Atypical antipsychotics: A review on the prevalence, monitoring, and management of their metabolic and cardiovascular side effects

Analysis of Atypical Antipsychotics-Induced Adverse Events Related to Diabetes Mellitus in Patients With Dementia Using the Japanese Adverse Drug Event Report Database

BACKGROUND

Patients with dementia are prescribed low-dose atypical antipsychotics (AAPs) to treat psycho-behavioral symptoms. Although AAPs are known to cause diabetes mellitus-related adverse events (DMAEs), information regarding AAPs-induced DMAEs experienced by patients with dementia is lacking.

OBJECTIVE

To use the Japan Adverse Drug Event Report (JADER) database to assess the onset tendencies and patterns of DMAEs attributable to AAPs prescribed to patients with dementia.

METHODS

We performed an analysis using dementia cases from the JADER database that were registered from April 2004 to December 2022. Data in the JADER database are completely anonymized; thus, we did not require institutional review board approval for using the JADER database in our study. The reporting odds ratio and proportional reporting ratio (PRR) were used to assess the onset tendencies of DMAEs with AAPs. In addition, Weibull shape parameters were used to assess the patterns of DMAEs that occur with the use of AAPs.

RESULTS

We identified AAPs associated with DMAEs. In particular, low doses of quetiapine showed the potential to induce DMAEs. An analysis of the onset of DMAEs showed the early failure patterns for AAPs (median onset = 38 days).

CONCLUSION AND RELEVANCE

The AAPs may cause DMAEs in patients with dementia. Low doses of quetiapine may induce DMAEs. Health care workers should focus on the development of DMAEs during the early administration period of AAPs. These results may assist with the safe management of patients with dementia who use AAPs.

Second-generation antipsychotic medications and metabolic disturbance in children and adolescents

Background

The second-generation antipsychotics (SGAs) are a group of antipsychotic drugs, used to treat psychiatric conditions. SGAs have been shown to precipitate rapid weight gain and dyslipidemia, as well as to promote insulin resistance, leading to the emergence of type 2 diabetes and metabolic syndrome. Prescriptions of SGAs in children have increased 6- to 10-fold during the last decade. This research work designed to find correlation between duration of second-generation antipsychotics (SGA) use, in children and adolescent, and the increase in metabolic syndrome disturbance components including weight gain, hypertension, hyperlipidemia and diabetes mellitus. This is cross-sectional analytic study was carried out in Suez Canal University Hospital, Psychiatry Outpatient Clinic on Children and adolescent aged 4–17 years. It included 151 children and adolescents diagnosed by Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). They were divided into two groups, 72 patients who regular on (SGA) as treated group and 79 patients who did not receive pharmacological medication as control group.

Results

The overall prevalence of metabolic syndrome in the current study was high 27.81% in SGA-treated children compared to 0.60% in control group. In the SGA-treated group, 22.22% had type 2 diabetes, compared with 2.53% in the control group. SGA-treated patients showed a highly significant increase in their weight, body mass index and waist circumference compared to their control group patients. The correlation of different metabolic syndrome indices and SGAs duration showed positive correlation with body mass index, fasting blood sugar, and blood lipids (low density lipoproteins and cholesterol) but negative correlation with high density lipoproteins. Blood pressure did not correlate with SGA-duration in the studied patients. Indices which showed correlation could be predictors of the metabolic syndrome developments. Although the correlation and regression model showed moderate degree of association, this is considered important issue for the young patients.

Conclusion

SGA treatment in children and adolescence confers a significantly increased risk for metabolic syndrome and SGA-treatment duration is important for MtS development.

Association of antipsychotic use with breast cancer: a systematic review and meta-analysis of observational studies with over 2 million individuals

AIMS

Despite reports of an elevated risk of breast cancer associated with antipsychotic use in women, existing evidence remains inconclusive. We aimed to examine existing observational data in the literature and determine this hypothesised association.

METHODS

We searched Embase, PubMed and Web of Science™ databases on 27 January 2022 for articles reporting relevant cohort or case-control studies published since inception, supplemented with hand searches of the reference lists of the included articles. Quality of studies was assessed using the Newcastle-Ottawa Scale. We generated the pooled odds ratio (OR) and pooled hazard ratio (HR) using a random-effects model to quantify the association. This study was registered with PROSPERO (CRD42022307913).

