Prolactin, flupenthixol decanoate and first episode schizophrenia - clinical and laboratory correlates

First-episode psychosis (FEP) patients are more sensitive to neuroleptic side-effects such as hyperprolactinemia. We examined the prolactin levels of previously minimally treated patients with first episode schizophrenia over their first year of treatment with flupenthixol decanoate and the relationship between prolactin levels, gender and clinical features of schizophrenia. Prolactin levels were assessed at three monthly intervals in 126 patients with first-episode schizophrenia in a single-site study conducted over 12 months during treatment with flupenthixol decanoate according to a fixed protocol. The mean prolactin level for the total sample was 11.91 ng/ml (standard deviation [SD]15.52) at baseline. Women had higher levels of prolactin than men at month 3, 6 and 12, reaching statistical significance at month 12 (p = 0.02). At 12 months more women than men had hyperprolactinemia (defined as more than 20 ng/ml for males, and as more than 25 ng/ml for females (p = 0.007). Using a mixed effect model, there was a significant association between prolactin change scores over 12 months and gender (p = 0.025) as well as Positive and Negative Syndrome Scale (PANSS) total scores (p = 0.001). In addition female gender (p = 0.04) and age (p = 0.02) correlated with the risk of hyperprolactinemia as categorical variable. In this study treatment with flupenthixol decanoate was associated with relatively low levels of hyperprolactinemia, likely owing to flupenthixol's relatively atypical mode of action, as well as to the low doses used in our study. We found an inverse correlation between total PANSS scores and prolactin levels, which could support the suggested theory of prolactin having antipsychotic properties. Our study confirms the importance of gender on the prolactin raising effects of antipsychotic treatment.

Estimating the optimal dose of flupentixol decanoate in the maintenance treatment of schizophrenia-a systematic review of the literature

RATIONALE

The licensed dose range for the long-acting injectable antipsychotic flupentixol decanoate (Depixol®) in the treatment of schizophrenia is very broad. This provides little useful direction to prescribers and may ultimately result in patients receiving unnecessarily high doses.

OBJECTIVES

We aimed to estimate the effect of dose of flupentixol decanoate on relapse rates in schizophrenia and on tolerability by expanding on an earlier review and including non-RCT and German-language studies, as well as using pharmacokinetic and pharmacodynamic data to offer guidance on dosing.

METHODS

A literature review using EMBASE, Medline, PsycINFO and PubMed was conducted. Treatment success rates at 6 months were extracted or extrapolated from the studies and plotted against dose to estimate a dose-response curve.

RESULTS

Data from 16 studies (n = 514) allowed estimation of a dose-response curve which rises steeply between the chosen placebo anchor (25% success rate) and 10 mg every 2 weeks before reaching a maximum between 20 and 40 mg every 2 weeks (80-95% success rates). Extrapyramidal side effects (EPSEs) were frequently seen (12-71% of participants) in that dose range. Two -weekly injections seem to provide the highest trough plasma concentration per dose administered and the lowest peak-to-trough concentration ratio. Plasma concentration varied up to 5-fold among individuals receiving the same dose.

CONCLUSIONS

The optimal dose of flupentixol decanoate is likely to be between 20 mg and 40 mg every 2 weeks although higher doses may be required in some individuals owing to variation in drug handling. Doses of flupentixol should be individually established in the range of 10 to 40 mg every 2 weeks according to response and tolerability.

Brain volume changes over the first year of treatment in schizophrenia: relationships to antipsychotic treatment

BACKGROUND

Progressive brain volume reductions have been described in schizophrenia, and an association with antipsychotic exposure has been reported.

METHODS

We compared percentage changes in grey and white matter volume from baseline to month 12 in 23 previously antipsychotic-naïve patients with a first episode of schizophrenia or schizophreniform disorder who were treated with the lowest effective dose of flupenthixol decanoate depot formulation, with 53 matched healthy individuals. Total antipsychotic dose was precisely calculated and its relationship with brain volume changes investigated. Relationships between volumetric changes and treatment were further investigated in terms of treatment response (changes in psychopathology and functionality) and treatment-related adverse-events (extrapyramidal symptoms and weight gain).

RESULTS

Excessive cortical volume reductions were observed in patients [-4.6 (6.6)%] v. controls [-1.12 (4.0)%] (p = 0.009), with no significant group differences for changes in subcortical grey matter and white matter volumes. In a multiple regression model, the only significant predictor of cortical volume change was total antipsychotic dose received (p = 0.04). Cortical volume change was not significantly associated with the changes in psychopathology, functionality, extrapyramidal symptoms and body mass index or age, gender and duration of untreated psychosis.

CONCLUSIONS

Brain volume reductions associated with antipsychotic treatment are not restricted to poor outcome patients and occur even with the lowest effective dose of antipsychotic. The lack of an association with poor treatment response or treatment-related adverse effects counts against cortical volume reductions reflecting neurotoxicity, at least in the short term. On the other hand, the volume reductions were not linked to the therapeutic benefits of antipsychotics.

Changes in brain regions associated with food-intake regulation, body mass and metabolic profiles during acute antipsychotic treatment in first-episode schizophrenia

We investigated whether morphological brain changes occurred in brain regions associated with body-weight homeostasis during acute antipsychotic treatment, and if so, whether they were related to changes in body mass and metabolic profile. Twenty-two antipsychotic-naive patients with first-episode schizophrenia received either risperidone long acting injection or flupenthixol decanoate over 13 weeks and were compared by structural MRI with 23 matched healthy volunteers at weeks 0, 4 and 13. Images were reconstructed using freesurfer fully-automated whole brain segmentation. The ventral diencephalon and prefrontal cortex were selected to represent the homeostatic and hedonic food intake regulatory systems respectively. Body mass was measured at weeks 0, 7 and 13 and fasting glucose and lipid profiles at weeks 0 and 13. Linear mixed effect models indicated significant group(⁎)time interactions for the ventral diencephalon volumes bilaterally. Ventral diencephalon volume reduction was strongly correlated bilaterally with body mass increase and HDL-cholesterol reductions, and unilaterally with blood glucose elevation. There were no significant changes in prefrontal cortical thickness. These findings implicate the ventral diencephalon, of which the hypothalamus is the main component, in the acute adipogenic and dyslipidaemic effects of antipsychotic medication.

