROUND

In clinical practice, Second Generation Antipsychotics (SGAs) are often used as first-line treatment for the Behavioral and Psychological Symptoms of Dementia (BPSD) in older adults due to their fewer neurological adverse events and similar effectiveness compared with First Generation Antipsychotics (FGAs). SGAs, however, are associated with more severe metabolic side effects (weight gain, hyperglycemia, diabetes risk, and hyperlipidemia) than FGAs are. In general, older patients, especially those affected by dementia, are at increased risk for malnutrition, and tend to have lower basal metabolism and reduced liver and kidney function. However, little is known about the metabolic side effects of antipsychotic drugs in this population.

METHODS

A comprehensive review of the literature published between January 1996 and December 2012 investigating the metabolic side effects related to FGAs and SGAs use in old patients affected by dementia.

RESULTS

Antipsychotic drugs currently used to treat BPSD in subjects with mild to moderate dementia are associated with weight gain. Currently, there are insufficient data to support a causal relationship between the use of FGAs and SGAs and changes in glucose homeostasis or lipid metabolism in older persons affected by severe dementia (MMSE <14).

CONCLUSION

A possible association between antipsychotic drugs use and weight gain might exist, in particular in subjects with mild to moderate dementia whereas no significant effects are demonstrated regarding glucose homeostasis and lipid metabolism. The antipsychotic drugs potential for causing metabolic abnormalities in older patients requires further specifically designed studies. Clinicians must be aware of this possibility even if the shorter periods of treatment administered in late-life might not be as harmful as it is in younger individuals.

The elderly safety imperative and antipsychotic usage

Behavioral and psychotic symptoms are common problems in older adults, and as the population ages, understanding the benefits and risks of antipsychotic usage is increasingly important. In this age group, psychotic symptoms may occur in patients with dementia or as part of schizophrenia, mood disorders, delirium, or delusional disorder. Various antipsychotics have been studied in older adults with psychotic symptoms, demonstrating mixed, but real, benefit, especially in relation to carefully selected patients. Caution is required because of the potential side effects and risks, which include increased mortality and cardiovascular and cerebrovascular events. This article reviews the use of antipsychotics in older adults, with emphasis on the risks and side effects, particularly in dementia patients with behavioral and psychotic symptoms.