Safety and efficacy of rapid dose administration of quetiapine in bipolar mania

A systematic review of the safety and efficacy of rapid titration of quetiapine running header: Rapid titration of Quetiapine- A systematic review

Quetiapine is a second-generation antipsychotic that is most favoured for its low propensity for extrapyramidal side effects. However, Quetiapine requires slow titration, which is disadvantageous. The brief review discussed research that trialled rapid titration of Quetiapine The author searched PubMed, Proquest, Embase, Google Scholar and Google Web using the keyword 'rapid titration' and 'quetiapine'. A total of 18 articles were included. The process, safety and efficacy of rapid titration of Quetiapine was examined. In conclusion, preliminary results appear to show that there is minimal difference in efficacy, between the rapid and traditional titration of Quetiapine. Sedation tended to occur more frequently and earlier among experimental group, and this might render rapid titration of Quetiapine to be suitable for agitated patients. There is a need for more large-scale, multisite, randomized clinical trials to examine the safety and efficacy of rapid titration of Quetiapine.

Rapid quetiapine loading in youths with bipolar disorder

OBJECTIVE

The aim of this study was to evaluate the tolerability and efficacy of rapid quetiapine loading in youth diagnosed with pediatric bipolar disorder (PBD).

METHOD

Quetiapine was started at 100 mg/day, and increased to 400 mg/day by day 5 in 75 bipolar children (6-16 years), presenting in an acute manic or hypomanic episode. Subsequent dose adjustments were predicated on the clinical picture. Response was defined as a ≥ 50% reduction in baseline scores on the Young Mania Rating Scale (YMRS). Clinical Global Impression-Improvement Scale (CGI-I) scores of "2 much improved" or "1 very much improved" were used as secondary measures of response. Remission was defined as a YMRS score of ≤ 12. Adverse events, blood pressure, weight change, somnolence, extrapyramidal syndrome (EPS), and akathisia were monitored to determine tolerability.

RESULTS

At 8 weeks, 94% of the sample had a CGI-I score ≤ 2, and 70% were in remission at 6 months. Sedation was reported by 50% of subjects during the first week; this rate dropped to 5.6% at 6 months.

CONCLUSION

The findings indicate that rapid dose administration of quetiapine in children and adolescents with PBD is generally well tolerated and efficacious.

High-dose loading with extended release quetiapine

Extended release quetiapine fumarate (quetiapine XR) was initiated at the recommended maximum dose 800 mg and maintained at the same dose in five patients with schizophrenia. Although the loadings of quetiapine XR were well tolerated in four patients in these five cases, one patient with a history of cerebral infarction developed serious side-effects, notably bladder distention and dizziness. This case series indicates that loading with maximum dose quetiapine XR may be tolerable and used safely in most schizophrenia patients with no other concurrent disease such as brain infarction.

Safety, tolerability and efficacy of a rapid dose escalation of quetiapine in bipolar I mania: the FATIMA study

OBJECTIVE

The FATIMA study (FAst TItration of quetiapine fumarate in bipolar I MAnia) evaluated the safety, tolerability and efficacy of a rapid dose escalation of quetiapine in acutely ill bipolar I patients experiencing a manic episode.

METHODS

In an open-label, phase II pilot study, 29 patients aged 18 years or older, hospitalised with a bipolar I manic episode, received quetiapine twice daily for 21 days. Quetiapine was administered at 200, 400, 600, then 800 mg/day on the first 4 days, with flexible dosing (400-800 mg/day) subsequently. The primary endpoint was the proportion of patient dropouts because of adverse drug reactions during the first 7 days. Secondary safety assessments included incidences of adverse drug reactions and significant changes in vital signs. Efficacy assessments included Young Mania Rating Scale (YMRS) and Clinical Global Impressions Severity of Illness (CGI-S) score changes from day 1 to day 21.

RESULTS

Twenty patients (69%) completed the study. No patients withdrew as a result of drug-related adverse events (AEs) during the first 7 days. Twenty-three patients reported 58 adverse events, and most of the adverse events were mild or moderate. No clinically relevant abnormalities in vital signs were reported. Mean YMRS and CGI-S scores decreased significantly from baseline to day 21 (p < 0.001). Response and remission rates were 78 and 70%, respectively, at the end of the study.

