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Isaacson SH, Pahwa R, Pagan F, Abler V, Truong D. Retrospective analyses evaluating the mortality risk associated with pimavanserin or other atypical antipsychotics in patients with Parkinson disease psychosis. Clin Park Relat Disord 2024; 10:100256. [PMID: 38770047 PMCID: PMC11103413 DOI: 10.1016/j.prdoa.2024.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/24/2024] [Accepted: 05/05/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Parkinson's disease (PD) is associated with increased mortality risk (MR), reflecting progression of motor and nonmotor symptoms. PD psychosis (PDP), a common nonmotor symptom, increases with prolonged disease and elevates the MR of PD even further. Pimavanserin is the only FDA-approved treatment for PDP. This review summarizes real-world evidence around the MR of patients with PDP treated with pimavanserin versus off-label atypical antipsychotics. Methods A PubMed search was conducted using the following search terms: pimavanserin AND antipsychotic AND mortality AND Parkinson's disease AND psychosis. Inclusion criteria specified the entry of retrospective, observational, and open-label studies comparing pimavanserin to atypical antipsychotics or untreated controls. Results A total of 10 of the 32 articles met inclusion criteria. Among five comparisons of pimavanserin with atypical antipsychotics, two were large (n = 21,719; n = 21,975), representative, Medicare-database studies, which demonstrated comparable or lower all-cause pimavanserin MR. Among three pimavanserin versus control studies, two reported lower or comparable pimavanserin MR and one, long-term care study reported higher MR for pimavanserin versus non-pimavanserin treated patients with unknown PDP status. Two open-label extensions reported pimavanserin mortality rates of 6.45 and 18.8 deaths per 100 patient-years, which are comparable to, or lower than, mortality rates for PD, PDP, and other atypical antipsychotics. Most studies (70 %; 7 of 10) demonstrated pimavanserin's MR was lower than or similar to other atypical antipsychotics or untreated controls. Conclusions Pimavanserin did not increase the MR in PDP. Pimavanserin's MR appears to be comparable to or lower than other atypical antipsychotics prescribed for PDP, including quetiapine.
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Affiliation(s)
- Stuart H. Isaacson
- Parkinson’s Disease and Movement Disorders of Boca Raton, 951 NW 13th Street, Bldg. 5-E, Boca Raton, FL 33486, USA
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, 2060 W 39th Ave, Kansas City, KS 66103, USA
| | - Fernando Pagan
- Department of Neurology, Georgetown University Medical Center, 3900 Reservoir Rd NW, Washington, DC 20007, USA
| | - Victor Abler
- Acadia Pharmaceuticals Inc, 12830 El Camino Real, San Diego, CA 92130, USA
| | - Daniel Truong
- The Parkinson and Movement Disorder Institute, 9940 Talbert Ave #100, Fountain Valley, CA 92708, USA
- Department of Psychiatry and Neuroscience, University of California Riverside, 900 University Ave, Riverside, CA 92521, USA
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Weintraub D, Espay AJ, Sharma VD, Tariot PN, Abler V, Pathak S, Stankovic S. Pimavanserin for psychosis in Parkinson's disease dementia: Subgroup analysis of the HARMONY Trial. Parkinsonism Relat Disord 2024; 119:105951. [PMID: 38113700 DOI: 10.1016/j.parkreldis.2023.105951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/15/2023] [Accepted: 12/03/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION Pimavanserin is FDA-approved to treat Parkinson's disease (PD) psychosis. We analyzed the effect of pimavanserin on psychosis in the PD dementia (PDD) subgroup from the phase 3 HARMONY trial. METHODS This subgroup analysis included PDD patients enrolled in an international, multicenter, randomized discontinuation study of pimavanserin for dementia-related psychosis. PDD patients with moderate-to-severe psychosis, age 50-90 years, received pimavanserin 34 mg/day for 12 weeks (open-label period). Those with a sustained psychosis response to pimavanserin at weeks 8 and 12 were randomized during the double-blind period to continue pimavanserin or receive placebo. Primary efficacy endpoint was time to psychosis relapse as measured by the SAPS-H + D and CGI-I. Safety was assessed, as were effects on motor symptoms and cognitive abilities using the ESRS-A and MMSE. RESULTS 392 patients were enrolled in HARMONY (mean age: 72.6 years; 38.8 % female): 59 had PDD; 49/59 remained on pimavanserin during the open-label period (safety analysis set), and 36/49 were randomized to pimavanserin (n = 16) or placebo (n = 20) in the double-blind phase (intent-to-treat analysis set). Risk of psychosis relapse was lower with pimavanserin 34 mg compared with placebo in the double-blind phase (HR = 0.052; 95 % CI 0.016-0.166; 1-sided nominal p < 0.001). During the open-label period, 46.9 % experienced a treatment-emergent adverse event; event incidence was similar across arms in the double-blind period. Pimavanserin did not adversely affect motor or cognitive function in either treatment phase. CONCLUSIONS Pimavanserin significantly reduced risk of psychosis relapse in patients with PDD, was well tolerated, and did not worsen motor or cognitive function.