Flupenthixol decanoate (depot) for schizophrenia or other similar psychotic disorders

BACKGROUND

Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment for schizophrenia.

OBJECTIVES

To evaluate the effects of flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, in terms of clinical, social and economic outcomes.

SEARCH METHODS

We identified relevant trials by searching the Cochrane Schizophrenia Group Trials Register in March 2009 and then for this update version, a search was run in April 2013. The register is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We contacted relevant pharmaceutical companies, drug approval agencies and authors of trials for additional information.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared with placebo or other antipsychotic drugs were included. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed trial quality and extracted data. For dichotomous data we estimated risk ratios (RR) with 95% confidence intervals (CI) using a fixed-effect model. Analysis was by intention-to-treat. We summated normal continuous data using mean difference (MD), and 95% CIs using a fixed-effect model. We presented scale data only for those tools that had attained prespecified levels of quality. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) we created 'Summary of findings tables and assessed risk of bias for included studies.

MAIN RESULTS

The review currently includes 15 randomised controlled trials with 626 participants. No trials compared flupenthixol decanoate with placebo.One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). Only two outcomes were reported with this single study, and it demonstrated no clear differences between the two preparations as regards leaving the study early (n = 60, 1 RCT, RR 3.00, CI 0.33 to 27.23,very low quality evidence) and requiring anticholinergic medication (1 RCT, n = 60, RR 1.19, CI 0.77 to 1.83, very low quality evidence).Ten studies in total compared flupenthixol decanoate with other depot preparations, though not all studies reported on all outcomes of interest. There were no significant differences between depots for outcomes such as relapse at medium term (n = 221, 5 RCTs, RR 1.30, CI 0.87 to 1.93, low quality evidence), and no clinical improvement at short term (n = 36, 1 RCT, RR 0.67, CI 0.36 to 1.23, low quality evidence). There was no difference in numbers of participants leaving the study early at short/medium term (n = 161, 4 RCTs, RR 1.23, CI 0.76 to 1.99, low quality evidence) nor with numbers of people requiring anticholinergic medication at short/medium term (n = 102, 3 RCTs, RR 1.38, CI 0.75 to 2.25, low quality evidence).Three studies in total compared high doses (100 to 200 mg) of flupenthixol decanoate with the standard doses (˜40mg) per injection. Two trials found relapse at medium term (n = 18, 1 RCT, RR 1.00, CI 0.27 to 3.69, low quality evidence) to be similar between the groups. However people receiving a high dose had slightly more favourable medium term mental state results on the Brief Psychiatric Rating Scale (BPRS) (n = 18, 1 RCT, MD -10.44, CI -18.70 to -2.18, low quality evidence). There was also no significant difference in the use of anticholinergic medications to deal with side effects at short term (2 RCTs n = 47, RR 1.12, CI 0.83 to 1.52 very low quality evidence). One trial comparing a very low dose of flupenthixol decanoate (˜6 mg) with a low dose (˜9 mg) per injection reported no difference in relapse rates (n = 59, 1 RCT, RR 0.34, CI 0.10 to 1.15, low quality evidence).

AUTHORS' CONCLUSIONS

In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. From the data reported in clinical trials, it would be understandable to offer standard dose rather than the high dose depot flupenthixol as there is no difference in relapse. However, data reported are of low or very low quality and this review highlights the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate.

Cost-effectiveness of long-acting injectable risperidone versus flupentixol decanoate in the treatment of schizophrenia: a Markov model parameterized using administrative data

We use longitudinal patient-level data from a German sickness fund with 7.26 million insured in a Markov-simulation model to assess the cost-effectiveness of long-acting injectable risperidone (LAI-RIS) compared with long-acting injectable flupentixol (LAI-FLX) in the long-term management of schizophrenia. We simulate treatment costs from the payer's perspective, hospitalization, the probability to be prescribed co-medication, and treatment discontinuation over a 2-year time horizon. Model inputs were derived from 935 patients hospitalized with schizophrenia between 2005 and 2008 who received either LAI-RIS or LAI-FLX for at least 1 month. After 2 years, 89.4% (95.8%) of patients who were initiated on LAI-RIS (LAI-FLX) discontinued the initial regimen. The number of days spent in hospital per month and patient was slightly lower with LAI-RIS (1.08 vs. 1.28 days, p<0.001). The proportion of patients receiving side-effect co-medication was lower with LAI-RIS (8.3 vs. 15.0% per month, p<0.001). Mean total costs of treatment per patient and month were 1,015 € under LAI-RIS and 395 € under LAI-FLX, resulting in an ICER of 3,088 € (95% CI [-913 €; 3,551 €]) for an avoided hospital day per patient and month in the base case scenario with a 15.1% probability of LAI-FLX being the dominant treatment strategy. Cost differences were mainly attributable to the higher drug costs of LAI-RIS. The effectiveness of LAI-RIS in preventing hospital days appears to be similar to LAI-FLX, with a slight superiority in side-effect and switching rates. This comes at the cost of substantially higher treatment expenses. From a decision-maker's point of view, the use of health insurance data as a source of input for decision models appears to be a reasonable alternative to models driven by clinical data only.

[Intervals between hospitalisations in schizophrenia patients under antipsychotics in depot-form versus oral second generation antipsychotics]

OBJECTIVE

The reduction of the frequency of rehospitalisation is important for improving the outcomes for patients with schizophrenia.

METHODS

This study compares the rate of rehospitalisation between patients with antipsychotics in depot-form (n = 77) and oral second-generation antipsychotics (SGA) (n = 156).

RESULTS

Patients with antipsychotics in depot-form had lower risk of rehospitalisation than with SGAs in oral-form after 24 months (p = 0.027) and 36 months (p = 0.018) (Kaplan-Meyer survival analysis, Log-Rank). Long intervals between two hospitalisations were found for flupentixol depot and clozapine.

