A Placebo Controlled Trial on Add-on Modafinil on the Anti-psychotic Treatment Emergent Hyperglycemia and Hyperlipidemia

Magnitude and associated factors of dyslipidemia among patients with severe mental illness in dire Dawa, Ethiopia: neglected public health concern

BACKGROUND

Lipid metabolism abnormalities are an emerging risk factor for cardiovascular diseases. Due to the nature of the condition and their unhealthy lifestyles, patients with mental illnesses have a doubled risk of morbidity and mortality from dyslipidemia compared to the general population. To our knowledge the magnitude of dyslipidemia in patients with mental illnesses in the eastern Ethiopia has not been reported in the literature to date. Therefore, the aim of the study was to assess and compare the magnitude of dyslipidemia and its predictors among patients with severe mental illnesses and non-mentally ill control patients.

METHODS

Nighty six subjects with serious psychiatric disorders and nighty six matched non-psychiatric control subjects who had no history of psychiatric illness were underwent a lipid profile test in Dire Dawa referral hospital, Ethiopia. The mentally ill clients were 18 years of age and older with schizophrenia, major depression, and bipolar disorders. Exposed study subjects were matched to control by age and sex. The data were cleaned and analyzed using SPSS software. A binary logistic regression model was used to determine the factors related to the magnitude of dyslipidemia. Both the crude odds ratio and the adjusted odds ratio with a 95% confidence interval were estimated.

RESULTS

The magnitude of dyslipidemia among mentally ill patients was significantly higher (63.54%) compared to non-exposed controls (31.9%) in the subjects studied. In multiple logistic regression, urban dwellers were six times (AOR = 6.14, 95% CI: 1.2, 16) more likely at risk of developing dyslipidemia compared to rural participants. Similarly, physically inactive participants were nearly two-times (AOR = 1.8, 95% CI: 1.1, 12.9) more likely to develop dyslipidemia compared to physically active study participants. Moreover, study participants who had raised body mass index were 2.1 times (AOR = 2.1, 95% CI: 1.17, 15.3) more likely having dyslipidemia than their counterparts.

CONCLUSIONS

This study revealed that the prevalence of dyslipidemia is higher among mentally ill patients compared to non-mentally ill control study participants. Place of residence, physical inactivity, and raised BMI were significantly associated with dyslipidemia. Therefore, intensive screening of patients for dyslipidemia and its components is necessary during follow-up.

Leveraging Human Plasma-Derived Small Extracellular Vesicles as Liquid Biopsy to Study the Induction of Cytochrome P450 3A4 by Modafinil

Preparations of plasma-derived small extracellular vesicles (sEVs) were deployed as liquid biopsy to study cytochrome P450 (CYP) 3A4 (CYP3A4) induction following modafinil 400 mg once daily × 14 days (young healthy volunteers, N = 10 subjects). Induction was confirmed using the 4β-hydroxycholesterol-to-cholesterol (4βHC/C) ratio, a plasma CYP3A4/5 biomarker, with a mean 2.1-fold increase (Day 15 vs. Day 1; 90% confidence interval (CI) = 1.8-2.3; P value = 0.0004). Proteomic analysis revealed the induction (mean Day 15 vs. Day 1 fold-increase (90% CI)) of both liver (1.3 (1.1-1.5), P value = 0.014) and nonliver (1.9 (1.6-2.2), P value = 0.04) sEV CYP3A4 protein expression. In CYP3A5 nonexpresser subjects, the baseline (pre-dose) 4βHC/C plasma ratio was more highly correlated with liver sEVs (r = 0.937, P value = 0.001) than nonliver sEVs (r = 0.619, P value = 0.101) CYP3A4 protein expression. When CYP3A5 expressers (CYP3A5*1/*3) were included, the correlation with liver sEVs (r = 0.761, P value = 0.011) and nonliver sEVs (r = 0.391, P value = 0.264) CYP3A4 protein was weaker. Although modafinil-induced changes in plasma 4βHC/C ratio did not correlate with sEVs CYP3A4 protein expression, the individual subject sEVs proteomic data were used successfully to predict victim drug (midazolam, triazolam, dextromethorphan, 17α-ethinylestradiol, and abemaciclib) area under the plasma concentration-time curve (AUC) ratios (AUCRs) following modafinil. Based on the AUCR values, modafinil was classified as a weak to moderate CYP3A4 inducer (vs. rifampicin). For the first time, it was possible to deploy plasma-derived sEVs to study CYP3A4 induction beyond rifampicin, a more potent CYP3A4 inducer.