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Affiliation(s)
- Daniel Weintraub
- Departments of Psychiatry and Neurology, Perelman School of Medicine at the University of Pennsylvania, 3615 Chestnut Street, #330, Philadelphia, PA, 19104, USA.
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, 3113 Bellevue Ave, Cincinnati, OH, 45219, USA.
| | - Vibhash D Sharma
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Pierre N Tariot
- Banner Alzheimer's Institute and University of Arizona College of Medicine, 901 E Willetta St, Phoenix, AZ, 85006, USA.
| | - Victor Abler
- Acadia Pharmaceuticals Inc., 12830 El Camino Real #400, San Diego, CA, 92130, USA.
| | - Sanjeev Pathak
- Acadia Pharmaceuticals Inc., 12830 El Camino Real #400, San Diego, CA, 92130, USA.
| | - Srdjan Stankovic
- Acadia Pharmaceuticals Inc., 12830 El Camino Real #400, San Diego, CA, 92130, USA.
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Alva G, Cubała WJ, Berrio A, Coate B, Abler V, Pathak S. Safety Profile of Pimavanserin Therapy in Elderly Patients with Neurodegenerative Disease-Related Neuropsychiatric Symptoms: A Phase 3B Study. J Alzheimers Dis 2024; 98:265-274. [PMID: 38427485 DOI: 10.3233/jad-231167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Background Pimavanserin, a 5-HT2A receptor inverse agonist/antagonist, is the only medication approved by the FDA for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Further expanding knowledge of the safety profile of pimavanserin in PDP and neurodegenerative diseases (NDD) such as Alzheimer's disease is of great interest for informing its use in patients with PDP (with or without dementia), given this population is highly sensitive to adverse effects following antipsychotic use. Objective This trial evaluated the effects of pimavanserin compared to placebo in frail older adults and elderly patients with neuropsychiatric symptoms related to NDD, such as hallucinations and delusions, to better understand the safety of pimavanserin in this population. Methods This was a phase 3b, 8-week treatment (study duration of up to 16 weeks), multicenter, randomized, double-blind, placebo-controlled, two-arm parallel-group trial (NCT03575052). The primary endpoint was safety and tolerability, measured by treatment-emergent adverse events (TEAEs). Secondary safety endpoints were change from baseline in motor and cognitive function; exploratory endpoints included suicidality, sleep quality, and neuropsychiatric symptoms. Results Incidences of TEAEs were similar between treatment groups; 29.8% reported ≥1 TEAE (pimavanserin: 30.4%; placebo: 29.3%), and 1.8% reported serious TEAEs (pimavanserin: 2.0%; placebo: 1.5%). Pimavanserin did not impact motor- or cognitive-related function. Conclusions Pimavanserin was well tolerated and not associated with motor or cognitive impairment. Together, these findings highlight the manageable and generally favorable safety profile of pimavanserin in patients with NDD, contributing to our knowledge on the safety of pimavanserin as it generalizes to patients with PDP.
