Effects of atypical antipsychotic drugs on QT interval in patients with mental disorders

Brexpiprazole toxicity in a paediatric patient

Brexpiprazole is a relatively new drug that has no published research or applications within the paediatric population. Brexpiprazole targets multiple receptors and can manifest as multisystem symptoms when ingested in supratherapeutic quantities. In this report, we discuss the case of a child in early childhood who presented with delayed neurological and cardiac symptoms 24 hours after accidental ingestion of brexpiprazole. Due to delayed onset, this case highlights that a high index of suspicion and prolonged observation are necessary to appropriately manage brexpiprazole overdose or accidental ingestion.

Incidences, risk factors, and clinical correlates of severe QT prolongation after the use of quetiapine or haloperidol

BACKGROUND

Case reports suggest that quetiapine or haloperidol use is associated with severe QT prolongation (SQTP) and torsades de pointes.

OBJECTIVE

The purpose of this study was to examine the incidences, risk factors, and outcomes of SQTP in quetiapine and haloperidol users.

METHODS

This study accessed electronic medical records from a multicenter health-care hospital system in Taiwan and included patients who received quetiapine or haloperidol therapy and had both baseline and follow-up electrocardiograms. SQTP was defined as a posttreatment corrected QT (QTc) interval exceeding 500 ms or an increase in QTc interval of >60 ms compared with the baseline value. We analyzed the risk factors and outcomes of SQTP using multivariate logistic regression.

RESULTS

Mean increases in QTc interval were +8.3 ± 51.8 and +8.9 ± 44.0 ms after the administration of quetiapine (n = 8832) and haloperidol (n = 2341). Among these users, 1149 (13.0%) and 333 (14.2%) developed SQTP, respectively. Common risk factors for SQTP included old age, heart failure, hypokalemia, amiodarone use, and baseline QTc interval. SQTP in quetiapine users was significantly associated with ventricular arrhythmias (odds ratio 2.84; 95% confidence interval 1.95-4.13) and sudden cardiac death (odds ratio 2.29; 95% confidence interval 1.44-3.66).

CONCLUSION

More than 10% of patients receiving quetiapine or haloperidol therapy developed SQTP, and many of them were exposed to risk factors for SQTP. SQTP in quetiapine users was significantly associated with increased risks of ventricular arrhythmias and sudden cardiac death. Clinicians should be vigilant for ventricular arrhythmias in quetiapine users who have risk factors for SQTP.

Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms

BACKGROUND

Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk.

METHODS

Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias.

RESULTS

Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed.

CONCLUSIONS

Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias.

AIMS

This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.

Myocarditis in patients on long-term antipsychotics -mechanism, management and recent updates

Objective

Clozapine is the first atypical antipsychotic drug and was frequently cited as the most effective antipsychotic for treatment-resistant schizophrenia, but it is associated with a concert of significant cardiotoxic side effects. Clozapine-induced Myocarditis (CIM) is diagnosed based on the combination of clinical symptoms, laboratory investigations, radiological findings, and sometimes biopsy. The literature on CIM management and clinical consensus on the best course of action is mixed.

Methodology

An all-language literature search on Medline, Cochrane, Embase, and Google Scholar until April 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "CIM," "clozapine," "cardiotoxicity," and "myocarditis." We explored the literature on CIM for its pathophysiology, diagnosis, monitoring, and management.

Results

The clinical features of CIM may be highly variable, ranging from asymptomatic disease to fulminant heart failure, and cessation of medication was the mainstay treatment of CIM, followed by supportive therapy. Other antipsychotics have also been linked with cardiotoxic side effects.

Conclusion

Despite being the most effective antipsychotic, clozapine is associated with a cardiotoxic side effect. Current literature suggests that these antipsychotic-related cardiotoxic events impact the treatment selection for schizophrenia and other psychotic disorders, and they must be kept in mind while designing new treatment protocols in the future.

Sudden unexplained death in schizophrenia patients: An autopsy-based comparative study from China

Explainable sudden deaths in schizophrenia patients due to both cardiac (SCD) and non-cardiac causes (SNCD) have been extensively documented. However, sudden unexplained death (SUD) in this cohort remains to be elucidated. This study retrospectively analyzed 18 SUD cases that underwent systematic autopsy at our institutes during the period 2010-2022. The etiological, demographic, and autopsy features of the SUD cases were then compared with 37 year-matched sudden explainable deaths (23 SCD cases and 14 SNCD cases). Our results showed that the average age of the SUD was 39.0 ( ± 8.4) years, with the disease duration of 11.8 ( ± 8.1) years and a male/female ratio of 11:7. Most cases occurred during daytime (72.2%) and outside of hospital (77.8%). A large proportion of the SUD cases (77.8%) had persistent psychiatric episodes before death. Clozapine was found to be the most commonly used antipsychotic (33.3%), followed by Olanzapine (27.8%), Risperidone (27.8%) and Chlorpromazine (27.8%) in the SUD cases. When compared among groups, the SUD cases showed significantly younger ages (p = 0.035), lower heart weight (p = 0.004) and lower proportion of Clozapine use (p = 0.045). The presence of persistent psychiatric episodes was significantly higher in the SUD group than in any explainable deaths (p = 0.018) and was an independent risk factor for SUD (OR = 4.205, p = 0.040). This is the first autopsy-based study of SUD cases from China. We conclude that a stable mental state maintained by antipsychotics (i.e., Clozapine) is vital to schizophrenia patients.

Effects of adjunctive pimavanserin and current antipsychotic treatment on QT interval prolongation in patients with schizophrenia

Background

Pimavanserin prolongs the QT interval, with mean increases in corrected QT (QTc) of 5-8 ms, and is currently being investigated for the treatment of negative symptoms of schizophrenia.

