Adverse effects of atypical antipsychotics : differential risk and clinical implications

Group II metabotropic glutamate receptors and schizophrenia

Schizophrenia is one of the most common mental illnesses, with hereditary and environmental factors important for its etiology. All antipsychotics have in common a high affinity for monoaminergic receptors. Whereas hallucinations and delusions usually respond to typical (haloperidol-like) and atypical (clozapine-like) monoaminergic antipsychotics, their efficacy in improving negative symptoms and cognitive deficits remains inadequate. In addition, devastating side effects are a common characteristic of monoaminergic antipsychotics. Recent biochemical, preclinical and clinical findings support group II metabotropic glutamate receptors (mGluR2 and mGluR3) as a new approach to treat schizophrenia. This paper reviews the status of general knowledge of mGluR2 and mGluR3 in the psychopharmacology, genetics and neuropathology of schizophrenia.

Management of schizophrenia with obesity, metabolic, and endocrinological disorders

People with schizophrenia have an increased prevalence of overweight/obesity, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome, which increases the risk for cardiovascular diseases and mortality. Part of this increased risk is attributable to the use of antipsychotic medications, especially second-generation antipsychotics. Antipsychotic drugs differ in their potential to induce weight gain, with clozapine and olanzapine exhibiting the highest weight gain liability; evidence for differing effects of antipsychotics on glucose and lipid metabolism is less convincing. Individuals with schizophrenia may develop hyperprolactinemia, with or without clinical symptoms, after starting antipsychotic medications. This effect is particularly frequent with first-generation antipsychotics and with the second-generation antipsychotic risperidone and paliperidone. Psychiatrists should be aware of metabolic and endocrine side effects of antipsychotics and should make every effort to prevent or minimize them to improve the patients' compliance and quality of life.

Mania and mortality: why the excess cardiovascular risk in bipolar disorder?

Individuals with bipolar disorder experience twice the cardiovascular mortality expected from general population estimates. The metabolic syndrome is more common in those with bipolar disorder, with a prevalence ratio of 1.6, and includes many traditional cardiovascular risk factors, which may explain much of the elevated risk. Manic symptom burden also predicts cardiovascular mortality, begging questions regarding other explanations for elevated cardiovascular risk. Ultimately, the mechanisms that lead to elevated cardiovascular risk in bipolar disorder are complex and potentially involve behavior, treatment, access to quality health care, and underlying pathophysiology. Much remains unknown about the etiology of any mechanisms inherent to illness or, for that matter, treatment effects. Addressing access and health behaviors can mitigate risk for individuals with bipolar disorder. Recent evidence indicates that psychiatrists are becoming aware of the vascular risk associated with bipolar disorder, although further education will improve monitoring and subsequent outcomes.

Asenapine versus olanzapine in acute mania: a double-blind extension study

OBJECTIVE

To assess the efficacy and tolerability of asenapine versus olanzapine in the extended treatment of bipolar mania.

METHODS

Patients with bipolar I disorder experiencing acute manic or mixed episodes who completed either of two 3-week, double-blind trials with asenapine 5 or 10 mg twice daily, olanzapine 5 to 20 mg once daily, or placebo were eligible for this 9-week, double-blind extension study. Patients receiving active medication in the 3-week trials continued the same regimen; those who had received placebo were blindly switched to asenapine but were assessed for safety outcomes only. The primary efficacy measure was the change from baseline to day 84 on the Young Mania Rating Scale (YMRS) total score in the per-protocol population. Results on the primary efficacy outcome were used to determine the noninferiority of asenapine versus olanzapine.

RESULTS

A total of 504 patients (placebo/asenapine, n = 94; asenapine, n = 181; olanzapine, n = 229) were enrolled in the extension study. At day 84, the mean (SD) change from baseline in YMRS total score was -24.4 (8.7) for asenapine and -23.9 (7.9) for olanzapine. Prespecified statistical analysis for noninferiority indicated no significant difference between asenapine and olanzapine. The overall incidence of treatment-emergent adverse events was similar across treatment groups (77% placebo/asenapine, 77% asenapine, 78% olanzapine). Clinically significant weight gain occurred in 10%, 19%, and 31% of the placebo/asenapine, asenapine, and olanzapine groups, respectively.