CONCLUSIONS

Antipsychotics in depot-form require and active and close outpatient treatment, which may account for long intervals between hospitalisation improved outcomes for patients with schizophrenia.

THE IMPACT OF SELF-HELP GROUP ATTENDANCE ON RELAPSE RATES AFTER ALCOHOL DETOXIFICATION IN A CONTROLLED STUDY

AIMS

Self-help groups such as Alcoholics Anonymous (AA) are widely recommended for aftercare of alcohol-dependent persons, even though scientific knowledge of its effectiveness is inconsistent. The aim of the present analysis was to elucidate whether persons attending AA groups regularly after detoxification have lower relapse rates within 1 year, compared to persons without self-help group attendance.

METHODS

Data for the present analysis were derived from the placebo-group of a multi-centre study in Germany (Wiesbeck et al., 2001). Patients were free to choose either self-help group attendance (N = 50) or no support (N = 28).

RESULTS

After 1-month of follow-up, there was a lower relapse rate in patients attending a self-help group as compared to the control group, a difference, however, that leveled off during the following months. Moreover, relapse rates did not differ significantly at any point of time between both groups. Levels of social functioning improved in both groups over 1 year.

CONCLUSIONS

The present study was unable to show an advantage of self-help group attendance in reducing relapses compared to the control group.

Modulator-induced interference in functional cross talk between the substrate and the ATP sites of human P-glycoprotein

The human P-glycoprotein (Pgp, ABCB1) is an ATP-dependent efflux pump for structurally unrelated hydrophobic compounds, conferring simultaneous resistance to and restricting bioavailability of several anticancer and antimicrobial agents. Drug transport by Pgp requires a coordinated communication between its substrate binding/translocating pathway (substrate site) and the nucleotide binding domains (NBDs or ATP sites). In this study, we demonstrate that certain thioxanthene-based Pgp modulators, such as cis-(Z)-flupentixol and its closely related analogues, effectively disrupt molecular cross talk between the substrate, and the ATP, sites without affecting the basic functional aspects of the two domains, such as substrate recognition, binding, and hydrolysis of ATP and dissociation of ADP following ATP hydrolysis. The allosteric modulator cis-(Z)-flupentixol has no effect on [alpha-(32)P]-8-azido-ATP binding to Pgp under nonhydrolytic conditions or on the K(m) for ATP during ATP hydrolysis. Both hydrolysis of ATP and vanadate-induced [alpha-(32)P]-8-azido-ADP trapping (following [alpha-(32)P]-8-azido-ATP breakdown) by Pgp are stimulated by the modulator. However, the ability of Pgp substrates (such as prazosin) to stimulate ATP hydrolysis and facilitate vanadate-induced trapping of [alpha-(32)P]-8-azido-ADP is substantially affected in the presence of cis-(Z)-flupentixol. Substrate recognition by Pgp as determined by [(125)I]iodoarylazidoprazosin ([(125)I]IAAP) binding both in the presence and in the absence of ATP is facilitated by the modulator, whereas substrate dissociation in response to vanadate trapping is considerably affected in its presence. In the Pgp F983A mutant, which is impaired in modulation by cis-(Z)-flupentixol, the modulator has a minimal effect on substrate-stimulated ATP hydrolysis as well as on substrate dissociation coupled to vanadate trapping. Finally, cis-(Z)-flupentixol has no effect on dissociation of [alpha-(32)P]-8-azido-ADP (or ADP) from vanadate-trapped Pgp, which is essential for subsequent rounds of ATP hydrolysis. Taken together, our results demonstrate a distinct mechanism of Pgp modulation that involves allosteric disruption of molecular cross talk between the substrate, and the ATP, sites without any direct interference with their individual functions.

[Incidence of rigor during treatment with flupentixol decanoate in comparison to risperidone]

STUDY OBJECTIVE

We investigated as to whether dosedependent extrapyramidal tolerance of Flupentixol decanoate is inferior to that of Risperidone.

METHOD

143 Risperidone and 177 Flupentixol decanoate treated patients were consecutively entered into this non - randomized open study and assessed with the Simpson-Angus-Scale regarding presence of rigor. Treatment comparisons of rigor frequency was done by Kaplan-Meier analysis.

RESULTS

The risk of rigor increased with dose on both treatments. EPMS-risk was not increased under treatment with Flupentixol decanoate (mean dose 35.06 +/- 19.7 mg/2 weeks) compared to Risperidone (mean daily dose: 5.2 +/- 2.5 mg/kg) when comparable weight standardized Haloperidol equivalence doses (WHE) were used.

CONCLUSION

This study offers limited evidence for methodological reasons. Yet, results do not support the view that EPS are more frequent on Flupentixol decanoate than on Risperidone when doses are comparable.

Long-acting injectable risperidone: safety and efficacy in stable patients switched from conventional depot antipsychotics

Long-acting injectable risperidone was assessed in schizophrenia patients who were symptomatically stable on conventional depot antipsychotics and who were then switched to long-acting risperidone. Participants in this open-label, multicentre, 12-week trial had received flupenthixol decanoate, fluphenazine decanoate, haloperidol decanoate, or zuclopenthixol decanoate for 4 months or longer. Each was considered symptomatically stable by investigators. After receiving two cycles of their conventional depot antipsychotic during the run-in period, patients were switched to receive long-acting risperidone every 2 weeks for 12 weeks at an initial dose of 25 mg. This dose could be increased in 12.5-mg increments at 4-week intervals. Ninety-two percent of the patients received all six injections; 62% received the 25-mg dose throughout the treatment period. Adverse events related to movement disorders were reported in 3%. Severity of movement disorders decreased during long-acting risperidone treatment. Positive and Negative Syndrome Scale (PANSS) total and factor scores and scores on the Clinical Global Impressions severity scale were significantly reduced during treatment; 48% of these stable patients showed further symptom improvement (> or =20% decrease in PANSS score at endpoint). The results indicate that patients with schizophrenia who are symptomatically stable during treatment with a conventional depot antipsychotic can be safely and effectively switched to long-acting injectable risperidone without a prior transition to oral risperidone.