RESULTS

Nine observational studies, including five cohort and four case-control studies, were eventually included for review (N = 2 031 380) and seven for meta-analysis (N = 1 557 013). All included studies were rated as high-quality (seven to nine stars). Six studies reported a significant association of antipsychotic use with breast cancer, and a stronger association was reported when a greater extent of antipsychotic use, e.g. longer duration, was operationalised as the exposure. Pooled estimates of HRs extracted from cohort studies and ORs from case-control studies were 1.39 [95% confidence interval (CI) 1.11-1.73] and 1.37 (95% CI 0.90-2.09), suggesting a moderate association of antipsychotic use with breast cancer.

CONCLUSIONS

Antipsychotic use is moderately associated with breast cancer, possibly mediated by prolactin-elevating properties of certain medications. This risk should be weighed against the potential treatment effects for a balanced prescription decision.

Investigation of the protective effect of resveratrol in an MK-801-induced mouse model of schizophrenia

Increasing evidence supports the view that oxidative stress and brain demyelination play an important role in the pathogenesis of schizophrenia. Resveratrol is a powerful antioxidant with neuroprotective effects. This study aimed to assess the effect of resveratrol on schizophrenia-like behaviors and possible brain demyelination induced by MK-801, an N-methyl-D-aspartate glutamate receptor antagonist, and the underlying neuroprotective mechanism. Resveratrol (40 mg/kg/day/, intraperitoneal) was administered to mice for 14 days. MK-801 (1 mg/kg/day, intraperitoneal) was injected into the mice 4 h after the resveratrol administration for 14 days. The open-field and elevated-plus maze tests were performed to detect behavior changes on the 15th day. Following the behavioral tests, the expression of the myelin basic protein (MBP) was measured with the real-time PCR (RT-PCR) method, while total oxidant capacity (TOS) and total antioxidant capacity (TAS), which are the biomarkers of oxidative damage, were measured with the ELISA method. Hematoxylin-eosin staining was also used to identify stereological and pathological changes in the brain. According to the results obtained, this study showed for the first time that resveratrol prevented glial cell infiltration induced in the brain by MK-801 and shrinkage of nerve cell nuclei in the hippocampus and corpus callosum. However, the resveratrol administrations did not correct behavioral disorders and demyelination of schizophrenia. Although resveratrol partially prevented oxidative damage in the brain in the mice that were injected with MK-801, it was determined that this effect was not statistically significant. These results showed that resveratrol administration partially protects tissues against MK-801-induced neurodegeneration, and resveratrol may be used in combination with different antioxidants or at different doses in future studies.

A Double-Blind, Placebo-Controlled Trial of Bupropion Add-on to Olanzapine or Risperidone in Overweight Individuals With Schizophrenia

BACKGROUND

Weight gain due to antipsychotics is a challenging clinical problem because, to date, no effective pharmacological strategies have been found. Bupropion is often used in people with schizophrenia for smoking cessation and is well tolerated. However, studies on its use as weight loss treatment are scarce. The aim of the study was to examine the effectiveness of bupropion as a single weight loss treatment in overweight individuals maintained on long-term olanzapine or risperidone.

METHODS

This randomized, double-blind, placebo-controlled, 8-week study included 26 overweight (body mass index ≥27 kg/m2) individuals with schizophrenia maintained on olanzapine (10-20 mg/d) or risperidone (2-4 mg/d). Participants were randomly allocated to a study group that received bupropion (150-300 mg/d) or to a placebo group. The positive and Negative Syndrome Scale and the Clinical Global Impression-Severity Scale were used to assess severity of psychosis at baseline and end of study (8 weeks).

RESULTS

Bupropion addition, but not placebo, was associated with a significant reduction in body weight. Severity of psychotic symptoms was not altered in either group.

CONCLUSIONS

The results demonstrate the efficacy of bupropion, compared with placebo, in patients maintained on chronic treatment with olanzapine or risperidone, both known to be major contributors to significant weight gain.

Monitoring for the metabolic side effects of second-generation antipsychotic medications: Psychiatrists' views and practices

PURPOSE

The aims of this study were to explore (1) the knowledge, attitudes, practices, and adherence of psychiatrists in Jordan regarding published guidelines for metabolic monitoring of patients taking second-generation antipsychotics (SGAs), and (2) their perceived barriers to metabolic screening.

METHODS

The study utilized a cross-sectional survey. Data were collected from 91 psychiatrists using a self-administered questionnaire.

FINDINGS

Almost 74% of psychiatrists reported they were aware of metabolic screening guidelines for patients taking SGA. However, the results of their assessment practices revealed a lack of adherence to these guidelines. Reported barriers to metabolic screening were the financial burden on the family and lack of family and patient compliance with recommendations of monitoring.