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Affiliation(s)
- Gus Alva
- Department of Psychiatry and Neuroscience, ATP Clinical Research, University of California at Riverside, Riverside, CA, USA
| | - Wiesław J Cubała
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Ana Berrio
- ACADIA Pharmaceuticals Inc., Princeton, NJ, USA
| | - Bruce Coate
- ACADIA Pharmaceuticals Inc., Princeton, NJ, USA
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Degirmenci Y, Angelopoulou E, Georgakopoulou VE, Bougea A. Cognitive Impairment in Parkinson's Disease: An Updated Overview Focusing on Emerging Pharmaceutical Treatment Approaches. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1756. [PMID: 37893474 PMCID: PMC10608778 DOI: 10.3390/medicina59101756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/17/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023]
Abstract
Cognitive impairment in patients with Parkinson's disease (PD) is one of the commonest and most disabling non-motor manifestations during the course of the disease. The clinical spectrum of PD-related cognitive impairment includes subjective cognitive decline (SCD), mild cognitive impairment (MCI) and PD dementia (PDD). As the disease progresses, cognitive decline creates a significant burden for the family members and/or caregivers of patients with PD, and has a great impact on quality of life. Current pharmacological treatments have demonstrated partial efficacy and failed to halt disease progression, and novel, effective, and safe therapeutic strategies are required. Accumulating preclinical and clinical evidence shows that several agents may provide beneficial effects on patients with PD and cognitive impairment, including ceftriaxone, ambroxol, intranasal insulin, nilotinib, atomoxetine, mevidalen, blarcamesine, prasinezumab, SYN120, ENT-01, NYX-458, GRF6021, fosgonimeton, INT-777, Neuropeptide S, silibinin, osmotin, cordycepin, huperzine A, fibroblast growth factor 21, Poloxamer 188, ginsenoside Rb1, thioredoxin-1, tangeretin, istradefylline and Eugenia uniflora. Potential underlying mechanisms include the inhibition of a-synuclein aggregation, the improvement of mitochondrial function, the regulation of synaptic plasticity, an impact on the gut-brain axis, the modulation of neuroinflammation and the upregulation of neurotrophic factors, as well as cholinergic, dopaminergic, serotoninergic and norepinephrine neurotransmission. In this updated overview, we aim to cover the clinical aspects of the spectrum of PD-related cognitive impairment and discuss recent evidence on emerging treatment approaches that are under investigation at a preclinical and clinical level. Finally, we aim to provide additional insights and propose new ideas for investigation that may be feasible and effective for the spectrum of PD-related cognitive impairment.
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Affiliation(s)
- Yildiz Degirmenci
- Department of Neurology, School of Medicine, Istanbul Health and Technology University, 34093 Istanbul, Turkey;
- Parkinson’s Disease and Movement Disorders Unit, Neurology Clinic, Sisli Kolan International Hospital, 34384 Istanbul, Turkey
| | - Efthalia Angelopoulou
- 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Eginition Hospital, 11528 Athens, Greece;
| | | | - Anastasia Bougea
- 1st Department of Neurology, Medical School, National and Kapodistrian University of Athens, Eginition Hospital, 11528 Athens, Greece;
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Hashemi N, Yang D, Shergold D, Tennen G, Fan-Lun C. Clozapine for Management of Neuropsychiatric Symptoms in Dementia with Lewy Bodies: Case Report and Literature Review. Can J Hosp Pharm 2023; 76:340-345. [PMID: 37767388 PMCID: PMC10522355 DOI: 10.4212/cjhp.3390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Affiliation(s)
- Nikoo Hashemi
- , BSc, MSc, PharmD, was, at the time this manuscript was prepared a PharmD candidate with the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario. She has now graduated
| | - Dean Yang
- , BScPhm, BCGP, is a staff pharmacist with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - David Shergold
- , MD, is a staff physician with the Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Gayla Tennen
- , MD, FRCPC, is a Lecturer with the Department of Psychiatry, University of Toronto, and a staff psychiatrist with the Department of Clinical Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Chris Fan-Lun
- , BScPhm, ACPR, BCGP, is an Adjunct Lecturer with the Leslie Dan Faculty of Pharmacy, University of Toronto, and is a Clinical Coordinator with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
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Isaacson SH, Goldstein M, Pahwa R, Singer C, Klos K, Pucci M, Zhang Y, Crandall D, Koblan KS, Navia B. Ulotaront, a Trace Amine-Associated Receptor 1/Serotonin 5-HT 1A Agonist, in Patients With Parkinson Disease Psychosis: A Pilot Study. Neurol Clin Pract 2023; 13:e200175. [PMID: 37273942 PMCID: PMC10238151 DOI: 10.1212/cpj.0000000000200175] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 04/04/2023] [Indexed: 06/06/2023]
Abstract