Objectives

To assess QT interval prolongation in 3 studies investigating once-daily pimavanserin as an adjunct to current antipsychotic treatment in patients with schizophrenia.

Methods

Electrocardiograms were unblinded from trials in which pimavanserin or placebo was added to main antipsychotics over 6 weeks (ENHANCE), 26 weeks (ADVANCE), and up to 78 weeks (ongoing 52-week, open-label extension study [study 035]) of treatment. Antipsychotic treatment was permitted throughout these studies. The 3 most frequently used antipsychotic treatments were examined-aripiprazole (including long-acting injectable), risperidone (including long-acting injectable), and olanzapine. QT intervals were corrected (QTc) using Fridericia's method, with elevated risk defined as either postbaseline value maximum of >500 ms or change from baseline to postbaseline maximum of >60 ms.

Results

Of patients treated with adjunctive pimavanserin in ENHANCE, there were no postbaseline QTc values >481 ms; one patient in each of the risperidone and aripiprazole groups had change from baseline to postbaseline maximum >60 ms. More patients had change from baseline to postbaseline maximum ranging from 31 to 60 ms in the risperidone plus adjunctive placebo group (n = 5; 6.6%) than those in the risperidone plus adjunctive pimavanserin group (n = 3, 4.1%). In the pimavanserin plus antipsychotic group of ADVANCE, one patient had postbaseline QTc value >481 ms, and one patient treated with aripiprazole had change from baseline to postbaseline maximum of >60 ms. In study 035, a change from double-blind baseline to overall postbaseline maximum >60 ms occurred in one patient treated with aripiprazole and pimavanserin and in one patient treated with risperidone and pimavanserin. Similar proportions of patients had changes from double-blind baseline to post double-blind baseline maximum between 31 and 60 ms across treatments. No adverse events associated with an increase in the QTc interval were reported.

Conclusions

Adjunctive pimavanserin with background antipsychotic treatment showed no evidence of QTc prolongation >500 ms postbaseline, consistent with previously reports on QT prolongation with pimavanserin.

Prevalence and Management of Metabolic Syndrome in Adult Psychiatric Patients Receiving Second-Generation Antipsychotics at Sheikh Khalifa Medical City

Introduction The establishment of second-generation antipsychotics in the early 1900s has shown greater benefits in many outcome domains. As atypical antipsychotics revealed an improvement in the shortcomings of first-generation antipsychotics, they also have significant limitations in terms of side effects. Background As a class, atypical antipsychotics have a more satisfactory profile in terms of extrapyramidal side effects but have other side effects, including metabolic syndrome. Moreover, a patient with severe mental illness has reduced life expectancy compared to the general population and increased dying risk by two to three folds due to the associated risk of metabolic syndrome. Metabolic syndrome induced by second-generation antipsychotics requires routine monitoring, suitable intervention, and management, including lifestyle modification, caregiver education, and the use of other medications like lipid-lowering agents, anti-diabetics, and adjunctive therapies. Method This is a retrospective observational study that involves a review of medical records of adult patients attending the psychiatry outpatient clinics in Shaikh Khalifa Medical City to whom oral second-generation atypical antipsychotics were prescribed between January 2016 and December 2017. All pediatric patients were excluded, as well as those who are on other agents known to induce metabolic syndrome, including first-generation antipsychotics, mood stabilizers, anxiolytics, and anti-depressants. Besides, a patient who already developed metabolic syndrome before starting atypical antipsychotics was excluded as well. IBM SPSS v. 25 (IBM Corp., Armonk, NY) and Jamovi 1.0.4.0 (The jamovi project (2021). [Computer Software]. Retrieved from https://www.jamovi.org) were used for statistical analysis. The Shapiro-Wilk was used to test for normality of data, One-way repeated measure analysis of variance (ANOVA) was used to determine whether there are any statistically significant differences between the means of BMI across the three pre-specified time points, Kendall's tau was used to test the correlation between categorical variables, and the paired t-test was used to determine whether there was a statistically significant mean difference between BMI at baseline and after one year, a p-value above 0.05 is considered non-significant. Result A total of 123 patients were included in this study out of 4123 patients. An olanzapine disintegrating tablet was the most used atypical antipsychotic among the study population, followed by risperidone and quetiapine, respectively. Furthermore, BMI was statistically significantly increased from baseline to six months (M = 2.37 kg/m2, p = .002), and from baseline to 12 months (M =3.26 kg/m2, p < .001) but not from six months to 12 months (M =1.41 kg/m2, p = .346). Due to lack of documentation and monitoring, it was difficult to assess the continuous change in total cholesterol level/high-density lipoprotein, glucose, and HbA1C level. It was observed that nine (7.32%) patients of those who have been included in the study started a treatment to manage the metabolic syndrome. Conclusion Patients on second-generation antipsychotics must be monitored and treated in case of metabolic syndrome development to decrease the high risk of mortality in such patients. Documentation of such complications, patient treatment, and progress is essential for outcome improvement.

Mapping the Knowledge of Antipsychotics-Induced Sudden Cardiac Death: A Scientometric Analysis in CiteSpace and VOSviewer

The drugs on the market for schizophrenia are first-generation and second-generation antipsychotics. Some of the first-generation drugs have more side effects than the other drugs, so they are gradually no longer being applied clinically. Years of research have shown that the risk of sudden cardiac death in psychotic patients is associated with drug use, and antipsychotic drugs have certain cardiotoxicity and can induce arrhythmias. The mechanism of antipsychotic-induced sudden cardiac death is complicated. Highly cited papers are among the most commonly used indicators for measuring scientific excellence. This article presents a high-level analysis of highly cited papers using Web of Science core collection databases, scientometrics methods, and thematic clusters. Temporal dynamics of focus topics are identified using a collaborative network (author, institution, thematic clusters, and temporal dynamics of focus topics are identified), keyword co-occurrence analysis, co-citation clustering, and keyword evolution. The primary purpose of this study is to discuss the visual results, summarize the research progress, and predict the future research trends by bibliometric methods of CiteSpace and VOSviewer. This study showed that a research hotspot is that the mechanisms of cardiotoxicity, the safety monitoring, and the assessment of the risk-benefit during clinical use of some newer antipsychotics, clozapine and olanzapine. We discussed relevant key articles briefly and provided ideas for future research directions for more researchers to conduct related research.