CONCLUSIONS

Asenapine was efficacious, showed noninferiority to olanzapine, and was well tolerated in the extended treatment of patients experiencing manic symptoms associated with bipolar I disorder.

Effects of switching to long-acting injectable risperidone from oral atypical antipsychotics on cognitive function in patients with schizophrenia

OBJECTIVE

To investigate changes in cognitive function and clinical features following a switch from oral atypical antipsychotics (AAPs) to long-acting injectable risperidone (LAIR) in patients with schizophrenia.

METHODS

Thirty-six patients with schizophrenia treated with oral AAPs participated in this open-label, 26-week study. Cognitive functions were measured at baseline and at 12 and 26 weeks. The secondary outcome measures included the Positive and Negative Syndrome Scale (PANSS), Social and Occupational Functioning Assessment Scale (SOFAS), Scale for Unawareness of Mental Disorder (SUMD), and measurements for extrapyramidal symptoms.

RESULTS

Significant improvements in cognitive function were observed in the backward Digit Span Test, Verbal Learning Test, Wisconsin Card Sorting Test, correct responses on the Continuous Performance Test, and Trail Making Test part B following a switch to LAIR. Scores on the PANSS, SOFAS, SUMD, and the Simpson-Angus Rating Scale also improved significantly. Most improvements in neurocognitive function were not correlated with clinical measures. Weight gain and hyperprolactinemia were the most common adverse events.

CONCLUSIONS

Switching from oral AAPs to LAIR improved cognitive function including vigilance, verbal learning and memory, executive function, sustained attention, and visuomotor speed in patients with schizophrenia. It was also effective for improving psychotic symptoms, social functioning, and insight.

Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC)

People with severe mental illnesses, such as schizophrenia, depression or bipolar disorder, have worse physical health and reduced life expectancy compared to the general population. The excess cardiovascular mortality associated with schizophrenia and bipolar disorder is attributed in part to an increased risk of the modifiable coronary heart disease risk factors; obesity, smoking, diabetes, hypertension and dyslipidaemia. Antipsychotic medication and possibly other psychotropic medication like antidepressants can induce weight gain or worsen other metabolic cardiovascular risk factors. Patients may have limited access to general healthcare with less opportunity for cardiovascular risk screening and prevention than would be expected in a non-psychiatric population. The European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) published this statement with the aim of improving the care of patients suffering from severe mental illness. The intention is to initiate cooperation and shared care between the different healthcare professionals and to increase the awareness of psychiatrists and primary care physicians caring for patients with severe mental illness to screen and treat cardiovascular risk factors and diabetes.

Efficacy and safety of quetiapine for depressive symptoms in patients with schizophrenia

OBJECTIVE

To investigate the efficacy and safety of quetiapine for depressive symptoms in patients with schizophrenia.

METHOD

Thirty-nine patients fulfilling DSM-IV-TR diagnostic criteria for schizophrenia and had depressive symptoms were studied in a prospective 6-week open-label design using quetiapine monotherapy. The brief psychiatric rating scale (BPRS), 17-item Hamilton depression rating scale (HAMD-17), Simpson-Angus rating scale, and the Barnes Akathisia rating scale (BARS) were used to assess patients at baseline, week 1, 2, 4, and 6.

RESULTS

Thirty patients (76.9%) completed this study. The dose of quetiapine at endpoint was 583 (+/-235 SD) mg/day. Treatment with Quetiapine was associated with significantly reduced depressive symptoms (HAMD-17 total score and BPRS depression/anxiety subscale) from the first week of treatment. Changes of mean score from baseline to endpoint were 7.8 +/- 6.2 for HAMD-17 total score and 3.4 +/- 3.6 for BPRS depression/anxiety subscale (LOCF, n = 39, p < 0.001). Quetiapine was well tolerated, with minimal extrapyramidal symptoms and non-significant increase in body weight (mean increase of 0.8 kg).

CONCLUSIONS

While the interpretation of findings from the open-label design of this study warrants appropriate caution, the results suggest that quetiapine may be an effective and tolerable treatment for depression in patients with schizophrenia.