Background and Objectives Ulotaront (SEP-363856) is a trace amine-associated receptor 1 agonist with 5-HT1A receptor agonist activity currently in phase 3 clinical development for the treatment of schizophrenia. In this exploratory, flexibly dosed study, ulotaront was evaluated for the treatment of Parkinson disease psychosis (PDP). Methods Patients with PDP requiring antipsychotic therapy were randomized, double-blind to ulotaront (25, 50, or 75 mg/d) or placebo. Mixed Model for Repeated Measures was used to assess change from baseline in the Scale for the Assessment of Positive Symptoms for Parkinson Disease (SAPS-PD) at 6 weeks (primary end point). Results The efficacy analysis sample comprised 38 patients (ulotaront, n = 24; placebo, n = 14). SAPS-PD total scores were numerically reduced in ulotaront-treated vs placebo-treated patients from week 1 to week 6: Least squares mean (95% confidence interval) difference in change from baseline at week 6 was -1.1 (-6.5, 4.3, p = 0.681). PDP symptom complete remission (≥100% improvement [reduction] from baseline in SAPS-PD total score) was observed in 25% of ulotaront-treated vs 0% of placebo-treated patients. SAPS-PD and Neuropsychiatric Inventory hallucinations subscales were numerically reduced vs placebo, and SAPS-PD total scores were reduced in patients with greater cognitive impairment (baseline Mini-Mental State Examination [MMSE] scores ≤24). Ulotaront improved Scales for Outcomes in Parkinson Disease Sleep Scale - Daytime Sleepiness scores (p = 0.022). There was no worsening of Unified Parkinson Disease Rating Scale Part III motor score, MMSE, or vital signs. Adverse events (≥10%) with ulotaront vs placebo included hallucinations (24% vs 14%), confusional state (20% vs 14%), dizziness (16% vs 7%), nausea (12% vs 7%), and falls (12% vs 21%). Discussion In this exploratory pilot study, ulotaront may decrease PDP symptoms without worsening motor function, particularly in patients with cognitive impairment. Trial Registration Information ClinicalTrials.gov identifier: NCT02969369; submitted: November 17, 2016; study start date: December 31, 2016. Classification of Evidence This Class II study was an exploratory pilot study that was underpowered to detect a statistically significant difference between ulotaront and placebo in the treatment of patients with Parkinson disease psychosis without worsening motor function.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Mark Goldstein
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Rajesh Pahwa
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Carlos Singer
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Kevin Klos
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Michael Pucci
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Yi Zhang
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - David Crandall
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Kenneth S Koblan
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
| | - Bradford Navia
- Parkinson's Disease and Movement Disorders Center of Boca Raton (SHI), FL; JEM Research Institute (MG), Lake Worth, FL; University of Kansas (RP), Kansas City; University of Miami Health System (CS), FL; The Movement Disorder Clinic of Oklahoma (KK), Tulsa; The Lockwood Group (MP), Stamford, CT; and Sunovion Pharmaceuticals Inc. (YZ, DC, KSK, BN), Marlborough, MA
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Heim B, Peball M, Krismer F, Djamshidian A, Seppi K. Pimavanserin: A Truly Effective Treatment for Parkinson's Disease Psychosis? A Review of Interventions. Neuropsychiatr Dis Treat 2023; 19:1303-1312. [PMID: 37274140 PMCID: PMC10239266 DOI: 10.2147/ndt.s371641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/20/2023] [Indexed: 06/06/2023] Open
Abstract
Parkinson's disease (PD) is the second-most common neurodegenerative disorder with a long-term 60% cumulative prevalence of PD psychosis. Medical treatment is limited to few atypical antipsychotic drugs with low affinity to dopamine D2 receptors. In 2016, pimavanserin, a selective 5-HT2A inverse agonist/antagonist, was approved by the US Food and Drug Administration (FDA) as the only treatment for PD psychosis (PDP). This article provides an overview of the epidemiology, pathophysiology, and treatment options for PDP and illuminates the mode of action and therapy options with pimavanserin and the current study data.
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Affiliation(s)
- Beatrice Heim
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marina Peball
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Krismer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Atbin Djamshidian
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Khan MA, Haider N, Singh T, Bandopadhyay R, Ghoneim MM, Alshehri S, Taha M, Ahmad J, Mishra A. Promising biomarkers and therapeutic targets for the management of Parkinson's disease: recent advancements and contemporary research. Metab Brain Dis 2023; 38:873-919. [PMID: 36807081 DOI: 10.1007/s11011-023-01180-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 02/04/2023] [Indexed: 02/23/2023]
Abstract
Parkinson's disease (PD) is one of the progressive neurological diseases which affect around 10 million population worldwide. The clinical manifestation of motor symptoms in PD patients appears later when most dopaminergic neurons have degenerated. Thus, for better management of PD, the development of accurate biomarkers for the early prognosis of PD is imperative. The present work will discuss the potential biomarkers from various attributes covering biochemical, microRNA, and neuroimaging aspects (α-synuclein, DJ-1, UCH-L1, β-glucocerebrosidase, BDNF, etc.) for diagnosis, recent development in PD management, and major limitations with current and conventional anti-Parkinson therapy. This manuscript summarizes potential biomarkers and therapeutic targets, based on available preclinical and clinical evidence, for better management of PD.