A selective 19F nuclear magnetic resonance spectroscopic method for the assay of the neuroleptic drug cis(Z)-flupentixol in human serum

This investigation was carried out to evaluate 19F nuclear magnetic resonance as an analytical tool for the measurement of the cis(Z) and trans(E) stereoisomers of the antipsychotic drug flupentixol in human serum. The method is based on the integration of appropriate signals of both analytes and an internal standard. The proposed method was applied to the analysis of real samples without any interference, manipulation of large samples, and lengthy instrument time. Experimental parameters were selected to optimize accuracy, precision, and analysis time. The calibration curves in human serum matrix were linear for cis(Z)- and trans(E)-flupentixol over the ranges 4.0-50.0 and 2.6-25.0 microg/mL, respectively, with respective minimum detectable limits (S/N=3) of 1.67 and 1.72 microg/mL. The method was validated through spike and recovery for the two isomers of flupentixol from a human serum matrix.

Flupenthixol in relapse prevention in schizophrenics with comorbid alcoholism: results from an open clinical study

Substance use, especially alcoholism, has been recognized as a significant problem in schizophrenic patients, though only a few studies on the effects of pharmacotherapy in these patients have been conducted so far. The thioxanthene neuroleptic flupenthixol, which can be given intramuscularly (i.m.) for improving compliance, has been studied as a possible anti-craving drug both in animal models of alcoholism and some clinical studies. Pilot studies suggest that comorbid schizophrenics with substance use may benefit from treatment with flupenthixol. Efficacy of flupenthixol (10-60 mg i.m.) in reducing alcohol consumption of dual diagnosis patients was studied in an open 6-month clinical trial in 27 schizophrenics with comorbid alcoholism. Twenty-one patients entered the intention-to-treat analysis. Fourteen subjects were completers, 13 dropped out. Six patients completely abstained from alcohol during treatment. Alcohol consumption was significantly reduced compared to baseline (4 weeks before treatment as measured by timeline follow-back interview). In general, while patients showed a marked improvement concerning alcohol consumption, only a slight improvement in psychopathology was recorded. Overall tolerability was good. These data indicate a probable beneficial effect of flupenthixol in schizophrenic patients with comorbid alcoholism. Although the efficacy of flupenthixol as an anti-craving drug in dual diagnosis patients has to be explored in further studies, the drug may be considered a promising medication for these patients.

Role of AMPA and NMDA receptors in the nucleus accumbens shell in turning behaviour of rats: interaction with dopamine receptors

The role of AMPA and NMDA receptors in the shell of the nucleus accumbens in turning behaviour of rats was investigated. Unilateral injection of the AMPA receptor agonist, AMPA (0.25, 0.4, 0.5 and 1 microg), into the shell of the nucleus accumbens dose-dependently produced contraversive pivoting, namely tight head-to-tail turning marked by abnormal hindlimb backward stepping, while injection of AMPA (0.5 microg) into the core produced only a marginal effect. This shell-specific AMPA effect was dose-dependently inhibited by the AMPA receptor antagonist, NBQX (1 and 10 ng), which alone did not produce turning behaviour. The AMPA-induced pivoting was also dose-dependently inhibited by the non-competitive NMDA receptor antagonist, MK-801 (0.1 and 0.5 microg). Neither MK-801 (0.1, 0.5 and 5 microg) nor the NMDA receptor agonist, NMDA (0.5 and 1 microg), injected unilaterally into the shell, produced turning behaviour. Unilateral injection of a mixture of dopamine D(1) (SKF 38393, 5 microg) and D(2) (quinpirole, 10 microg) receptor agonists into the shell has been found to elicit contraversive pivoting. The dopamine D(1)/D(2) receptor antagonist, cis-(Z)-flupentixol (1 and 10 microg), injected into the shell, in doses known to block dopamine D(1)/D(2) receptor-mediated pivoting, also significantly inhibited AMPA (0.5 microg)-induced pivoting. Moreover, both NBQX (1 and 10 ng) and MK-801 (0.1 and 0.5 microg), injected into the shell, significantly inhibited dopamine D(1)/D(2) receptor-mediated pivoting. It is therefore concluded that unilateral stimulation of AMPA receptors in the shell of the nucleus accumbens can elicit contraversive pivoting, and that both AMPA and dopamine D(1)/D(2) receptors play a critical role in shell-specific pivoting in contrast to NMDA receptors that at best play only a modulatory role.

[The risk of rehospitalisation during therapy with atypical and typical neuroleptics--a contribution to differential indication]

Atypical neuroleptics have a lot of advantages compared with conventional substances. It is still disadvantageous that a depot-medication is missing. The role of the form of application has been studied in a schizophrenia-out-patient department. In 25 out-patients under therapy with atypical neuroleptics the time of rehospitalisation per year was retrospectively determined and compared with that of 25 out-patients receiving depot-medication. Both groups were comparable with regard to some patient-characteristics and predictors of the course of the disease. It turned out that for patients with depot-neuroleptics the time spent in hospital per year was half of that for patients under atypical drugs. It had been in the same range in both groups 4 to 6 years ago and had decreased until the last year of the catamnesis in patients with depot-medication, but not in those with atypics. Typical neuroleptics as oral medication are disadvantageous in this respect. Despite efforts to reach a good compliance in all patients, preferable effects of atypical drugs with regard to negative symptoms are opposed by less favourable rehospitalisation times. This has to be taken into consideration in differential indication.

A falling HbA1c is not necessarily an indicator of improving diabetes control

The finding of a very low haemoglobin A1c (HbA1c) (1.4%) in a diabetic patient with fairly high plasma glucose levels prompted haematological investigations, which revealed auto-immune haemolysis and a Hb concentration of 7.7 g/L. Following treatment, both Hb and HbA1c concentrations increased roughly in parallel until, 4 months later, Hb was 13.8 g/L, HbA1c 5.2% and plasma glucose was 6.8 mmol/L. This case illustrates that a falling HbA1c cannot always be attributed to improving glucose control in diabetic patients.