Drug-induced torsades de pointes: data mining of the public version of the FDA Adverse Event Reporting System (AERS)

AIMS

To investigate spontaneous reports of TdP present in the public version of the FDA Adverse Event Reporting System (AERS) in the light of what is already known on their TdP-liability.

METHODS

Reports of TdP from January 2004 through December 2007 were retrieved from the public version of the AERS database. All reports were selected from REACTION files and the relevant suspected and/or interacting drugs were identified from DRUG files. Qualitative analysis was performed by the case/non-case method. Cases were represented by TdP reports, whereas non-cases were all reports of adverse drug reactions other than TdP. Quantitative analysis was assessed by calculating the crude and adjusted reporting odds ratio (ROR), as a measure of disproportionality, with the 95% confidence interval.

RESULTS

Reports of TdP were 1665 over a 4-year period, involving 376 active substances. Thirty-five drugs with at least 10 reports were identified: amiodarone and methadone were associated with the highest number of cases (113 and 83 respectively) and most of the other reports were ascribable to antibacterials, antidepressants and antipsychotics; remarkable differences in number of cases and ROR were present among agents within each therapeutic class. A disproportionate reporting was also observed for other compounds such as donepezil, famotidine and mitoxantrone.

CONCLUSIONS

Large spontaneous reporting databases represent an important source for signal detection of rare adverse drug reactions (ADR), such as TdP. The number of reports associated to donepezil, famotidine and mitoxantrone could be considered unexpected on the basis of current evidence and needs further investigations on their true TdP-liability.

A UK consensus on the administration of aripiprazole for the treatment of mania

Aripiprazole has recently received approval for the treatment of moderate to severe manic episodes in bipolar I disorder and prevention of new manic episodes in aripiprazole-responsive patients. Aripiprazole differs from other antipsychotics in its pharmacology, and the need for prescribing guidance in the UK was recently identified. A UK multidisciplinary panel was convened in November 2007. This report describes the consensus agreed during the meeting on the optimal approach to prescribing aripiprazole: how best to approach initiation of, and switching to, treatment with aripiprazole and management strategies for side effects. A literature review of the randomised controlled clinical trials of aripiprazole in mania supports these recommendations. Aripiprazole should be initiated at 15 mg/day (range 5-20 mg/day). If necessary, adjunctive medication should be used in early treatment to manage side effects or assist in management of symptoms such as agitation. When switching to aripiprazole, the therapeutic dose of current treatment should be maintained while adding aripiprazole 15 (5-20) mg/day. Only once an effective dose of aripiprazole is reached should previous medication be reduced. Nausea, insomnia and agitation typically resolve within days. Some principles for dosing and switching are provided to assist with a successful treatment outcome with aripiprazole in mania.

Subjective side effects of antipsychotics and medication adherence in people with schizophrenia

AIM

This paper is a report of a study conducted to describe the prevalence of antipsychotic medication side effects in individuals with schizophrenia, and to assess if a relationship existed between side effects and medication-taking.

BACKGROUND

Non-adherence to antipsychotics is common in people with schizophrenia. There is a direct relationship between non-adherence and relapse, but it is unclear if an association exists between side effects and non-adherence.

METHOD

The Liverpool University Neuroleptic Side-effect Rating Scale was used with a convenience sample of 81 mental health service users with schizophrenia. Participants were recruited from one urban and one rural area in Australia in 2004. Data were analysed using Statistical Package for Social Science and nonparametric statistical methods based on the nature of data.

FINDINGS

Around 20% of participants had missed taking their medication at least once in the week before data collection. About half experienced one or more side effects, but the level of accumulated side effects was not associated with medication omission. Older participants were more likely to experience anticholinergic and allergic side effects than their younger counterparts. Younger women were more likely to experience hormone-related side effects than older women. Overall, medication omission was not statistically significantly correlated with any of the seven Liverpool University Neuroleptic Side-effect Rating Scale subscales.

CONCLUSION

Greater attention needs to be paid to age- and gender-specific side effects and to monitoring side effects in people prescribed atypical medication antipsychotics. Service users, case managers and prescribers may need additional training to assist them to identify side effects and to take steps to ameliorate or at least minimize their effects.