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Affiliation(s)
- Mohammad Ahmed Khan
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Nafis Haider
- Prince Sultan Military College of Health Sciences, Dhahran, 34313, Saudi Arabia
| | - Tanveer Singh
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, TX, 77807, USA
| | - Ritam Bandopadhyay
- Department of Pharmacology, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, 144411, Punjab, India
| | - Mohammed M Ghoneim
- Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Ad Diriyah, 13713, Saudi Arabia
| | - Sultan Alshehri
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Murtada Taha
- Prince Sultan Military College of Health Sciences, Dhahran, 34313, Saudi Arabia
| | - Javed Ahmad
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran, 11001, Saudi Arabia
| | - Awanish Mishra
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER) - Guwahati, Sila Katamur (Halugurisuk), Kamrup, Changsari, Assam, 781101, India.
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9
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Rajagopalan K, Rashid N, Kumar S, Doshi D. Health care resource utilization patterns among patients with Parkinson's disease psychosis: analysis of Medicare beneficiaries treated with pimavanserin or other-atypical antipsychotics. J Med Econ 2023; 26:34-42. [PMID: 36444507 DOI: 10.1080/13696998.2022.2152600] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pimavanserin (PIM) is the only FDA-approved atypical antipsychotic (AAP) for hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Comparative real-world analyses demonstrating its benefits are needed. OBJECTIVES To evaluate health care resource utilization (HCRU) outcomes among PDP patients treated with PIM vs. other-AAPs. METHODS Retrospective cohort analysis of Parts A, B, and D claims from 100% Medicare sample from 01 January 2013-31 December 2019 was conducted. PDP Patients initiating (i.e. index date) continuous monotherapy (PIM vs. other-AAPs) for ≥12-months during 01 January 2014-31 December 2018 without 12-months pre-index AAP use were selected after 1:1 propensity score matching (PSM) on 31 variables (sex, race, region, age, and 27 Elixhauser comorbidities). HCRU outcomes included: annual all-cause and psychiatric hospitalization (short-term stay, long-term stay, and SNF-stay [skilled nursing facility]) rates, annual all-cause and psychiatric-ER visit rates, mean per-patient-per-year (PPPY) hospitalizations, and average length of stay (ALOS). PIM and other-AAPs were compared using generalized linear models (GLM) controlled for demographic characteristics, comorbidities, coexisting-dementia, and coexisting insomnia. RESULTS Of 12,164 PDP patients, 48.41% (n = 5,889) were female, and mean age was 77 (±8.14) years. Among 1:1 matched patients (n = 842 in each), 37.8% (n = 319) on PIM vs. 49.8% (n = 420) on other-AAPs (p < .05) reported ≥1 all-cause hospitalizations, respectively. Specifically, short-term and SNF-stay among PIM patients vs. other-AAPs were: 34% (n = 286) vs. 46.2% (n = 389) and 20.2% (n = 170) vs. 31.8% (n = 267) (p < .05), respectively. Similarly, 9.6% (n = 81) of PIM vs. 14.6% (n = 123) of other-AAPs patients had ≥1 psychiatric hospitalization (p < .05). Furthermore, ≥1 all-cause and psychiatric ER visit among PIM vs. other-AAPs were 61.6% (n = 519) vs. 69.4% (n = 584) and 5.2% (n = 43) vs. 10.2% (n = 86) (p < .05), respectively. PIM also had significantly lower ALOS, and mean PPPY short-term hospitalization and SNF-stays. CONCLUSIONS In this analysis of PDP patients, PIM monotherapy resulted in nearly 12% and 7% lower all-cause hospitalizations and ER visits vs. other-AAPs.