Depot flupenthixol decanoate for schizophrenia or other similar psychotic disorders

BACKGROUND

Anti-psychotic drugs are the mainstay treatment for schizophrenia and similar psychotic disorders. Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment.

OBJECTIVES

To evaluate the effects flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, in terms of clinical, social and economic outcomes.

SEARCH STRATEGY

Relevant trials were identified by searching Biological Abstracts (1982-1998), Cochrane Library (Issue 2, 1998), Cochrane Schizophrenia Group's Register (December 1998), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). The references of all identified trials were inspected for more studies and the first author of each included trial and relevant pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared to placebo or other antipsychotic drugs. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data Peto odds ratios (OR) with 95% confidence intervals (CI) were estimated. Where possible, the number needed to treat statistic (NNT) was also calculated. Analysis was by intention-to-treat. Normal continuous data were summated using the weighted mean difference (WMD). Scale data were presented only for those tools that had attained pre-specified levels of quality.

MAIN RESULTS

No trials compared flupenthixol decanoate to placebo. One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). There were no clear differences between the two preparations. When flupenthixol decanoate was compared to other depot preparations, there were no differences between depots for outcomes such as death, global impression, relapse (OR 1.16 CI 0.7-1.9) or leaving the study early (OR 1.00 CI 0.6-1.7). Two small studies suggest that flupenthixol decanoate is responsible for less movement disorders than other depot antipsychotic drugs (OR 0.23 CI 0.08-0.7, NNT 5). This finding did not hold for specific side effects, such as tremor (OR 1.2 CI 0.3-4) and tardive dyskinesia (OR 1.60 CI 0.4-6). Two trials comparing high doses of flupenthixol decanoate to the standard approximately 40mg per injection reported no significant difference for the outcome of relapse (OR 0.32 CI 0.09-1.2). One small (n=59) trial comparing a very low dose of flupenthixol decanoate ( approximately 6 mg/IM) to a very low dose approximately 9 mg per injection also reported no difference in relapse rates (OR 0.3 CI 0.1-1.1).

REVIEWER'S CONCLUSIONS

From the data reported in clinical trials, it would be understandable if those suffering from schizophrenia, who are willing to take flupenthixol decanoate, would request the standard dose rather than the high dose. In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. The choice of which depot to use must therefore be based on clinical judgement and the preferences of people with schizophrenia and their carers. Managers and policy makers should expect better data than the research community has provided thus far. This review highlighted the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate, in particular when compared to oral antipsychotics. Future studies should also consider hospital and service outcomes, satisfaction with care and record economic data.

Inhibitory effect of alkylating modulators on the function of P-glycoprotein

Modulators of P-glycoprotein (P-gp) are often themselves transported out of cells, thereby limiting their effectiveness. It may be possible to develop more effective modulators of multidrug resistance by designing drugs that irreversibly block the function of P-gp. Therefore, we studied the effect of the mustard derivatives of fluphenazine (FPN) and trans-flupenthixol (FPT) on P-gp function. Both fluphenazine-mustard (FPN-M) and trans-flupenthixol-mustard (FPT-M) possessed alkylating activity, as assayed using 4-(p-nitrobenzyl) pyridine. Multidrug-resistant MCF-7/AdrR cells were incubated with FPN or FPN-M, or FPT or FPT-M for 1 h, washed for varying number of times in phosphate-buffered saline (PBS), then resuspended in medium containing [3H]vinblastine (VBL), and assayed for steady-state accumulation of the drug. Washing had far less of an effect on the ability of FPN-M and FPT-M to increase VBL accumulation compared to their parent compounds. After eight washes in excess PBS, the cells initially exposed to FPN or FPT accumulated only 30% and 50% of the initially accumulated drug, whereas the FPN-M- or FPT-M-treated cells accumulated approximately 75% and 90% of the control, respectively. FPN-M and FPT-M also increased the uptake and decreased the efflux of VBL from MDR cells despite repeated washing. We also examined the effects of these modulators on sensitivity of MDR cells to cytotoxic agents. FPN-M and FPT-M sensitized MCF-7/AdrR cells to VBL and doxorubicin to a greater extent than their parent compounds. These studies point out the potential of "irreversible" P-gp modulators to produce prolonged chemosensitization.

[Total illness costs of schizophrenia and monetary evaluation of prevention of recurrence exemplified by a standard depot neuroleptic (flupenthixol decanoate)]

Treatment of patients suffering from schizophrenia is very expensive. However, by consistently and methodically performed medical prophylaxis the disease can be controlled sufficiently well. Regular prophylactic treatment compared to repeated treatment of acute episodes has both medical advantages and reduces cost by reducing the rate of hospitalisation. Prophylactic treatment with Flupentixoldecanoat can save up to 68% of costs.

Tolerability of low dose neuroleptics: a case control study of flupenthixol

There are no data available on the risk of extrapyramidal symptoms when using long-term flupenthixol in low dosage in patients suffering from anxiety and depressive disorders. In a case control study 106 patients essentially treated with the neuroleptic flupenthixol in a so-called low, non-antipsychotic dosage were compared to n=37 otherwise comparable patients who never had been treated with neuroleptics. The investigator was blind to the previous treatment conditions. Extrapyramidal symptoms were found although with a low prevalence and mild degree: 6.7% tardive dyskinesia, none in controls; pseudoparkinsonism 26%, 16% in controls. Extrapyramidal side-effects, especially tardive dyskinesia, have to be considered in the individual weighing of therapeutic benefits and risks even when prescribing flupenthixol in low dosages.

Large variations of plasma levels during maintenance treatment with depot neuroleptics

BACKGROUND

Stability of neuroleptic medication has been associated with optimal clinical effect and minimal side-effects. Depot administration is assumed to yield better stability.