Antipsychotics cardiotoxicity: What's known and what's next

Chronic use of antipsychotic medications entails a dilemma between the benefit of alleviating psychotic symptoms and the risk of troubling, sometimes life-shortening adverse effects. Antipsychotic-induced cardiotoxicity is one of the most life-threatening adverse effects that raises widespread concerns. These cardiotoxic effects range from arrhythmia to heart failure in the clinic, with myocarditis/cardiomyopathy, ischemic injuries, and unexplained cardiac lesions as the pathological bases. Multiple mechanisms have been proposed to underlie antipsychotic cardiotoxicity. This review aims to summarize the clinical signs and pathological changes of antipsychotic cardiotoxicity and introduce recent progress in understanding the underlying mechanisms at both the subcellular organelle level and the molecular level. We also provide an up-to-date perspective on future clinical monitoring and therapeutic strategies for antipsychotic cardiotoxicity. We propose that third-generation antipsychotics or drug adjuvant therapy, such as cannabinoid receptor modulators that confer dual benefits — i.e., alleviating cardiotoxicity and improving metabolic disorders — deserve further clinical evaluation and marketing.

Differential diagnosis and comorbid physical illness of schizophrenia

Background: Schizophrenia is a neurodevelopmental disorder that generally develops during adolescence or early adulthood. However, differentiating it from psychosis caused by a physical illness is difficult due to the phenotypebased diagnostic system. In this review, differential diagnosis of schizophrenia and the comorbid physical illnesses of patients with schizophrenia will be discussed.Current Concepts: Psychotic symptoms can be caused by various physical illnesses, and patients with schizophrenia have many physical comorbidities. Symptoms of psychosis can also be expressed by physical illness including brain tumors, encephalitis, temporal lobe epilepsy, autoimmune disease, and genetic disease. For the differential diagnosis of other physical illnesses that can cause psychosis, biological tests are essential. Depending on the cause, antipsychotics and treatment of physical diseases are required. In addition, patients with schizophrenia have many comorbid medical conditions such as obesity, diabetes, cardiovascular disease, but the diagnosis rate is low, and the mortality is higher than that of the general population due to untreated medical diseases.Discussion and Conclusion: The differential diagnoses of schizophrenia and physical illness causing psychosis are important. To decrease the high mortality of patients with schizophrenia, periodic physical condition examinations and mental status examinations should be conducted.

Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review

Many critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.

Delirium in the NICU: Risk or Reality?

Delirium is a frequent complication of critical illness in adult and pediatric populations and is associated with significant morbidity and mortality. Little is known about the incidence, risk, symptoms, or treatment of delirium in the NICU. Only 4 cases of NICU delirium have been reported, but many pediatric studies include infants. The Cornell Assessment of Pediatric Delirium tool has been validated in neonatal and infant populations for identification of delirium. Initial treatment should focus on identification and reversal of the cause, with pharmacologic management reserved for patients with symptoms that do not resolve or that significantly impact medical care. Routine use of intravenous haloperidol should be avoided because of the high incidence of serious adverse effects, but it may be considered in patients with significant symptoms who are unable to take oral medications. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) appear to be efficacious with a low incidence of adverse effects. Risperidone has weight-based dosing and a liquid dosage form available, making it a good option for use in the NICU. Additional data from large cohorts of NICU patients routinely screened for delirium, and treated as indicated, are needed.

QTc Interval Prolongation with Therapies Used to Treat Patients with Parkinson's Disease Psychosis: A Narrative Review

In addition to the classic motor symptoms of Parkinson's disease (PD), people with PD frequently experience nonmotor symptoms that can include autonomic dysfunction and neuropsychiatric symptoms such as PD psychosis (PDP). Common patient characteristics, including older age, use of multiple medications, and arrhythmias, are associated with increased risk of corrected QT interval (QTc) prolongation, and treatments for PDP (antipsychotics, dementia medications) may further increase this risk. This review evaluates how medications used to treat PDP affect QTc interval from literature indexed in the PubMed and Embase databases. Although not indicated for the treatment of psychosis, dementia therapies such as donepezil, rivastigmine, memantine, and galantamine are often used with or without antipsychotics and have minimal effects on QTc interval. Among the antipsychotics, data suggesting clinically meaningful QTc interval prolongation are limited. However, many antipsychotics have other safety concerns. Aripiprazole, olanzapine, and risperidone negatively affect motor function and are not recommended for PDP. Quetiapine is often sedating, can exacerbate underlying neurogenic orthostatic hypotension, and may prolong the QTc interval. Pimavanserin was approved by the US Food and Drug Administration (FDA) in 2016 and remains the only FDA-approved medication available to treat hallucinations and delusions associated with PDP. However, pimavanserin can increase QTc interval by approximately 5-8 ms. The potential for QTc prolongation should be considered in patients with symptomatic cardiac arrhythmias and those receiving QT-prolonging medications. In choosing a medication to treat PDP, expected efficacy must be balanced with potential safety concerns for individual patients.