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Abler V, Brain C, Ballard C, Berrio A, Coate B, Espay AJ. Motor- and cognition-related safety of pimavanserin in patients with Parkinson's disease psychosis. Front Neurol 2022; 13:919778. [PMID: 36277907 PMCID: PMC9580496 DOI: 10.3389/fneur.2022.919778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/07/2022] [Indexed: 12/01/2022] Open
Abstract
Background Pimavanserin, a selective 5-HT2A inverse agonist/antagonist, is the only treatment approved by the US Food and Drug Administration for hallucinations and delusions associated with Parkinson's disease (PD) psychosis. Aim We aimed to evaluate motor- and cognition-related safety in pimavanserin-treated patients with PD psychosis. Methods This analysis included patients with PD psychosis treated with pimavanserin 34 mg from a pooled analysis of 3 randomized, double-blind, placebo-controlled, 6-week studies [NCT00477672 (study ACP-103-012), NCT00658567 (study ACP-103-014), and NCT01174004 (study ACP-103-020)] and a subgroup of patients with PD dementia with psychosis from HARMONY (NCT03325556), a randomized discontinuation study that included a 12-week open-label period followed by a randomized double-blind period of up to 26 weeks. Motor- and cognition-related safety were examined. Results The pooled analysis included 433 randomized patients (pimavanserin, 202; placebo, 231). Least squares mean (standard error [SE]) change from baseline to week 6 Unified Parkinson's Disease Rating Scale (UPDRS) II + III score was similar for pimavanserin [−2.4 (0.69)] and placebo [−2.3 (0.60)] (95% Confidence Interval [CI]:−1.9, 1.6). The change from baseline to week 6 for UPDRS II and UPDRS III scores was similar between groups. In the HARMONY open-label period, 49 patients with PD dementia with psychosis were treated with pimavanserin 34 mg, 36 of whom were randomized in the double-blind period (pimavanserin, 16; placebo, 20). In the open-label period, the mean (SE) change from baseline to week 12 (n = 39) Extra-Pyramidal Symptom Rating Scale (ESRS-A) score was −1.7 (0.74); in the double-blind period, the results were generally comparable between the pimavanserin and placebo arms. The change from baseline in Mini-Mental State Examination (MMSE) score was also comparable between pimavanserin- and placebo-treated patients in HARMONY [open-label (n = 37): mean (SE) change from baseline to week 12, 0.3 (0.66)]. Rates of motor- and cognition-related adverse events were similar between pimavanserin and placebo in both analyses. Conclusions Pimavanserin 34 mg was well tolerated and did not yield a negative impact on motor- or cognition-related function in patients with PD psychosis.
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Affiliation(s)
- Victor Abler
- Acadia Pharmaceuticals Inc, San Diego, CA, United States
| | - Cecilia Brain
- Acadia Pharmaceuticals Inc, San Diego, CA, United States
| | - Clive Ballard
- University of Exeter Medical School, Exeter, United Kingdom
| | - Ana Berrio
- Acadia Pharmaceuticals Inc, San Diego, CA, United States
| | - Bruce Coate
- Acadia Pharmaceuticals Inc, San Diego, CA, United States
| | - Alberto J. Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Alberto J. Espay
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11
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Screening, Diagnosis, and Management of Parkinson's Disease Psychosis: Recommendations From an Expert Panel. Neurol Ther 2022; 11:1571-1582. [PMID: 35906500 PMCID: PMC9362468 DOI: 10.1007/s40120-022-00388-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/29/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Hallucinations and delusions present with psychosis are debilitating non-motor symptoms of Parkinson's disease, with a prevalence of up to 50-70% at some point during the course of the disease. Often patients and caregivers do not report the presence of hallucinations or delusions unless specifically questioned. A panel of experts in neurology and geriatric psychiatry convened to develop a simple screening tool and guidance on diagnosis and treatment of Parkinson's disease psychosis (PDP). METHODS The working group reviewed literature for existing PDP guidelines on diagnosis and management and identified gaps in recommendations. The group discussed and developed a screening tool and treatment guidance that addressed the gaps in existing methodology based on their clinical experience. RESULTS The proposed screening tool consists of two parts: (1) a brief pre-visit screening portion to be completed by the patient and caregiver, and (2) a clinician portion to be completed via clinical interview of the patient and caregiver. If psychotic symptoms are present, an appropriate treatment plan is developed for PDP based on evaluation. CONCLUSIONS This simple screening tool and treatment guidance offers a practical clinical approach for clinicians in the diagnosis and management of PDP.