Prevalence and Associated Factors of Dyslipidemia Among Psychiatric Patients on Antipsychotic Treatment at Hawassa University Comprehensive Specialized Hospital

Background:

Dyslipidemia is one of the adverse metabolic outcomes associated with psychotropic medications and the nature of the mental illness itself. Therefore, this study aimed to assess magnitude of dyslipidemia and associated factors among patients with severe mental illness on antipsychotic treatments.

Methods:

A cross-sectional study was conducted among 245 patients with severe mental illness in Hawassa University Comprehensive Specialized Hospital, Sidama Regional state, Southern Ethiopia. Socio-demographic and other important data were collected using a structured questionnaire through a systematic random sampling technique. Individual dyslipidemia was characterized by the National Cholesterol Education Program Adult Treatment Panel-III (NCEP ATP-III) guideline.

Results:

Mean total cholesterol (TC) was significantly higher in males when compared to females (162.2 mg/dl vs 121 mg/dl, P = .023). While, mean LDL-cholesterol was significantly higher in females when compared to males (100.9 mg/dl vs 93.6 mg/dl, P = .028). Overall 58.4% (95% CI: 52.2-64.8) of participants had at least 1 dyslipidemia. The prevalence of TC ⩾200 mg/dl, HDL-cholesterol <40 mg/dl, triglyceride (TG) and LDL-cholesterol were 61 (24.9%), 75 (30.6%), 66 (26.9%), and 47 (19.2%), respectively. Female sex and smoking were significantly and positively associated with LDL-c dyslipidemia, the aOR (95% CI) were 2.1 (1.0-4.2) for female sex and 3.4 (1.1-10.5) for smoking. Also, Age >40 years was significantly associated with TC dyslipidemia, the aOR (95% CI) was 2.0 (1.1-3.7).

Conclusion:

More than half of psychiatric patients are at risk of developing cardiovascular and other related health problems. Therefore, periodic screening of lipid profiles during healthcare follow-up is mandatory to limit risks of cardiovascular-related comorbidities among patients with severe mental illness.

Influence of the use of atypical antipsychotics in metabolic syndrome

OBJECTIVES

To describe the possible relationship between the use of antipsychotic drugs and the presence of metabolic syndrome. Other objectives are to list the main side effects of antipsychotic treatment, and to determine if there is any pharmacological treatment that can contribute towards counteracting metabolic syndrome.

MATERIAL AND METHOD

A narrative bibliographic review was carried out of the following databases: PubMed, Cochrane, CINAHL, IBECS, LILACS and HealthCare. Preference in the selection process was given to clinical trials and systematic review articles or review articles and some articles that were considered relevant because of their content. The time period was limited to between January 2014 and November 2019. The languages were English and Spanish. Repeated articles and those that were not related to the objectives were rejected. The search criteria were: "antipsychotic AND metabolic syndrome"; "schizophrenia AND metabolic syndrome"; "bipolar disorder AND metabolic syndrome"; "metabolic syndrome AND suicide NOT disorder"; "metabolic syndrome AND prisons"; "metabolic syndrome AND prolactin".

RESULTS

24 articles were selected out of the 510 that were consulted. The relationship between atypical antipsychotics and metabolic syndrome was evident. Other anticholinergic, antidopaminergic effects, extrapyramidal syndromes, neuroleptic malignant syndrome, hypotension, arrhythmias, sedation, hypovitaminosis D, increased prolactin, sexual dysfunction, sleep disturbances, etc. are also highlighted. Pharmacological associations with other drugs were also found.

DISCUSSION

There is a relationship between the use of atypical antipsychotics and weight gain, lipid disorders, glucose and high blood pressure. There are some associated drugs that decrease some symptoms (ranitidine, topiramate, metformin, melatonin, modafinil). Patients taking this type of medication should be monitored and encouraged to lead healthy lifestyles.