Effects of Antipsychotics on Arrhythmogenic Parameters in Schizophrenia Patients: Beyond Corrected QT Interval

PURPOSE

Antipsychotic drugs have been implicated as risk factors for QT prolongation, which is a predictor of sudden cardiac death. However, the QT interval is considered an imperfect marker for proarrhythmic risk. Recently, improved methods, namely, QT dispersion (QTD), QTD ratio (QTDR), T wave peak-to-end interval (Tp-e), Tp-e/QT ratio and Tp-e/QTc ratio, have been regarded as proarrhythmic risk markers. We attempted to reevaluate the risk of sudden cardiac death due to antipsychotics use by measuring these improved evaluation methods.

PATIENTS AND METHODS

We retrospectively evaluated QTc, QTD, QTDR, Tp-e, Tp-e/QT ratio and Tp-e/QTc ratio from the medical records of 410 patients with schizophrenia diagnosed by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, or 5th Edition. Information on drugs administered was obtained from medical records. We investigated the correlation between each index on ECG and medication, such as antipsychotics, prescribed to participants with linear regression analysis. We also compared each index between 235 healthy controls and 235 patients matched for age and sex.

RESULTS

Positive correlations between QTc and levomepromazine and brexpiprazole were identified. Levomepromazine and lithium were positively correlated with QTD. Levomepromazine, quetiapine, asenapine, clozapine and carbamazepine were positively correlated with QTDR. Levomepromazine, olanzapine, brexpiprazole and lithium were positively correlated with Tp-e. Olanzapine, brexpiprazole and lithium were positively correlated with the Tp-e/QT ratio. Olanzapine, brexpiprazole and lithium were positively correlated with Tp-e/QTc ratio. Significant differences in all indexes were noted between the patients and healthy controls.

CONCLUSION

According to our results, the prediction of the risk of sudden cardiac death by each index was inconsistent. We should evaluate the predictive factor of ventricular arrhythmia according to various electrocardiogram indexes because QTc alone could not identify the risk of sudden cardiac death.

The Prevalence, Risk Factors and Clinical Correlates of QTc Prolongation in Chinese Hospitalized Patients With Chronic Schizophrenia

Background: The QTc interval may be significantly prolonged in schizophrenia patients taking antipsychotics. Few studies have addressed QTc prolongation (QTP) in Chinese patients. Objectives: This study was designed to evaluate the prevalence of QTP and its clinical correlates in Chinese hospitalized patients with chronic schizophrenia. Methods: A total of 436 inpatients and 291 normal controls matched with age and sex were included. QTc prolongation was defined as 2 standard deviations (SD) above the mean value of normal controls. Positive and Negative Syndrome Scale (PANSS) and its five-factor model were used to evaluate psychopathological symptoms. Results: QTc interval was significantly longer in patients than in normal controls. The prevalence of QTP is 8.26% in Chinese hospitalized patients with chronic schizophrenia. More women than men displayed QTP. Compared with patients without QTP, the patients with QTP had significantly higher concrete/disorganized subscore, lower low density lipoprotein (LDL) and lower total protein (TP). Furthermore, binary logistic regression analysis showed that higher number of hospitalizations, higher concrete/disorganized subscore and lower LDL were risk factors for QTP. Correlation analysis indicated significant association between QTc interval and the following variables: sex, age, duration of illness, the number of hospitalizations, PANSS total score, fasting blood glucose (FPG). Finally, a multiple regression analysis showed that older age, antipsychotic polypharmacy, higher PANSS total score, and lower LDL were risk factors for QTP. Among them, LDL seemed to be a protective factor for QTP. Conclusions: QTc interval was longer in schizophrenia patients than in normal controls. The prevalence of QTP is 8.26% in Chinese hospitalized patients with chronic schizophrenia. Some clinical characteristics were risk factors for QTP. And LDL seemed to be a protective factor for QTP.

How Can Drug Metabolism and Transporter Genetics Inform Psychotropic Prescribing?

Many genetic variants in drug metabolizing enzymes and transporters have been shown to be relevant for treating psychiatric disorders. Associations are strong enough to feature on drug labels and for prescribing guidelines based on such data. A range of commercial tests are available; however, there is variability in included genetic variants, methodology, and interpretation. We herein provide relevant background for understanding clinical associations with specific variants, other factors that are relevant to consider when interpreting such data (such as age, gender, drug-drug interactions), and summarize the data relevant to clinical utility of pharmacogenetic testing in psychiatry and the available prescribing guidelines. We also highlight areas for future research focus in this field.

Quetiapine and other antipsychotics combined with opioids in legal autopsy cases: A random finding or cause of fatal outcome?

Opioid poisoning is a frequent cause of death in drug addicts and occurs with opioid treatment. Quetiapine is often found in forensic autopsies and may increase the risk of fatal opioid poisoning by enhancing sedation, respiratory depression, hypotension and QT prolongation. We systematically searched for studies of acute toxicity of quetiapine or other antipsychotics combined with morphine or methadone. Case reports describing toxicity of quetiapine combined with morphine or methadone were also included. We retrieved one human study that observed pharmacokinetic interaction between quetiapine and methadone, and 16 other human studies. Fourteen investigated the combination of droperidol and morphine in treatment doses, and some indicated an additive sedative effect. Five animal studies with acepromazine in combination with morphine or methadone were located and indicated an additive effect on sedation and hypotension. Six forensic case reports in which death could have been caused solely by quetiapine, the opioid, or other drugs were found. Thus, acute toxicity of quetiapine combined with morphine or methadone has not been studied. Because of quetiapine's effects on alpha-adrenoceptors, muscarinic and histamine receptors, human ether-a-go-go-channels and methadone kinetics, we suggest further research to clarify if the indicated additive effects of opioids and droperidol or acepromazine are also true for quetiapine.