PRACTICE IMPLICATIONS

Metabolic side effects of SGAs are important in Arab countries, where baseline levels of obesity and metabolic syndrome are already high in the general population. By virtue of their close proximity to patients, nurses are ideally placed to monitor how patients perceive SGAs and to provide information, advice, and counseling support.

The G Protein-Coupled Glutamate Receptors as Novel Molecular Targets in Schizophrenia Treatment-A Narrative Review

Schizophrenia is a severe neuropsychiatric disease with an unknown etiology. The research into the neurobiology of this disease led to several models aimed at explaining the link between perturbations in brain function and the manifestation of psychotic symptoms. The glutamatergic hypothesis postulates that disrupted glutamate neurotransmission may mediate cognitive and psychosocial impairments by affecting the connections between the cortex and the thalamus. In this regard, the greatest attention has been given to ionotropic NMDA receptor hypofunction. However, converging data indicates metabotropic glutamate receptors as crucial for cognitive and psychomotor function. The distribution of these receptors in the brain regions related to schizophrenia and their regulatory role in glutamate release make them promising molecular targets for novel antipsychotics. This article reviews the progress in the research on the role of metabotropic glutamate receptors in schizophrenia etiopathology.

Circulating IGFBP-2 levels reveal atherogenic metabolic risk in schizophrenic patients using atypical antipsychotics

OBJECTIVES

Second generation antipsychotics (SGAs) induce weight gain and dyslipidemia, albeit with important intervariability. Insulin-like growth factor binding protein (IGFBP)-2 is proposed as a circulating biomarker negatively associated with waist circumference and hypertriglyceridemia. Thus, we tested whether metabolic alterations developed upon the use of SGAs are associated with plasma IGFBP-2 levels.

METHODS

A cross-sectional study was performed in 87 men newly diagnosed with schizophrenia and administered for approximately 20 months with olanzapine or risperidone as their first antipsychotic treatment. Plasma IGFBP-2 concentration, anthropometric data, as well as glucose and lipid profiles were determined at the end of the treatments.

RESULTS

IGFBP-2 levels were similar between patients using olanzapine or risperidone and were negatively correlated with waist circumference, insulin sensitivity, and plasma triglycerides (TG). A higher proportion of men with a hypertriglyceridemic (hyperTG) waist phenotype was found in patients with IGFBP-2 levels lower than 220 ng/mL (43% for olanzapine and 13% for risperidone) compared to those with IGFBP-2 above this threshold (10% and 0%, respectively).

CONCLUSIONS

IGFBP-2 may have a role in altering metabolic risk in schizophrenic patients using SGAs. Longitudinal studies are required to evaluate whether IGFBP-2 can predict the development of a hyperTG waist phenotype in this population.

The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second-generation antipsychotics

WHAT IS KNOWN AND OBJECTIVE

Metabolic syndrome is a well-documented adverse effect of second-generation antipsychotics (SGAs). Patients with metabolic syndrome are at an increased risk of potentially fatal cardiovascular events, including myocardial infarction and stroke. This elevated risk prompted the creation of a national guideline on metabolic monitoring for patients on SGAs in 2004. However, monitoring practices remained low at our clinic. To address this concern, a clinical decision support system was developed to alert providers of monitoring requirements. The purpose of this study is to determine the effect of the best practice alert (BPA), and to assess the impact of provider and patient characteristics on metabolic laboratory (lab) order rates.

METHODS

A retrospective chart review was conducted at a large outpatient psychiatric clinic. Data were collected from all adult patients who were prescribed an SGA and triggered the BPA (indicating lab monitoring is needed for the patient). Data collection included a variety of patient, provider and alert variables. The primary outcome was a composite of fasting blood glucose (FBG), haemoglobin A1c (HbA1c) and/or fasting lipid panel order rates. Secondary outcomes included the rate of valid response, which considered appropriate reasons for not ordering labs (ie monitoring already completed during recent primary care visit), as well as order rates of individual labs.

RESULTS AND DISCUSSION

Data from 1112 patients were collected and analysed. Patients with a thought disorder diagnosis had significantly more labs ordered than those without. No other patient factors affected order rates. Resident psychiatrists and nurse practitioners ordered significantly more labs and had significantly more valid responses than attending psychiatrists. An active alert, which fired during medication order entry, was associated with a higher rate of lab ordering and valid response compared to a passive alert, which fired whenever a prescribing healthcare provider opened the chart.

