Schizophrenia relapse after stopping olanzapine treatment during pregnancy: a case report

Novel report on congenital talipes equinovarus (CTEV) following olanzapine exposure during pregnancy: case report and short review

Olanzapine is widely used during pregnancy to manage mood and psychotic disorders with overall beneficial effects. There have been past reports of olanzapine exposure during early pregnancy and clubfoot in two newborns from India and Israel. We report a woman in Nepal diagnosed with schizophrenia and treated with olanzapine throughout the pregnancy delivering a baby boy with congenital talipes equinovarus deformity. Like in many other low-income settings, pregnancy was unplanned, and pre-conception counselling was not done. Research in mice has revealed the negative effects of olanzapine on bone development. Further reports would strengthen this potential association between exposure to olanzapine in the first trimester and the occurrence of clubfoot in the baby.

Place of the partial dopamine receptor agonist aripiprazole in the management of schizophrenia in adults: a Delphi consensus study

BACKGROUND

Aripiprazole is a second-generation antipsychotic, efficacious in patients with schizophrenia during acute episodes. Due to its pharmacological profile, aripiprazole may be of interest in patients with specific clinical profiles who have not been studied extensively in randomised clinical trials.

OBJECTIVES

To capture experience with aripiprazole in everyday psychiatric practice using the Delphi method in order to inform decision-making on the use of aripiprazole for the treatment of patients with schizophrenia in clinical situations where robust evidence from clinical trials is lacking.

METHODS

The scope of the survey was defined as the management of schizophrenia in adults. A systematic literature review was performed to identify the different clinical situations in which aripiprazole has been studied, and to describe the level of clinical evidence. Clinical profiles to include in the Delphi survey were selected if there was a clear interest in terms of medical need but uncertainty over the efficacy of aripiprazole. For each clinical profile retained, five to seven specific statements were generated and included in a questionnaire. The final 41-item questionnaire was proposed to a panel of 406 French psychiatrists with experience in the treatment of schizophrenia. Panellists rated their level of agreement using a Likert scale. A second round of voting on eleven items was organised to clarify points for which a consensus was not obtained in the first round.

RESULTS

Five clinical profiles were identified in the literature review (persistent negative symptoms, pregnancy, cognitive dysfunction, addictive comorbidity and clozapine resistance). Sixty-two psychiatrists participated in the first round of the Delphi survey and 33 in the second round. A consensus was obtained for 11 out of 41 items in the first round and for 9/11 items in the second round. According to the panellists' clinical experience, aripiprazole can be used as maintenance treatment for pregnant women, is relevant to preserve cognitive function and can be considered an option in patients with a comorbid addictive disorder or with persistent negative symptoms.

CONCLUSION

These findings may help physicians in choosing relevant ways to use aripiprazole and highlight areas where more research is needed to widen the evidence base.

Long-acting injectable aripiprazole in pregnant women with schizophrenia: a case-series report

Antipsychotic long-acting formulations (LAI-AP) have emerged as a new therapeutic choice to treat patients presenting a severe mental disorder. Despite that, to date, there is a lack of safety data and studies regarding the use of LAI-AP formulations in pregnant women. Here we present the first six-case series of pregnant women with schizophrenia treated with aripiprazole-LAI reported in the literature. All patients remained psychopathologically stable through pregnancy and the postpartum period, and all of them were in treatment with aripiprazole-LAI. To date, all infants remain healthy with normal developmental milestones, without the presence of congenital malformations or adverse effects. Lack of information on safety data regarding the use of new antipsychotic formulations remains important in treating women with mental illness who desire to become pregnant. Further studies in this clinical population with a larger number of patients included remains necessary.

Antipsychotics in Postpartum Psychosis

BACKGROUND

Psychotic episodes in the postpartum period are life-threatening psychiatric emergencies, requiring urgent medical attention and admission to a psychiatric hospital.

AREAS OF UNCERTAINTY

Although the postpartum psychosis (PPP) is the most severe psychiatric disorder associated with parturition, there is little information about what interventions are most effective. Because there are no specific guidelines for the treatment of PPP, the aim of the present review was to examine the available evidence regarding the treatment of PPP.