The Benefits of Olanzapine in Palliating Symptoms

OPINION STATEMENT

Olanzapine has become a major drug in the management of chemotherapy-induced nausea and vomiting as a prophylactic agent. In addition, a recent randomized trial has demonstrated its benefits in treating nausea and vomiting associated with advanced cancer. The added benefit to olanzapine is that it also stimulates appetite. As a result, since it treats multiple symptoms associated with advanced cancer, it is likely to become the antiemetic of choice in palliative care at least in the USA. The added benefit of treating insomnia and the avoidance of benzodiazepines should place olanzapine in at the top of the list of drugs to use for patients who do complain of insomnia. There is no good evidence that it potentiates the respiratory depression of opioids unlike benzodiazepines. The evidence is weak that olanzapine in as an adjuvant analgesic. Hopefully, future trials will explore this in greater depth. The benefits of adding olanzapine to potent opioids are that it may reduce craving, drug cues, and opioid misuse. Other symptoms like anxiety and depression may be addressed by the addition of olanzapine to standard antidepressants.

The characteristic of cognitive impairments in patients with bipolar II depression and its association with N-acetyl aspartate of the prefrontal white matter

Background

Cognitive deficit is acknowledged as a core feature of clinical manifestations of bipolar disorder (BD). However, the underlying mechanism of cognitive impairment in bipolar II depression has remained uncertain. We aim to determine the association of cognitive impairments with biochemical metabolism using proton magnetic resonance spectroscopy (¹H-MRS) and a battery of neuropsychological testing.

Methods

The current study was designed to assess four cognitive domains in a sample of 110 patients with bipolar II depression and 110 healthy controls, using a battery of 6 cognitive tests, including the Digit Symbol Substitution Test (DSST), Wisconsin Cart Sorting Test (WCST), Trail Making Test Part B (TMT-B), Digit Span Test (DST), TMT-part A (TMT-A) and Verbal Fluency Test (VFT). Metabolite levels were obtained in the following brain regions of interest: bilateral prefrontal white matter (PWM), bilateral anterior cingulate cortex (ACC), bilateral lenticular nucleus (LN), and bilateral thalamus. N-acetyl aspartate (NAA)/creatine (Cr) and choline-containing compounds (Cho)/Cr ratios are analyzed.

Results

Patients with bipolar II depression performed significantly worse on DSST (score), TMT (completion time), DSB (score), and VFT (valid word number) when compared with healthy controls. In the bilateral PWM, NAA/Cr ratios in the PWM were significantly reduced (bilaterally) than those in healthy controls. Correlation analysis was conducted with data from patients with bipolar II depression, we found that the NAA/Cr ratio of the left PWM was positively correlated with the score of DS and DSB, and the NAA/Cr ratio of the right PWM was negatively correlated with the completion time of TMT-B.

Conclusions

Our findings suggested that psychomotor speed, executive function, working memory, and verbal fluency are impaired in patients with BD II depression. Hypoactivity NAA/Cr in bilateral PWM may be associated with BD II depression's pathophysiology and results in cognitive dysfunction.

Aberrant amplitude low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) in generalized anxiety disorder (GAD) and their roles in predicting treatment remission

Background

Generalized anxiety disorder (GAD) is a common affective disorder characterized by comprehensive anxiety with dysregulation of brain activity which can be reflected by functional magnetic resonance imaging (f-MRI). We aimed to examine abnormal aberrant amplitude low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) in GAD and evaluate their ability to predict treatment remission.

Methods

Using resting-state fMRI (Rs-fMRI), we examined ALFF and ReHo in 30 GAD patients and 30 healthy control (HC) participants. Using on DEPASF4.3 Advanced Edition, voxel-based two-sample t-test analysis was performed on the ALFF and ReHo maps to compare GAD to HC groups, and to compare remitters (n=9) and non-remitters (n=21). Pearson's correlation analysis was used to explore the relationship between baseline Hamilton Anxiety Rating Scale (HAM-A) scores/illness duration and mean ALFF/ReHo values. The severity of GAD symptoms was rated with HAM-A. Remission was defined as HAM-A ≤7 by week 8.

Results

Compared to the HC group, GAD patients showed lower ALFF in the right postcentral and right precentral gyrus; lower ReHo in the right precentral, right postcentral, and left precentral gyrus; and higher ReHo in the left posterior cingulate cortex. ALFF values for left postcentral gyrus was negatively correlated with baseline HAM-A, while that of the middle frontal gyrus was positively correlated with baseline HAM-A scores. ReHo value of the left postcentral gyrus was negatively correlated with baseline HAM-A, while that of the right middle frontal gyrus was positively correlated with baseline HAM-A scores. ALFF of the right frontal_superior_orbital and right frontal-medial-orbital cortex was positively correlated with illness duration. ReHo of the left supplementary motor area cortex was negatively correlated with illness duration. Remitters showed higher ALFF in the left hippocampus and higher ReHo value in the right postcentral cortex compared to nonremitters.

Conclusions

These results suggest that altered regional brain activity and local synchronization may be related to the pathophysiology of GAD and have certain value in predicting remission in treatment.

Up-to-date expert opinion on the safety of recently developed antipsychotics

Introduction There are several new and emerging antipsychotic medication strategies recently marketed or under clinical development for the treatment of several mental disorders. There is the need to provide an up-to-date overview on the safety of this new generation of antipsychotic medications, which includes also the third-generation antipsychotics (TGA). Areas covered The authors aimed at providing a synthesis of the most current evidence about the safety profile of the recently developed and/or marketed antipsychotics. Qualitative synthesis followed an electronic search made inquiring of the following databases: MEDLINE, Embase, PsycINFO, and the Cochrane Library from inception until March 2020, combining free terms and MESH headings for the topics of TGA and recently developed and/or marketed antipsychotics as following: ((safety OR adverse events OR side effects) AND ((brexpiprazole OR cariprazine OR inhaled loxapine OR lumateperone (ITI-007) OR lurasidone OR pimavanserin OR roluperidone (MIN-101) OR transdermal patch asenapine)). Expert opinion Overall, newer antipsychotics display a good safety profile, with a well-demonstrated lower metabolic liability compared to second-generation antipsychotics. Furthermore, TGA appear to specifically target negative symptomatology and improving cognitive domains. Abbreviations Aps=Antipsychotic Drugs; AEs = Adverse Effects; EPS = Extrapyramidal Symptoms; NMS = Neuroleptic malignant syndrome; D = Dopamine; K_i = Inhibitory Constant; 5-HT = Serotonin; ECG = Electrocardiogram; H = Histamine; M = Muscarinic; BMI = Body Mass Index.