Weight gain with clozapine: 8-year cohort naturalistic study among hospitalized Chinese schizophrenia patients

OBJECTIVE

Clozapine is associated with significant weight gain. However, it is still debatable whether the majority of weight gain occurs in the early phase of treatment or if weight gain is a persistent side effect. The inconsistent results in previous outpatient studies may be due to many confounding factors, such as variations in drug adherence, diet content, activity level and environmental factors. The objective of this study was to investigate long-term weight changes in hospitalized Chinese schizophrenic patients treated with clozapine.

METHODS

Patients were admitted at the largest mental hospital in Taiwan and had routine monthly body weight monitoring during the study period. Retrospective chart reviews were conducted to obtain demographic data, age at which clozapine treatment was initiated, and weight changes after the initiation of clozapine treatment.

RESULTS

The study sample consisted of 349 hospitalized schizophrenic patients, including 204 males (58.8%), with an average age at clozapine initiation of 38.6+/-9.3 and an average clozapine dosage of 318+/-9.3 mg/day. Body weight increased over time, and reached a plateau at month 42. Younger age at clozapine initiation (P=0.0038) and lower baseline body mass index (BBMI) (P<0.0001) were associated with more weight gain. The patients with BBMI<25 gained significantly more weight (10.98+/-8.48 kg) compared to patients with BBMI>or=25 (1.17+/-13.29 kg) (P=0.004).

CONCLUSIONS

Similar to reports on Caucasians, clozapine-associated weight gain in Chinese patients reached a plateau at month 42. Younger patients with normal BBMI were associated with higher risk of weight gain.

Metabolic and Cardiac Side Effects of Second-generation Antipsychotics: What Every Clinician Should Know

In 2007, 5 of the 7 second-generation antipsychotics were listed in the Top 200 Drugs prescribed by retail sales in the United States. Cardiovascular disease is the leading cause of natural death in individuals with schizophrenia. Second-generation antipsychotics have been implicated with metabolic and cardiovascular adverse effects, and it is important for nonpsychiatric practitioners to be familiar with the monitoring parameters recommended for these agents. This article discusses the risk of weight gain, hyperglycemia, hyperlipidemia, hyperprolactinemia, and cardiovascular concerns associated with second-generation antipsychotic agents. It also discusses the proposed mechanisms for each of these adverse effects. Furthermore, it reviews suggested monitoring parameters to help manage cardiovascular disease in this patient population, and to improve the gap that exists between mental health care and physical health care in the schizophrenic population.

Metabolic syndrome in people with schizophrenia: a review

Metabolic syndrome and other cardiovascular risk factors are highly prevalent in people with schizophrenia. Patients are at risk for premature mortality and overall have limited access to physical health care. In part these cardio-metabolic risk factors are attributable to unhealthy lifestyle, including poor diet and sedentary behaviour. But over recent years it has become apparent that antipsychotic agents can have a negative impact on some of the modifiable risk factors. The psychiatrist needs to be aware of the potential metabolic side effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness. Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population.

Aripiprazole: in major depressive disorder

Aripiprazole, an oral quinolinone, is the first atypical antipsychotic agent to be approved in the US as adjunctive treatment in adult patients with major depressive disorder (MDD). In two large, well-designed trials in patients with MDD who had an inadequate response to standard antidepressant therapy, 6 weeks' adjunctive therapy with aripiprazole 2-20 mg/day improved mean Montgomery Asberg Depression Rating Scale (MADRS) total scores (primary endpoint) to a significantly greater extent than adjunctive placebo treatment. Improvements in mean MADRS total score during the double-blind phase favoured adjunctive aripiprazole treatment from 1-2 weeks onward, with per-protocol subgroup analyses showing that mean changes were not affected by the specific standard antidepressant therapy used, age or sex of the patient or the mean MADRS total scores at the start of double-blind adjunctive therapy. In general, secondary endpoint scores, including those for the Sheehan Disability Scale, Clinical Global Impression (CGI) Improvement scale and CGI Severity of Illness scale, improved to a significantly greater extent with adjunctive aripiprazole than with adjunctive placebo treatment, with significantly higher response and remission rates in the aripiprazole groups. In these two pivotal trials, adjunctive aripiprazole 2-20 mg/day was generally well tolerated, with most treatment-emergent adverse events being of mild to moderate severity.