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12
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Sabbagh M, Small GW, Isaacson SH, Torres-Yaghi Y, Pagan F, Pahwa R. Unmet needs in the diagnosis and treatment of Parkinson's disease psychosis and dementia-related psychosis. Int J Psychiatry Clin Pract 2022; 27:69-81. [PMID: 35574992 DOI: 10.1080/13651501.2022.2058406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Dementia due to Parkinson's disease and Alzheimer's disease are associated with behavioural and psychological symptoms, including psychosis. Long-term management presents a challenge for health care providers and caregivers. Symptoms of psychosis include hallucinations and delusions; if untreated, these can lead to institutionalisation, decreased quality of life, and significant patient and caregiver distress. A critical step in the effective management of dementia-related psychosis (DRP) is the identification and diagnosis of affected patients. The lack of a standardised diagnostic approach presents a barrier to treatment and there are no consensus guidelines for DRP. Furthermore, there are no approved therapies for the treatment of DRP. Antipsychotic medications are often prescribed off-label, even though some are associated with an increased risk of adverse events or mortality. We present currently available screening tools and guidelines for the diagnosis and treatment of Parkinson's disease psychosis and DRP in the context of what is needed for effective management of psychosis.KEY POINTSWe present currently available screening tools and guidelines for Parkinson's disease psychosis and dementia-related psychosis, and discuss the unmet need for simple clinical diagnostic tools and treatment guidelines.The identification of psychosis is variable across different settings and specialties, without a unified approach to screening, definition, or diagnosis.Currently used tools for defining and assessing psychosis in a research setting are usually too cumbersome for everyday clinical practice.The development of a standardised set of diagnostic criteria would provide clinicians the opportunity to improve the detection, treatment, and quality of life of patients and their caregivers.
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Affiliation(s)
- Marwan Sabbagh
- Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Gary W Small
- Department of Psychiatry, Hackensack University Medical Center, Behavioral Health Service, Hackensack Meridian Health, Hackensack, NJ, USA
| | - Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
| | - Yasar Torres-Yaghi
- Department of Neurology, National Parkinson's Foundation Center for Excellence, Translational Neurotherapeutics Program, Movement Disorders Program, MedStar Georgetown Hospital, Washington, DC, USA
| | - Fernando Pagan
- Department of Neurology, National Parkinson's Foundation Center for Excellence, Translational Neurotherapeutics Program, Movement Disorders Program, MedStar Georgetown Hospital, Washington, DC, USA
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
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13
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Badwal K, Kiliaki SA, Dugani SB, Pagali SR. Psychosis Management in Lewy Body Dementia: A Comprehensive Clinical Approach. J Geriatr Psychiatry Neurol 2022; 35:255-261. [PMID: 33461372 DOI: 10.1177/0891988720988916] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Lewy body dementia (LBD) is asynucleinopathy that results in clinical manifestation of motor and neuropsychiatric symptoms. The disease burden associated with psychosis in LBD patients is significantly higher compared to other types of dementia or even to LBD without psychosis. Effective care management processes should include consideration of de-prescribing any offending agents including anticholinergics and dopaminergic agents, followed by nonpharmacological and low risk pharmacological approach. If addition of pharmacological agents is required, consideration should be given to acetylcholinesterase inhibitors, pimavanserin and atypical antipsychotics such as quetiapine or clozapine. Side effects of these medications should be considered prior to selection and initiation of a medication regimen. Goals of care and functional assessment are a crucial part of the optimized care plan, given overall guarded prognosis, in the context of numerous complications observed in this population. Palliative care consultation could facilitate symptom control and timely enrollment into hospice if consistent with patient's goals.
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Affiliation(s)
- Karun Badwal
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shangwe A Kiliaki
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sagar B Dugani
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sandeep R Pagali
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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14
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Isaacson SH, Citrome L. Hallucinations and delusions associated with Parkinson's disease psychosis: safety of current treatments and future directions. Expert Opin Drug Saf 2022; 21:873-879. [PMID: 35466847 DOI: 10.1080/14740338.2022.2069240] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Over half of Parkinson's disease (PD) patients develop psychotic symptoms, and PD psychosis (PDP) is associated with significant distress to patients, caregiver burden, and impairs quality of life. Pharmacological therapy is limited to atypical antipsychotics. AREAS COVERED : This review will summarize efficacy but will focus on the safety of antipsychotics for treating PDP, and in particular the off-target safety issues including cognitive impairment, sleep disturbance, cardiovascular effects, and motor function. EXPERT OPINION : Pimavanserin is the only medication approved in the US for treating PDP, however clozapine is also considered efficacious. Despite lack of substantial evidence for efficacy, quetiapine is commonly used to treat PDP. Despite the effectiveness of pimavanserin and clozapine for treating PDP, a need exists for additional pharmacological agents that are effective for PDP while providing an acceptable safety and tolerability profile. Medications to treat PDP should avoid worsening motor function, and also minimize sleep disturbances, cognitive impairment, cardiovascular effects, and other non-motor safety concerns. A neutral effect or reduction in mortality risk associated with PD and PDP would be ideal, and low rate of discontinuation due to AEs is desirable. Lastly, medications that can be used safely in combination with other pharmacological agents is essential.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, Florida, USA
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15
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Austgen G, Marsh L. Cognitive dysfunction and neuropsychiatric aspects of Parkinson's disease. PROGRESS IN BRAIN RESEARCH 2022; 269:59-90. [PMID: 35248207 DOI: 10.1016/bs.pbr.2022.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Movement abnormalities, by definition, and cognitive changes, to varying extents, affect every patient with Parkinson's disease (PD) and are attributed to the underlying neurodegenerative disease. Various psychiatric disorders occur in most patients at some point over the course of PD, including in the prodromal phase. Even though psychiatric disturbances tend to aggravate motor and cognitive deficits, they are under-recognized and under-treated, and the role of the underlying neurological disease is often minimized. To provide an integrated approach to understanding neuropsychiatric aspects of PD, this chapter reviews how cognitive changes in PD relate to the common psychiatric disturbances in PD along with the prevalence, phenomenology, pathophysiology, and treatment of each.