Brexpiprazole in the treatment of schizophrenia and agitation in Alzheimer's disease

Schizophrenia is a disabling psychiatric disorder marked by progressive loss of functionality in activities of daily living with each relapse. Antipsychotics, the mainstay of therapy for schizophrenia, treat hallucinations and delusions but may have intolerable side effects, including metabolic disturbances and extrapyramidal symptoms. Brexpiprazole, a second-generation antipsychotic with dopamine partial agonist properties, was approved by the US FDA in 2015 for the treatment of schizophrenia and adjunctive treatment of major depressive disorder and by the EU in 2018 for adults with schizophrenia. Additionally, brexpiprazole has recently been studied for the treatment of agitation in Alzheimer's dementia, an area of largely unmet need. Overall, well-tolerated brexpiprazole expands the armamentarium of treatment options available for these conditions.

Methylation of the MAOA promoter is associated with schizophrenia

Background

Earlier studies have shown that patients with schizophrenia have abnormalities in DNA methylation. Monoamine oxidase A (MAOA) has been extensively studied due to its biological role in neurological function. However, the relationship between the DNA methylation of the MAOA gene and schizophrenia is unclear. This study aims to elucidate the relationship between the methylation of the MAOA gene promoter and schizophrenia.

Methods

There were 151 individuals with schizophrenia (104 males and 47 females), which were diagnosed according to DSM-V, the DNA of peripheral blood of all samples was extracted and chemically modified with bisulfite. The promoter region of MAOA gene was sequenced by Methylation Target Technical Method (MethylTargetTM), and 247 controls (204 males and 43 females) included in the study. MAOA gene promoter methylation was compared between the case and control groups. Meanwhile, we measured DNA methylation in two regions of MAOA (MAOA-2 and MAOA-3).

Results

In the male schizophrenia group (BM) and the male control group (DM), MAOA-2 and MAOA-3 methylation were positively associated with schizophrenia. In the female schizophrenia group (BF) and the female control group (DF), MAOA-2 methylation was associated with schizophrenia.

Conclusions

Although the role of gene methylation in the development of schizophrenia is still unclear, our findings suggest that DNA methylation of MAOA may contribute to the onset of schizophrenia.

Combination of olanzapine and samidorphan has no clinically relevant effects on ECG parameters, including the QTc interval: Results from a phase 1 QT/QTc study

BACKGROUND

OLZ/SAM is a combination of olanzapine, an atypical antipsychotic, and samidorphan, an opioid antagonist, and is in development for the treatment of schizophrenia and bipolar I disorder. OLZ/SAM is under development with the intent to provide the established antipsychotic efficacy of olanzapine while mitigating olanzapine-associated weight gain. This thorough QT study assessed the effects of therapeutic and supratherapeutic doses of OLZ/SAM on cardiac repolarization in patients with schizophrenia.

METHODS

In this randomized, double-blind, placebo- and positive (moxifloxacin)-controlled, parallel-group study, 100 patients aged 18 to 60 years with stable schizophrenia were randomized 3:2 to the active arm and control arm. Subjects in the active arm received a therapeutic dose of 10/10 mg (10 mg olanzapine/10 mg samidorphan) on days 2-4, 20/20 mg on days 5-8, and a supratherapeutic dose of 30/30 mg (1.5 times and 3 times the maximum recommended daily dose of olanzapine and samidorphan, respectively) on days 9-13, and moxifloxacin-matched placebo on days 1 and 14. Subjects in the control arm received a single oral dose of moxifloxacin 400 mg and moxifloxacin-matched placebo on days 1 and 14 in a nested crossover fashion, along with OLZ/SAM-matched placebo on days 2-13. Serial electrocardiograms (ECGs) and simultaneous plasma drug concentrations were determined pre- and post-dose. The effects of OLZ/SAM on heart rate and ECG parameters (QT interval with Fridericia's correction [QTcF], PR and QRS interval, and T-wave morphology) were evaluated, and the primary endpoint was change from baseline in QTcF (ΔQTcF). The relationship between drug concentration and ΔQTcF (C-QTc) was evaluated using a linear mixed-effects model. Safety monitoring included adverse events reporting and clinical laboratory assessments.

RESULTS

Based on primary analysis using C-QTc modeling, no clinically concerning QTc effect (ie, placebo-corrected ΔQTcF [ΔΔQTcF] ≥10 msec) was observed across the OLZ/SAM dose range tested (10/10 to 30/30 mg), up to olanzapine and samidorphan concentrations of approximately 110 and 160 ng/mL, respectively. The slope (90% confidence interval [CI]) of the C-QTc relationship was shallow and not significant for either olanzapine or samidorphan (0.03 [-0.01, 0.08] and 0.01 [-0.01, 0.04] msec per ng/mL, respectively). The predicted ΔΔQTcF (90% CI) was 2.33 (-2.72, 7.38) and 1.38 (-3.37, 6.12) msec at the observed geometric mean maximal concentration (C_max) of olanzapine (62.6 ng/mL) and samidorphan (75.1 ng/mL) on day 13, respectively. The study's assay sensitivity was confirmed by the C-QTc relationship of moxifloxacin. OLZ/SAM was well tolerated at all doses; adverse events occurring in >5% of subjects treated with OLZ/SAM were somnolence, weight increased, nausea, and dizziness.