CONCLUSION

Rapid dose escalation of quetiapine to 800 mg/day over 4 days was well tolerated and effective in reducing symptoms within 5 days in acutely ill bipolar I patients with a manic episode.

Real-world use of quetiapine in early psychosis: An acute inpatient and community follow-up effectiveness study

Objective. To evaluate the use of quetiapine in first episode psychosis in adolescents and adults in a 26-week open-label trial. Methods. Consenting patients were recruited from consecutive acute psychiatric admissions. Quetiapine was increased stepwise to 750 mg. Baseline, 2, 4, 12, 16, 20 and 26 week measurement included: BPRS, PANSS, CGI, and indices of tolerability and safety. Change was assessed using repeated measures ANOVA. Results. Of 73 first admission patients with psychosis, 15 entered the study. Loss of otherwise eligible patients was mainly related to prospective consent, which appeared to cause selection bias. All 15 patients were retained for 4-week Intention-to-Treat Analysis; nine completed the 26-week protocol (Completers Analysis). Non-completers dropped out shortly after 4 weeks. In the ITT Analysis, there was significant improvement on BPRS Total (P<0.01), PANSS Positive (P<0.05), and CGI (P<0.01) scores. No change in the 2-week BPRS Total score predicted subsequent non-response to quetiapine. In the Completers Analysis, onset of significant PANSS Negative score reduction did not occur until week 12. By 26 weeks all efficacy measures had substantially improved; and substance abuse was markedly less prevalent (P=0.02). Adverse events included postural hypotension, drowsiness, and significant weight gain (P=0.001).

CONCLUSIONS

This uncontrolled trial suggests quetiapine is an effective first-line treatment in young early psychosis patients. Prospective consent is a major barrier to evaluating acute care for psychotic disorder.

Quetiapine for acute mania in bipolar disorder

PURPOSE

The efficacy and tolerability of quetiapine in the treatment of acute mania were reviewed.

SUMMARY

Five randomized, placebo-controlled trials involving quetiapine as monotherapy or adjunct therapy in combination with either divalproex or lithium in the treatment of bipolar mania in either adolescents or adults were identified and reviewed. The primary outcome measure used in the trials was a change in Young Mania Rating Scale total scores. Monotherapy trials evaluated quetiapine, lithium, haloperidol, and placebo. Quetiapine was superior to placebo in both trials. Quetiapine and lithium showed comparable efficacy in one study, though lithium serum concentrations may have been suboptimal. Haloperidol was superior to quetiapine in efficacy at day 21 but similar at day 84. In the two trials evaluating quetiapine or placebo as adjunct therapy to lithium or divalproex, quetiapine was significantly more efficacious than placebo in one trial. In adolescents, quetiapine was more effective than placebo as an adjunct to divalproex. The most common adverse effects clearly attributable to quetiapine in these trials were somnolence and dry mouth. Quetiapine did not induce extrapyramidal effects, but weight gain was notable with the drug.

CONCLUSION

While quetiapine treatment demonstrated efficacy in the majority of the studies, the robustness of its efficacy is questionable. The use of quetiapine as first-line therapy for acute mania is not recommended based on the available results and cost considerations. However, it may be a useful second-line agent, particularly when sensitivity to extrapyramidal symptoms limits treatment options.

Atypical antipsychotics in the treatment of mood disorders

PURPOSE OF REVIEW

The aim of the present study is to evaluate the use and the usefulness of atypical antipsychotics in patients with affective symptomatology. Recent literature has been reviewed to show the potential use and usefulness of the atypical medications in patients suffering from depression or mania.

RECENT FINDINGS

The use of amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone in depression (both bipolar I and II) as well as in manic states has been evaluated. Preference was given to well designed randomized clinical trials. The effectiveness of the atypical antipsychotics in manic states has been shown. It is suggested that when an antipsychotic agent is needed, preference should be given to an atypical antipsychotic over the classic drug.

SUMMARY

The potential benefit from the use of atypical antipsychotics in both depression and mania seems to be clinically justified.