Current awareness: Pharmacoepidemiology and drug safety

In order to keep subscribers up‐to‐date with the latest developments in their field, John Wiley & Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of pharmacoepidemiology and drug safety. Each bibliography is divided into 20 sections: 1 Reviews; 2 General; 3 Anti‐infective Agents; 4 Cardiovascular System Agents; 5 CNS Depressive Agents; 6 Non‐steroidal Anti‐inflammatory Agents; 7 CNS Agents; 8 Anti‐neoplastic Agents; 9 Haematological Agents; 10 Neuroregulator‐Blocking Agents; 11 Dermatological Agents; 12 Immunosuppressive Agents; 13 Autonomic Agents; 14 Respiratory System Agents; 15 Neuromuscular Agents; 16 Reproductive System Agents; 17 Gastrointestinal System Agents; 18 Anti‐inflammatory Agents ‐ Steroidal; 19 Teratogens/fetal exposure; 20 Others. Within each section, articles are listed in alphabetical order with respect to author. If, in the preceding period, no publications are located relevant to any one of these headings, that section will be omitted.

Safety profile of iloperidone: a pooled analysis of 6-week acute-phase pivotal trials

Iloperidone, a mixed D2/5-HT2 antagonist, is currently in clinical development for the treatment of schizophrenia. This article assesses the short-term safety of iloperidone using a pooled analysis of 3 phase 2, short-term acute schizophrenia studies conducted between 1998 and 2002 (N = 1943). Patients exposed to 3 dose ranges of iloperidone, another antipsychotic, or placebo were compared on rates of serious adverse events (SAEs), adverse events (AEs), extrapyramidal symptoms, akathisia, prolactin, weight and metabolic parameters, QTc, and other standard safety parameters. The most common treatment-related AEs observed with iloperidone were dizziness, headache, dry mouth, nausea, and insomnia. Discontinuation due to AEs was 4.8% for iloperidone, 7.6% for haloperidol, 6.2% for risperidone, and 4.8% for placebo. Iloperidone groups showed better overall performance on the Extrapyramidal Symptom Rating Scale and Barnes Akathisia Scale than risperidone or haloperidol groups. Patients taking iloperidone experienced a mild weight increase (range, 1.5-2.1 kg) similar to that of risperidone (1.5 kg), whereas those on haloperidol and placebo showed mean weight loss (-0.1 kg and -0.3 kg, respectively). QTc interval significantly increased across all iloperidone groups (least squares mean change from baseline to end point, 2.9-9.1 msec) and for haloperidol (5.0 msec). No significant QTc changes occurred in the risperidone or placebo groups. Iloperidone was associated with no change from baseline in total cholesterol, mild elevation in serum glucose, and slight decrease in triglycerides. Prolactin levels decreased with iloperidone and increased significantly with risperidone and haloperidol. These short-term trials suggest that iloperidone has a reassuring safety profile in many of the areas that are of potential concern, including relatively low dropout rates because of AEs, low extrapyramidal symptoms, akathisia, and prolactin elevation, and a modest short-term effect on weight gain.

Acute and long-term adverse effects of antipsychotics

Antipsychotics have become the cornerstone of management for many severe mental disorders. Primarily developed for the treatment of schizophrenia, several antipsychotics have been indicated for bipolar mania, bipolar depression, and irritability associated with autistic disorder. Antipsychotics are also used off label for psychotic or refractory depression; refractory anxiety disorders; and conditions associated with agitated or aggressive behaviors. Due to the severity and chronicity of severe mental disorders, the broad range of potential treatment targets, and the relative ease of use of second-generation antipsychotics (SGAs), which are associated with a lower risk of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD), prescribing rates have increased considerably over the last decade. With increased utilization of these medications comes a greater responsibility to appropriately recognize, monitor, and manage side-effect clusters that can adversely affect physical and mental outcomes.