CONCLUSIONS

This thorough QT study in patients with stable schizophrenia demonstrated that OLZ/SAM, in doses and plasma concentrations up to supratherapeutic levels, does not have a clinically relevant effect on ECG parameters, including QT/QTc prolongation.

Efficacy and safety of brexpiprazole in acute management of psychiatric disorders: a meta-analysis of randomized controlled trials

Brexpiprazole is a new atypical antipsychotic for schizophrenia management and as adjunct in major depressive disorder (MDD). We searched randomized controlled trials (RCT) to review brexpiprazole efficacy and tolerability in acute management of schizophrenia and MDD using PubMed, EUDRACT, ClinicalTrials.gov and Cochrane Central Register of Controlled Trials. A meta-analysis was conducted using the identified 14 RCT to assess its efficacy using positive and negative syndrome scale (PANSS), clinical global impressions - severity of illness (CGI-S), personal and social performance scale (PSP), Montgomery-Åsberg depression rating scale (MADRS), Sheehan disability scale (SDS) and Hamilton depression rating scale (HDRS17). The mean difference comparing brexpiprazole and placebo were PANSS -4.48, CGI-S -0.23 and PSP 3.24 favoring brexpiprazole. Compared to aripiprazole and quetiapine, brexpiprazole showed similar efficacy. In MDD, brexpiprazole showed efficacy compared to placebo demonstrated by MADRS -1.25, SDS -0.37 and HDRS17 -1.28. Brexpiprazole was associated with side effects including akathisia risk ratio (RR) = 1.72; weight increase RR = 2.74 and somnolence RR = 1.87. Compared to 4 mg, brexpiprazole 2 mg was associated with less risk of akathisia and somnolence. Brexpiprazole demonstrated significant improvements in schizophrenia and MDD and is well-tolerated; however, associated with akathisia and somnolence. These findings will guide psychiatrists and pharmacists in their clinical role for supporting psychiatric patients care.

Cytochrome P450 (CYP450) Interactions Involving Atypical Antipsychotics are Common in Community-Dwelling Older Adults Treated for Behavioral and Psychological Symptoms of Dementia

Treatment of behavioral and psychological symptoms of dementia (BPSD) and comorbidities often necessitates the concomitant use of antipsychotics and non-antipsychotic drugs, thereby potentiating the risk for drug–drug interactions (DDIs). The primary objective of our study was to identify potentially clinically relevant cytochrome P450 (CYP)-mediated DDIs involving antipsychotics among participants enrolled in the Program of All-Inclusive Care for the Elderly (PACE) with BPSD. Additionally, we wanted to determine the prevalence of antipsychotic use in this population. The study included 10,001 PACE participants. The practice setting used a proprietary clinical decision support system (CDSS) to analyze simultaneous multidrug interactions. A retrospective analysis of pharmacy claims data was conducted to identify DDIs involving antipsychotics prescribed for BPSD, using snapshots of medication profiles paired with the CDSS. Of the participants who met inclusion criteria, 1190 (11.9%) were prescribed an antipsychotic; of those, 1071 (90.0%) were prescribed an atypical antipsychotic. Aripiprazole commonly caused (being a perpetrator drug 94.6% of the time) potential DDIs with antidepressants (e.g., duloxetine, venlafaxine, mirtazapine), opioids (e.g., hydrocodone, oxycodone, tramadol) and metoprolol via the CYP2D6 isoform. Risperidone commonly caused (85.7%) potential DDIs with donepezil, lamotrigine and trazodone via the CYP3A4 isoform. Quetiapine exclusively suffered (100%) from potential DDIs with amlodipine, buspirone, omeprazole or topiramate via the CYP3A4 isoform. Antipsychotics are commonly prescribed to PACE participants for BPSD treatment and they may interact with other drugs used to treat comorbidities. A thorough review of concomitant medications will help mitigate the likelihood of potentially dangerous CYP-mediated DDIs involving antipsychotics.

Antiemetic drugs: what to prescribe and when

Nausea and vomiting are common symptoms with many possible causes, including the adverse effects of drugs. If a drug is indicated, the cause guides the choice of antiemetic drug The main antiemetic classes include antagonists of the serotonin, dopamine, histamine, muscarinic and neurokinin systems, corticosteroids and benzodiazepines. Some antiemetics appear more effective for specific indications Serotonin and neurokinin antagonists, such as ondansetron and aprepitant, are highly effective in treating chemotherapy-induced nausea and vomiting. Metoclopramide and antihistamines are first-line options for nausea and vomiting in pregnancy Serotonin antagonists and some dopamine antagonists, such as metoclopramide, can prolong the QT interval on the ECG. Dopamine antagonists can cause extrapyramidal adverse effects, particularly in children

Effects of medications on ventricular repolarization in children with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a multifactorial neurodevelopmental disorder that manifests during childhood. Methylphenidate (MPH), which is a psychostimulant drug, has been often prescribed for the treatment of ADHD in patients. It may increase the risk of fatal arrhythmias by impairing ventricular repolarization. Indicators of ventricular repolarization in ECG are intervals of QT, corrected QT (QTc), QT dispersion (QTd), T-peak to T-end (Tp-e), and Tp-Te/QTc ratio. We aimed to determine ventricular repolarization findings before and after MPH drug therapy in children with ADHD. The study retrospectively examined the medical records of 33 children aged 6-15 years who received MPH for ADHD and who had a control ECG one month after medication. The ECG parameters, heart rate, intervals of QRS, QT, QTc, QTd, Tp-Te, and Tp-Te/QTc ratio, were compared for each patient before and after drug therapy. No significant change was observed in heart rate, QRS, QT, QTc, and QTd interval in ECGs of patients after treatment but pre and posttreatment mean Tp-Te interval was 73.4 ± 9.72 ms and 79.7 ± 10.48 ms, and mean Tp-Te/QTc ratio was 0.17 ± 0.024 and 0.18 ± 0.023, respectively (P = 0.015, P = 0.028). Tp-Te intervals and Tp-Te/QTc ratios remained within normal values after treatment with MPH, but values were higher than baseline.