DATA SOURCES

The PubMed database was searched based on the title and the abstract, using the key words "postpartum psychosis," "postpartum psychosis antipsychotics," "postpartum psychosis treatment," and "postpartum psychosis pharmacotherapy," for both interventional and observational, irrespective of language.

RESULTS

A number of 14 publications met the study criteria, including case reports and case series. The antipsychotics (APs) use included both first generation APs, such as haloperidol and chlorpromazine, and second generation APs, mainly, olanzapine, quetiapine, and risperidone. The most frequently used AP was olanzapine. Olanzapine and quetiapine seem to be the most acceptable during breastfeeding. Proposed treatment algorithms for the successful management of PPP are discussed.

CONCLUSIONS

The existing studies to date do not allow to draw a definitive conclusion regarding which treatment is the most effective or the most adequate. Existing evidence suggests that APs alone or in combination are responsible for sustained remission and that treated PPP has a higher pace of improvement of the mental status, with a rapid discharge from the hospital. Clinical studies to compare the efficacy and safety of different APs in the PPP are needed to provide guidance on treatment interventions.

The pharmacological management of metabolic syndrome

INTRODUCTION

The metabolic syndrome includes a constellation of several well-established risk factors, which need to be aggressively treated in order to prevent overt type 2 diabetes and cardiovascular disease. While recent guidelines for the treatment of individual components of the metabolic syndrome focus on cardiovascular benefits as resulted from clinical trials, specific recent recommendations on the pharmacological management of metabolic syndrome are lacking. The objective of present paper was to review the therapeutic options for metabolic syndrome and its components, the available evidence related to their cardiovascular benefits, and to evaluate the extent to which they should influence the guidelines for clinical practice. Areas covered: A Medline literature search was performed to identify clinical trials and meta-analyses related to the therapy of dyslipidemia, arterial hypertension, glucose metabolism and obesity published in the past decade. Expert commentary: Our recommendation for first-line pharmacological are statins for dyslipidemia, renin-angiotensin-aldosteron system inhibitors for arterial hypertension, metformin or sodium/glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists (GLP-1RAs) for glucose intolerance, and the GLP-1RA liraglutide for achieving body weight and waist circumference reduction.

Recent Reason for Hindering Medications for Perinatal Mental Disorders in Japan

BACKGROUND

We examined the recent reasons for hindering antipsychotic medications during pregnancy in Japan.

METHODS

We retrospectively analyzed the medical charts of all women who gave birth after 22 weeks' gestation at Japanese Red Cross Katsushika Maternity Hospital from August 2016 to July 2017.

RESULTS

Four pregnant women with mental disorders (three schizophrenia and one adjustment disorder) kept the interruption of medications under their partners' compulsion. All of their partners had a history of mental disorders (two schizophrenia, one anxiety disorder and one adjustment disorder).

CONCLUSION

In cases of pregnancy requiring mental health care, mental health care on partners seemed to be also needed.

Behavioral Emergencies: Special Considerations in the Pregnant Patient

This article describes psychiatric emergencies in pregnant women. The perinatal period is a time of psychiatric vulnerability. Up to 1 in 6 pregnant women experience major depressive disorder, and 1 in 4 pregnant women with bipolar disorder experience mood exacerbation. We discuss the management of severe mental illness in pregnancy, risk to mother and child of untreated psychiatric illness in pregnancy, risk of relapse of psychiatric disorders in pregnancy with medication discontinuation, psychopharmacologic considerations of teratogenicity and other fetal adverse effects, acute agitation in the pregnant patient, suicidality in pregnancy, and emergency considerations related to substance use disorders.

Dilemma of treating schizophrenia during pregnancy: a Case series and a review of literature

BACKGROUND

The choice of antipsychotic treatment during pregnancy remains controversial, mainly due to a lack of exposure and outcome data. Randomized clinical trials are practically impossible due to ethical reasons. Our reports describe three cases of closely monitored female patients with schizophrenia who were treated with olanzapine during pregnancy. The novelty of reports is that all patients were previously treated with olanzapine long acting injectable (LAI) for an average period of 3.8 years. During the LAI treatment period they were in remission and then refused to continue with LAI mainly due to treatment modality (injectable administration).