METHOD

Thirty patients on depot neuroleptic treatment were followed during three years with repeated measurements of plasma level and concurrent ratings of clinical symptoms and side-effects.

RESULTS

Of 120 blood samples 35 (29%) measurements were outside +/-2 s.d. measurement error (expected 5%). Perphenazine levels were more variable (46%) than haloperidol (25%) and flupenthixol (12.5%). No relationship was found between side-effect ratings and fluctuations of plasma levels.

CONCLUSION

Depot neuroleptic medication does not eliminate a clinically unwanted and sometimes marked variation in plasma level.

[Non-compliance and lack of indications for depot treatment as reasons for exclusion from adequate prevention of recurrence]

OBJECTIVE

The paper reports on the recruitment of a multicenter study on ambulant prophylactic treatment of schizophrenic disorders.

METHODS

For a study of the relapse-preventative effect of different dose patterns of Flupentixol, a screening phase was carried out among of 1129 schizophrenic patients. The aim of the screening phase was to establish the criteria for exclusion or inclusion in the treatment phase of the study.

RESULTS

Only 62 patients could be included. The reason for 54 patients not being included was a lack of compliance from either the patient or the clinician. The meaning of patient- and therapist-compliance in carrying out a multicenter study is also discussed.

Subjective experience of treatment, side-effects, mental state and quality of life in chronic schizophrenic out-patients treated with depot neuroleptics

Attitude towards treatment, side-effects, mental state and quality of life was assessed in 53 chronic schizophrenic out-patients on maintenance treatment with depot neuroleptics. It was found that 60% of the patients viewed depot medication positively, while only 8% viewed it negatively. Only 70% of patients complained about side-effects, even though 94% had scored as having them. Hypokinesia and hyperkinesis were the side-effects least noticed by the patients, but most noticed by the treating physician, while the opposite was the case with psychic side-effects. Only 49% of patients thought they had a psychotic illness, and there was no correlation between the patients' own evaluation of the severity of their illness and their score on the Positive and Negative Symptom Scale (PANSS) or the treating physician's evaluation. Quality of life did not correlate with either side-effect score or PANSS score. The schizophrenic patients' assessment of their condition was therefore in general different both from that of the treating physician and from that determined using rating scales.

Morphological and histochemical changes in the liver of albino Wistar rat given flupenthixol depot

Histological findings and histoenzymatic reactions have shown that Flupenthixol Depot (FPX dep.) injected to rats in therapeutic doses induced morphologically observable degenerative lesions in the liver. No significant difference in the intensity of the lesions between the groups of male and female animals was found.

Chronic dopamine antagonism facilitates opiate-induced feeding

Chronic interference with dopamine (DA) transmission has been found to facilitate opiate reward and opiate-induced behavioral activation derived from the nucleus accumbens. This study was aimed at determining the extent to which these effects are generalizable to opiate-induced feeding. Rats were tested for their feeding response to morphine following chronic interference with DAergic transmission with the long-acting neuroleptic, flupenthixol decanoate (FLU). It was found that FLU-treated animals showed an enhanced feeding response to morphine following three and four weeks of DA blockade, but not on weeks 1 and 2. Neither morphine treatment in FLU-control animals nor chronic FLU treatment alone produced any such time-dependent facilitation in feeding. The results indicate that the increased sensitivity to the rewarding effects of opiates following chronic DA blockade is generalizable to opiate-induced feeding.

Successful treatment with flupenthixol decanoate of a patient with both schizophrenia and alcoholism

There is growing evidence that substance abuse is a major problem in patients with schizophrenia. With respect to alcohol, alledegly the most frequently abused drug among schizophrenics, clinical and epidemiological studies would suggest that the risk of alcoholism is approximately four times greater (Cuffel, 1992; Mueser et al., 1990; Soyka et al., 1993; Soyka, 1994). A variety of hypotheses have been proposed to explain this phenomenon, including the so-called "self-medication hypothesis". Some authors feel that substance abuse in schizophrenics might be due to extrapyramidal and other side-effects caused by neuroleptic treatment or inadequate remission of psychotic symptoms. There remains, at present, an obvious lack of both psychosocial and psychopharmacological studies of treatment in "dual diagnosis" schizophrenics (Mueser et al., 1992). Changes in dopaminergic neurotransmission and dopamine-receptor dysfunction have been linked both to the development of psychotic symptoms and to alcoholism/substance abuse, and thus give rise to the question as to whether some dual diagnosis patients might benefit from neuroleptic treatment in both domains. A number of dopamine receptor subtypes in different regions of the brain seems to be involved in the development of schizophrenia and substance abuse. Modifications of D2-receptor subtype function have been implicated in psychotic symptoms, and changes in the D1- and D2-receptor function in substance abuse such as cocaine abuse and alcoholism (Spealman et al., 1990; 1991; 1992), especially in the mesolimbic dopaminergic reward system. Accordingly, the "ideal" neuroleptic drug for dual diagnosis schizophrenics should be effective in both receptor subtypes.(ABSTRACT TRUNCATED AT 250 WORDS)

A single injection of either flupenthixol decanoate or haloperidol decanoate produces long-term changes in cocaine self-administration in rats

The effect of decanoate forms of flupenthixol and haloperidol on cocaine self-administration was evaluated. Forty-two male Wistar rats were implanted with chronically indwelling jugular cannulae and trained to self-administer cocaine (0.6 mg/inj) either on a fixed ratio (FR) 1 schedule or a progressive ratio (PR) schedule. After a stable response pattern was established, animals received a single i.m. injection of either flupenthixol (2.0 mg), haloperidol (2.5 mg) or vehicle (0.1 ml oil). Both neuroleptics produced a long lasting increase in cocaine intake on a FR 1 schedule which reached a peak on post-injection day three and diminished slowly over the next seven days. All animals maintained on a PR schedule showed a long lasting decline in breaking points. These data suggest that the decanoate forms of flupenthixol and haloperidol may attenuate the reinforcing effects of cocaine and indicate that the therapeutic value of depot neuroleptics as anti-cocaine treatments would depend on the economics of cocaine availability.