Modafinil for people with schizophrenia or related disorders

BACKGROUND

People with schizophrenia have a range of different symptoms, including positive symptoms (hallucinations and delusions), negative symptoms (such as social withdrawal and lack of affect), and cognitive impairment. The standard medication for people with schizophrenia is antipsychotics. However, these medications may not be effective for all symptoms of schizophrenia, as cognitive and negative symptoms are usually hard to treat. Additional therapies or medications are available for the management of these symptoms. Modafinil, a wakefulness-promoting agent most frequently used in narcolepsy or shift work sleep disorder, is one intervention that is theorised to have an effect of these symptoms.

OBJECTIVES

The primary objective of this review was to assess the effects of modafinil for people with schizophrenia or related disorders.

SEARCH METHODS

On 27 April 2015, 24 May 2017, and 31 October 2019, we searched the Cochrane Schizophrenia Group's register of trials, which is based on regular searches of CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials. There are no language, time, document type, or publication status limitations for the inclusion of records in the register.

SELECTION CRITERIA

We selected all randomised controlled trials comparing modafinil with placebo or other treatments for people with schizophrenia or schizophrenia-spectrum disorders.

DATA COLLECTION AND ANALYSIS

We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CI. We used a random-effects model for the meta-analysis. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for the included studies.

MAIN RESULTS

Eleven studies including a total of 422 participants contributed to data analyses. Most studies had a small population size (average 38 people per study) and were of short duration. We also detected a high risk of bias for selective outcome reporting in just under 50% of the trials. We therefore rated the overall methodological quality of the included studies as low. We considered seven main outcomes of interest: clinically important change in overall mental state, clinically important change in cognitive functioning, incidence of a clinically important adverse effect/event, clinically important change in global state, leaving the study early for any reason, clinically important change in quality of life, and hospital admission. All studies assessed the effects of adding modafinil to participants' usual antipsychotic treatment compared to adding placebo to usual antipsychotic treatment. Six studies found that adding modafinil to antipsychotic treatment may have little or no effect on overall mental state of people with schizophrenia, specifically the risk of worsening psychosis (RR 0.91, 95% CI 0.28 to 2.98; participants = 209; studies = 6, low-quality evidence). Regarding the effect of modafinil on cognitive function, the trials did not report clinically important change data, but one study reported endpoint scores on the MATRICS Consensus Cognitive Battery (MCCB): in this study we found no clear difference in scores between modafinil and placebo treatment groups (MD -3.10, 95% CI -10.9 to 4.7; participants = 48; studies = 1, very low-quality evidence). Only one study (N = 35) reported adverse effect/event data. In this study one serious adverse event occurred in each group (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low-quality evidence). One study measured change in global state using the Clinical Global Impression - Improvement Scale. This study found that adding modafinil to antipsychotic treatment may have little or no effect on global state (RR 6.36, 95% CI 0.94 to 43.07, participants = 21; studies = 1, very low-quality evidence). Nine studies found that modafinil has no effect on numbers of participants leaving the study early (RR 1.26, 95% CI 0.63 to 2.52 participants = 357; studies = 9, moderate-quality evidence). None of the trials reported clinically important change in quality of life, but one study did report quality of life using endpoint scores on the Quality of Life Inventory, finding no clear difference between treatment groups (MD -0.2, 95% CI -1.18 to 0.78; participants = 20; studies = 1, very low-quality evidence). Finally, one study reported data for number of participants needing hospitalisation: one participant in each group was hospitalised (RR 0.84, 95% CI 0.06 to 12.42; participants = 35; studies = 1, very low-quality evidence).

AUTHORS' CONCLUSIONS

Due to methodological issues, low sample size, and short duration of the clinical trials as well as high risk of bias for outcome reporting, most of the evidence available for this review is of very low or low quality. For results where quality is low or very low, we are uncertain or very uncertain if the effect estimates are true effects, limiting our conclusions. Specifically, we found that modafinil is no better or worse than placebo at preventing worsening of psychosis; however, we are uncertain about this result. We have more confidence that participants receiving modafinil are no more likely to leave a trial early than participants receiving placebo. However, we are very uncertain about the remaining equivocal results between modafinil and placebo for outcomes such as improvement in global state or cognitive function, incidence of adverse events, and changes in quality of life. More high-quality data are needed before firm conclusions regarding the effects of modafinil for people with schizophrenia or related disorders can be made.