WHAT IS NEW AND CONCLUSION

Prescribers may associate metabolic syndrome with schizophrenia or with use of SGAs specifically in thought disorders, even though these medications pose a risk for all indications. Higher rates of monitoring by resident physicians may have been due to spending more time with patients during the encounter and in documentation. Lastly, the active BPA was an effective tool to increase metabolic monitoring in patients taking SGAs. Continued education on the importance of regular metabolic monitoring should be implemented for all providers.

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.

Long-acting injectable antipsychotics and their use in court-ordered treatment: A cross-sectional survey of psychiatric pharmacists' perceptions

Introduction

People with serious mental illness may be subjected to “court-ordered treatment” (COT), per the mental health statutes of their respective state. COT enforces adherence to a psychiatric treatment regimen and may involve involuntary medication administration. Long-acting injectable (LAI) antipsychotics are frequently used in this setting, although little is known about the clinical effectiveness or patterns of use of these agents in the context of COT. Because psychiatric pharmacists are medication experts, we sought to characterize their perceptions and experiences on this topic.

Methods

A cross-sectional, electronic, 14-item survey was administered via the College of Psychiatric and Neurologic Pharmacists listserv from October 9, 2018, to November 9, 2018. The survey collected demographic information, experience and use of LAI antipsychotics at each practice site, and perception of LAI antipsychotics.

Results

Of 843 possible respondents, 72 completed the survey, yielding an 8.5% response rate. LAIs were perceived as underused or adequately used as a whole, with a significant difference in perception favoring the opinion that LAIs are underused versus overused for those respondents who perceived an adherence benefit (P = .042). We also found that LAIs were used disproportionately in the context of COT versus oral formulations (P = .03).

Discussion

The use of LAIs in the context of COT has not been studied, and it may expose this vulnerable population to adverse effects from medications they are legally compelled to take. Further research on the perceptions of other interdisciplinary team members and the clinical impact of LAI use in COT is needed.

Immunoendocrine Peripheral Effects Induced by Atypical Antipsychotics

Atypical antipsychotics (AAP) or second-generation antipsychotics are the clinical option for schizophrenia treatment during acute psychoses, but they are also indicated for maintenance during lifetime, even though they are being used for other psychiatric conditions in clinical practice such as affective disorders and autism spectrum disorder, among others. These drugs are differentiated from typical antipsychotics based on their clinical profile and are a better choice because they cause fewer side effects regarding extrapyramidal symptoms (EPS). Even though they provide clear therapeutic benefits, AAP induce peripheral effects that trigger phenotypic, functional, and systemic changes outside the Central Nervous System (CNS). Metabolic disease is frequently associated with AAP and significantly impacts the patient's quality of life. However, other peripheral changes of clinical relevance are present during AAP treatment, such as alterations in the immune and endocrine systems as well as the intestinal microbiome. These less studied alterations also have a significant impact in the patient's health status. This manuscript aims to revise the peripheral immunological, endocrine, and intestinal microbiome changes induced by AAP consumption recommended in the clinical guidelines for schizophrenia and other psychiatric disorders.

Metabolic outcomes of bergamot polyphenolic fraction administration in patients treated with second-generation antipsychotics: a pilot study

Second-generation antipsychotics (SGAs) are notoriously associated with a marked increase in body weight and with a wide range of metabolic adverse effects, and their chronic use is related with an increased risk for the development of metabolic syndrome (MS). Different adjunctive treatments have been proposed to reduce SGAs-induced weight gain and/or metabolic abnormalities with inconsistent or too limited evidence to support their regular clinical use, thus suggesting the need to find new possible treatments. Bergamot polyphenolic fraction (BPF) has been proven effective in patients with MS, as demonstrated by a concomitant improvement in lipemic and glycemic profiles. The present study was aimed to explore the efficacy and safety of BPF treatment on metabolic parameters in a sample of subjects receiving atypical antipsychotics. Fifteen outpatients treated with SGAs assumed BPF at the oral daily dose of 1000 mg/day for 30 days. Fasting levels of glucose, glycated hemoglobin, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides were determined. BPF administration resulted in a statistically significant reduction of body weight (P=.004) and in a trend for body mass index decrease (P=.005). No significant differences in other and metabolic parameters were observed. Our findings suggest that BPF, at the daily dose of 1000 mg for 30 days, could be an effective and safe agent to prevent weight gain associated with atypical antipsychotic use. However, further clinical trials with adequately powered and well-designed methodology are needed to better explore the BPF effectiveness on the SGAs-induced weight gain and metabolic side effects.