Correct titration of non-drugs and some other methodological issues

Doctors' prescription and dosing behaviour was investigated using data from 9 clinical trials in 550 patients treated with psychotropics. 7 trials were conducted under double- and 2 under single-blind conditions. In 3 of these trials, oral and i.m. preparations were used demanding a double-dummy design. All patients were evaluated on a weekly or 2-week basis using psychopathological rating scales (i.e. Hamilton Anxiety Scale, Hamilton Depression Scale, Clinical Global Impressions, Simpson and Angus EPS). It was found that (a) oral-medication titration was 3- to 4-fold more broad-ranging than i.m. medication titration, (b) oral placebo was titrated to the same extent as the oral investigational drugs, and (c) the titration schedule did not follow protocol requirements. Moreover, the average doses in all drug and placebo groups were the same. Concomitant medication like sleep inducers was found to be more closely related to doctors' habits than to actual medical need. Independent of trial and investigational drug, 10-33% of all patients received additional sleep inducers.

Changing the light intensity of the visual environment results in large differences in numbers of synapses and in photoreceptor size in the retina of the young adult rat

A quantitative light- and electron-microscopic study has been made of the retinae of rats which were exposed to different lighting conditions for between one and 15 weeks in young adulthood, having been reared in identical conditions during development. The width of the inner and outer segments of the photoreceptors and the width of the outer plexiform layer varied inversely with the light intensity under diurnal lighting conditions of 10 h light/14 h dark. Linear regression analysis showed that the widths were inversely related to the fourth root of the light intensity as measured in lux. Both central and peripheral areas of retina showed a similar change. No change was seen in the widths of the inner plexiform layer, or of the inner and outer nuclear cell layers. Nor was there a difference in the packing density or size of the nuclei in the nuclear cell layers. The number of ribbon synapses in the outer plexiform layer also varied inversely with the intensity of diurnal light. Linear regression analysis showed that the number of synapses was inversely correlated with the fourth root of the light intensity and was positively correlated with the width of the outer plexiform layer. The number of ribbon synapses was increased by up to two and a half times in constant darkness compared to diurnal light of 35 lux. The increase was present but not maximal after one week of exposure. The length of synaptic ribbons was unchanged. The nerve terminals forming such synapses were increased in size but not in number. After one week, there was little or no additional change in the retinal widths and number of synaptic ribbons with time. However, there was a progressive increase with time in nerve terminal size (two-fold in area) in constant darkness. There was some evidence of a slight decrease in nerve terminal number and increase in size of retinal nuclei with age. It is concluded that the adult retina responds to a different lighting environment by a relatively rapid change in the size of photoreceptor segments, by a progressive and large change in number of ribbon synapses and by a slower progressive and large change in the size of photoreceptor nerve terminals. The response is quantitatively determined by the strength of the stimulus but not in a linear fashion. These results are compared with the effects of environmental stimulation of other areas of the nervous system.

The decanoates of flupenthixol and clopenthixol in the treatment of chronic schizophrenic in-patients. Implications for community psychiatry

Vagrant chronic schizophrenic subjects in a stable untreated state received in-patient treatment with either Flupenthixol decanoate or Clopenthixol decanoate. Both drugs were found to be significantly effective and well tolerated. The apparent better response to Flupenthixol decanoate was seen as dose-dependent. The findings and their implications for Community Psychiatry, particularly in developing countries are discussed.

The Scottish first episode schizophrenia study. VIII. Five-year follow-up: clinical and psychosocial findings. The Scottish Schizophrenia Research Group

Forty-four schizophrenic patients were followed up for five years after their first admission to hospital for a first episode of illness. Thirteen (30%) of 43 patients had not relapsed; 28 of the 30 patients who did relapse did so within the first 42 months. The relapses occurred despite antipsychotic drug therapy. Also, 24% of patients had at least one course of ECT. Only 19% of the patients at five years were in open employment; unemployment was strongly associated with relapse. Eighteen per cent had neither relapses nor schizophrenic symptoms at follow-up. Poor outcome at five years was associated with greater psychological distress among relatives at first admission. At five years 43% of relatives continued to show case level psychological stress.

Efficacy and tolerability of flupenthixol decanoate in the treatment of depression and psychosomatic disorders: a multicenter trial in general practice

1. A number of controlled as well as uncontrolled studies indicate that flupenthixol in a low-dose regimen is effective in treating syndromes with depression, anxiety, and psychosomatic disorders. 2. In view of the low compliance rates among patients suffering from depressive syndromes, the author evaluated the efficacy and tolerability of flupenthixol decanoate i.m. in an unselected collective of such patients treated in general practices. 3. Flupenthixol decanoate i.m. induced remission in 25% of patients suffering from chronic pain, in 29% of patients with psychosomatic disorders. Patients with depression and anxiety remitted in 27% of the cases. Therapeutic benefit was seen in more than 90% of the patients. 4. The best results were observed in patients 1) who had not been treated with psychotropic drugs before, 2) whose disease had a duration of less than one year, 3) who were under 40 years of age, and 4) who were treated with a dose lower than 0.5 ml (10 mg flupenthixol decanoate).

Rationalizing neuroleptic polypharmacy in chronic schizophrenics: effects of changing to a single depot preparation

This study investigated the effects of transferring patients on combined depot and oral neuroleptics to a single depot preparation; a secondary objective was to assess the effects of transferring patients from one depot neuroleptic to another. It was found that, whereas transferring from one depot preparation (flupenthixol) to another (fluphenazine) had no clear disadvantage for the patients, changing over from a combined oral and depot (fluphenazine) regimen to equivalent doses of depot alone resulted in an unacceptably high rate of relapse. The reasons for this may relate to either the unique pharmacokinetics of these drugs or subtle qualitative differences between them. It is suggested that caution is necessary whenever attempts are made to rationalize polypharmacy in schizophrenic patients.