QTc dispersion and interval changes in drug-free borderline personality disorder adolescents

Emotional instability and dysregulation represent a core feature of borderline personality disorder (BPD) and abnormal patterns of sympathetic/parasympathetic activity have been repeatedly investigated in individuals with this disorder. Such abnormalities may represent the substrate for an arrhythmogenic risk that could materialize the following specific drug exposure. In this work, we decided to assess basal-corrected QT interval and dispersion (QTc and QTcd) for estimating such risk in a sample of drug-free adolescents with diagnosis of BPD. In this cross-sectional comparative study, we recruited n = 70 female adolescent BPD (14.7 ± 1.3 years), free of medications, alcohol or recreational drugs. Furthermore, n = 70 matched female healthy controls (CTRL, 14.6 ± 1.5 years) were enrolled. QTc and QTcd were manually assessed on a standard 12-lead ECG by a single experienced investigator who was unaware of clinical outcomes. QTcd was increased by 7 ms on average in BPD vs. CTRL (+ 18%, p = 0.03). QTc was decreased by about 15 ms on average in BPD vs. CTRL (p = 0.003). A mild correlation was found between QTc and QTcd in BPD (r = 0.25, p = 0.03) that was not present in CTRL. No correlation was found between either QTc or QTcd, and age in both groups. Mildly increased QTcd characterizes the cardiac activity regardless of drug exposure in female adolescents with BPD. This information may be of value to clinicians striving to use neuroleptic and antidepressant drugs with a lower risk of QTcd increase.

Mortality risk following acute coronary syndrome among patients with schizophrenia: A meta-analysis

Patients with schizophrenia have a higher incidence of coronary artery disease. This meta-analysis was performed to evaluate the influence of a prior diagnosis of schizophrenia on mortality following acute coronary syndrome (ACS). Relevant longitudinal follow-up studies were obtained via systematic search of PubMed and Embase databases. A random effect model was used to perform the meta-analysis. This meta-analysis included 3,611,343 hospitalized patients with ACS from nine follow-up studies. The results show that, in patients with schizophrenia, ACS was associated with a significantly higher risk of mortality (multivariate adjusted risk ratio [RR]: 1.66, p < .001) with significant heterogeneity (I2 = 93%) compared to the results of mentally healthy patients. Subgroup analyses demonstrated that patients with schizophrenia were associated with higher ACS mortality within one month (RR: 1.68, p < .001) and during a follow-up period of ≥one year (RR: 1.71, p = .01), in studies with (RR: 1.65, p = .06) and without the adjustment of revascularization treatments (RR: 1.68, p = .004), as compared with the results of mentally healthy patients. These results indicate that patients with schizophrenia have a higher than expected mortality risk in the case of acute coronary events.

[Antipsychotic pharmacotherapy for delirious syndromes - only temporary, symptom-oriented and considering QTc time]

BACKGROUND

QTc prolongation is a common and serious side effect of antipsychotics in the treatment of delirium. Nevertheless, the occurrence of ventricular tachycardia is rarely reported, so that the clinical relevance of a QTc prolongation triggered in this way remains unclear.

METHOD

The focus of this review is on the antipsychotic pharmacotherapy of delirium.

RESULTS AND CONCLUSIONS

In individual cases, before the prescription of an antipsychotic due to a delirium, a risk-benefit assessment must be made for the patient. For this purpose, patient and substance-specific risk factors for QTc prolongation must be checked and, if possible, reduced. A specific recommendation for an antipsychotic with assured low QTc interference can not be given because all antipsychotics for delirium treatment are potentially QTc-prolonging. Antipsychotic delirium treatment should be monitored, especially in patients with a high risk profile, for QTc prolongation by regular ECG controls.

Practical Guidance on the Use of Lurasidone for the Treatment of Adults with Schizophrenia

Introduction

Lurasidone is an atypical antipsychotic that was approved in Europe in 2014 for the treatment of schizophrenia in adults aged ≥ 18 years. Clinical experience with lurasidone in Europe is currently limited, and there is therefore a need to provide practical guidance on using lurasidone for the treatment of adults with schizophrenia.

Methods

A panel of European psychiatrists with extensive experience of prescribing lurasidone was convened to provide recommendations on using lurasidone to treat adults with schizophrenia.

Results

Extensive evidence from clinical trials and the panel’s clinical experience suggest that lurasidone is as effective as other atypical agents, with the possible exception of clozapine. Lurasidone is associated with a lower propensity for metabolic side effects (in particular, weight gain) and hyperprolactinaemia than most other atypical antipsychotics and has a relatively benign neurocognitive side effect profile. Patients switching to lurasidone from another antipsychotic may experience weight reduction and/or improvements in the ability to focus/concentrate. Most side effects with lurasidone (such as somnolence) are transitory, easily managed and/or ameliorated by dose adjustment. Akathisia and extrapyramidal symptoms may occur in a minority of patients, but these can be managed effectively with dose adjustment, adjunctive therapy and/or psychosocial intervention.

Conclusions

Given the crucial importance of addressing the physical as well as mental healthcare needs of patients, lurasidone is a rational therapeutic choice for adults with schizophrenia, both in the acute setting and over the long term.

Funding

Sunovion Pharmaceuticals Europe Ltd.

Electronic supplementary material

The online version of this article (10.1007/s40120-019-0138-z) contains supplementary material, which is available to authorized users.