CASE PRESENTATION

The patients were relatively young, diagnosed with schizophrenia and were previously successfully treated with long acting injectable. The women were pregnant for the first time. In two cases, the patients had become pregnant during remission and they continued treatment with oral olanzapine. In the third case, olanzapine treatment was initiated during admission for a relapse.

CONCLUSIONS

There are no controlled studies for the use of olanzapine therapy in pregnant women. More studies are needed to determine the effects of antipsychotics, including olanzapine, on pregnant women and the developing fetus. Schizophrenia relapse during pregnancy may expose the mother and the fetus to high risk if olanzapine is stopped. It is important to assess the risks and benefits of treating pregnant or breastfeeding women with antipsychotics, and weigh these against possible risks of anomalies and developmental problems to the fetus or child.

Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review

Since the discovery of chlorpromazine (CPZ) in 1952, first-generation antipsychotics (FGAs) have revolutionized psychiatric care in terms of facilitating discharge from hospital and enabling large numbers of patients with severe mental illness (SMI) to be treated in the community. Second-generation antipsychotics (SGAs) ushered in a progressive shift from the paternalistic management of SMI symptoms to a patient-centered approach, which emphasized targets important to patients - psychosocial functioning, quality of life, and recovery. These drugs are no longer limited to specific Diagnostic and Statistical Manual of Mental Disorders (DSM) categories. Evidence indicates that SGAs show an improved safety and tolerability profile compared with FGAs. The incidence of treatment-emergent extrapyramidal side effects is lower, and there is less impairment of cognitive function and treatment-related negative symptoms. However, treatment with SGAs has been associated with a wide range of untoward effects, among which treatment-emergent weight gain and metabolic abnormalities are of notable concern. The present clinical review aims to summarize the safety and tolerability profile of selected FGAs and SGAs and to link treatment-related adverse effects to the pharmacodynamic profile of each drug. Evidence, predominantly derived from systematic reviews, meta-analyses, and clinical trials of the drugs amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, ziprasidone, CPZ, haloperidol, loxapine, and perphenazine, is summarized. In addition, the safety and tolerability profiles of antipsychotics are discussed in the context of the "behavioral toxicity" conceptual framework, which considers the longitudinal course and the clinical and therapeutic consequences of treatment-emergent side effects. In SMI, SGAs with safer metabolic profiles should ideally be prescribed first. However, alongside with safety, efficacy should also be considered on a patient-tailored basis.

Neurodevelopmental outcomes in infants exposed in utero to antipsychotics: a systematic review of published data

The proportion of pregnancies exposed to either second-generation antipsychotics (SGAs) or first-generation antipsychotics (FGAs) varies between 0.3%-2% of all pregnancies, but, until now, little is known about the potential neurobehavioral teratogenicity of antipsychotics. Assessing this safety facet is the aim of this article. PubMed, Scopus, and Google Scholar were searched for eligible articles. PubMed (1954 to May 2016) was searched using several medical subject headings, variously combined. PubMed search results were also limited using the search filter for human studies published in English. Scopus and Google Scholar searches were filtered for article title (antipsychotics/neuroleptics, pregnancy). After excluding duplicates, 9,250 articles were identified and 29 met the following inclusion criteria: only articles that provided original/primary data on neurodevelopmental outcome in human offspring older than 4 months of age, independently of the study design, were selected for review. Indeed, some relevant neurodevelopmental milestones are achieved at this time. Length of study and neurodevelopmental assessment methodology did not influence the study selection. Unfortunately, published data on neurodevelopmental teratogenicity of SGAs mainly derive from case reports and small case-series studies. Even findings emerging from case-control and prospective/retrospective studies are of limited clinical relevance because of their small sample sizes. Limited data are also available on FGAs. Hence, we have to conclude that the long-term neurodevelopmental outcomes for children exposed in utero remain unclear. Low to very low quality evidence of retrieved data makes impossible to confirm or exclude potential long-lasting untoward effects on infant neurocognitive development associate with antenatal exposure to either SGAs or FGAs.