Perphenazine decanoate and cis(z)-flupentixol decanoate in maintenance treatment of schizophrenic outpatients. Serum levels at the minimum effective dose

Two groups of schizophrenic outpatients were treated with perphenazine decanoate (N = 20) and cis(z)-flupentixol decanoate (N = 24) respectively. Every 3 months the dose was gradually reduced until symptoms appeared that were suggestive of a prodromal phase of a psychotic episode. A slightly higher dose was then promptly reinstituted (the minimum effective dose). At each dose level, two blood samples were drawn for determination of serum concentration. The mean minimum effective dose of perphenazine decanoate was 99.3 mg/2 weeks (range 21.6-270.5), while the mean minimum effective dose of cis(z)-flupentixol decanoate was 60 mg/2 weeks (range 20-250). The corresponding mean serum level of perphenazine decanoate was 7.3 nmol/l (range 2.0-18.1) and of cis(z)-flupentixol decanoate 7.8 nmol/l (range 1.2-37.0). There was a significant correlation between the administered doses and the corresponding serum levels for both drugs (r = 0.87, P less than 0.01). A weak positive correlation was found between serum levels at the minimum effective dose and symptom intensity (BPRS total score) (r = 0.53, P less than 0.02) for perphenazine, but not cis(z)-flupentixol. No correlation was found between serum levels and side effects or length of neuroleptic treatment. It is concluded that the serum drug concentrations corresponding to the lowest effective dose are so variable that routine serum level monitoring may be of limited value in the long-term maintenance treatment of schizophrenia.

The Scottish first episode schizophrenia study. VII. Two-year follow-up. Scottish Schizophrenia Research Group

Of 49 schizophrenic patients followed up 2 years after their first admission to hospital, 37% were well, 47% had been readmitted to hospital at some time over the 2 years, and 38% showed schizophrenic symptoms at follow-up. A poor outcome at 2 years was associated with male sex, poor outcome after the first 5 weeks of the first admission, negative schizophrenic symptoms on first admission, and a diagnosis of definite or probable schizophrenia using the Feighner criteria. Only 23% were in employment. A small double-blind discontinuation study of maintenance antipsychotic medication during the second year found more relapses in those switched to placebo medication. Repeat psychometric assessment at 2 years confirmed modest improvements found at 12 months; that is, there was no evidence of intellectual decline. Relatives showed no more psychosocial distress than that found in a normal community sample; what distress there was correlated with patients' schizophrenic symptoms.

Neuroleptic malignant syndrome: another medical cause of acute abdomen

We present a patient with neuroleptic malignant syndrome and intestinal pseudo-obstruction misdiagnosed as being secondary to septicaemia. The management of the patient is discussed with emphasis on the role of creatine kinase and liver function tests.

Two cases of agranulocytosis on addition of a butyrophenone to a long-standing course of phenothiazine treatment

Two cases of agranulocytosis occurring after addition of a butyrophenone to a course of phenothiazine treatment are reported and possible mechanisms for this interaction are discussed.

Outpatient treatment of 'crack' cocaine smoking with flupenthixol decanoate. A preliminary report

"Crack" cocaine abuse often produces severe cocaine dependence that is refractory to available pharmacological and outpatient psychotherapeutic treatments. We conducted two preliminary investigations evaluating the efficacy of flupenthixol decanoate, a depot xanthene requiring infrequent intramuscular administration, in the treatment of cocaine withdrawal. Ten outpatient crack cocaine smokers with poor prognoses were administered flupenthixol decanoate in an open-label, open-ended trial. Flupenthixol decanoate was well tolerated and appeared to decrease cocaine craving and use markedly and rapidly, producing a 260% increase in the average time retained in treatment among these subjects. These promising but preliminary data, combined with the magnitude of problems presented by crack, warrant rapid, expanded double-blind assessment of flupenthixol decanoate in cocaine-abuse treatment.

The Scottish First Episode Schizophrenia Study V. One-year follow-up. The Scottish Schizophrenia Research Group

Of 49 schizophrenic patients followed up 12 months after their first admission to hospital, only about 45% had experienced no relapse and had no schizophrenic symptoms; a poorer outcome was more often found in Feighner positive than Feighner negative schizophrenic patients. The patients' overall level of unemployment had more than doubled to 51%. In patients whose acute episodes responded to treatment, pimozide taken once weekly as maintenance therapy was as effective as intramuscular flupenthixol decanoate, but tardive dyskinesia appeared in two patients receiving weekly pimozide; the repeat psychometric assessment at 12 months found modest improvements, i.e. no evidence of intellectual decline, in Matrices, Block Design, and Digit Copying tests. Forty per cent of relatives still showed significant psychological distress, which correlated with patients' schizophrenic symptoms, and the relatives' social functioning remained poorer than that of a normal community sample.

Radioreceptor assay in checking serum concentration in long-term treatment with cis(z)-flupenthixol decanoate

24 patients have been treated with cis(z)-flupenthixol decanoate for 6-12 months. Intramuscular injections were given about every 3 weeks. Before treatment and on each day of injection the mental state was assessed by BPRS and registration of side effects was performed. Blood samples were taken 7 days after each injection and on the last day of the dosage interval. Neuroleptic activity was determined in serum by RRA and expressed in cis(z)-flupenthixol equivalents. The drug level was significantly correlated to the dose. No clear relationship between drug level and clinical results as well as side effects was found. Less pronounced variations of the drug level between subsequent injections resulted in a positive therapeutic response.

Double-blind comparison of half-dose and standard-dose flupenthixol decanoate in the maintenance treatment of stabilised out-patients with schizophrenia

A double-blind controlled trial of 50% dose reduction in maintenance treatment in stable out-patients with low BPRS scores and good social function shows a significantly higher relapse rate in the low-dose group at 12 months (P less than 0.05). After an interval of 24-36 months from dose reduction, 56-76% had experienced a relapse and 76-79% had resumed their former dosage. No clear advantage was shown for the lower dose in either a reduction of side-effects or improved social function, but a reduced prevalence or lower rate of symptom emergence for tardive dyskinesia was suggested.