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Affiliation(s)
- Gabriela Austgen
- Behavioral Neurology & Neuropsychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Laura Marsh
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Professor, Division of Neuropsychiatry, Menninger Department of Psychiatry and Behavioral Sciences and Department of Neurology, Baylor College of Medicine, Houston, TX, United States.
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16
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Abstract
Cognitive impairment affects up to 80% of patients with Parkinson's disease (PD) and is associated with poor quality of life. PD cognitive dysfunction includes poor working memory, impairments in executive function and difficulty in set-shifting. The pathophysiology underlying cognitive impairment in PD is still poorly understood, but there is evidence to support involvements of the cholinergic, dopaminergic, and noradrenergic systems. Only rivastigmine, an acetyl- and butyrylcholinesterase inhibitor, is efficacious for the treatment of PD dementia, which limits management of cognitive impairment in PD. Whereas the role of the serotonergic system in PD cognition is less understood, through its interactions with other neurotransmitters systems, namely, the cholinergic system, it may be implicated in cognitive processes. In this chapter, we provide an overview of the pharmacological, clinical and pathological evidence that implicates the serotonergic system in mediating cognition in PD.
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17
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Schneider JS, Kortagere S. Current concepts in treating mild cognitive impairment in Parkinson's disease. Neuropharmacology 2022; 203:108880. [PMID: 34774549 DOI: 10.1016/j.neuropharm.2021.108880] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 12/15/2022]
Abstract
Impairment in various aspects of cognition is recognized as an important non-motor symptom of Parkinson's disease (PD). Mild cognitive impairment in PD (PD-MCI) is common in non-demented PD patients and is often associated with severity of motor symptoms, disease duration and increasing age. Further, PD-MCI can have a significant negative effect on performance of daily life activities and may be a harbinger of development of PD dementia. Thus, there is significant interest in developing therapeutic strategies to ameliorate cognitive deficits in PD and improve cognitive functioning of PD patients. However, due to significant questions that remain regarding the pathophysiology of cognitive dysfunction in PD, remediation of cognitive dysfunction in PD has proven difficult. In this paper, we will focus on PD-MCI and will review some of the current therapeutic approaches being taken to try to improve cognitive functioning in patients with PD-MCI.
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Affiliation(s)
- Jay S Schneider
- Dept. of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | - Sandhya Kortagere
- Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA 19129, USA
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18
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Senderovich H, Patel P, Jimenez Lopez B, Waicus S. A Systematic Review on Cannabis Hyperemesis Syndrome and Its Management Options. Med Princ Pract 2022; 31:29-38. [PMID: 34724666 PMCID: PMC8995641 DOI: 10.1159/000520417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 10/18/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Several forms of cannabinoids are currently being used to manage nausea and vomiting (N/V). Emerging cases of refractory N/V associated with chronic cannabis use among adults and older patients have been reported named cannabis hyperemesis syndrome (CHS). CHS is a condition that leads to repeated and severe N/V in long-term users of cannabinoids. OBJECTIVE The aim of this study was to outline current treatments for the management of CHS. METHODS A systematic review was conducted using PubMed, Ovid MEDLINE, Cochrane Central, EMBASE, and Google Scholar. Databases were used to search for articles on CHS published from January 2009 to June 2021, yielding 225 results of which 17 were deemed relevant and underwent review by 2 separate reviewers. RESULTS The duration of cannabis administration ranged between 6 months to 11 years may precipitate symptoms of CHS. The Rome IV diagnostic criteria of CHS require cannabinoid use and persistence of N/V symptoms for at least the past 6 months. Cannabis cessation is noted to be the most successful management, but other treatments also demonstrated symptom relief; these include hot water hydrotherapy, topical capsaicin cream, haloperidol, droperidol, benzodiazepines, propranolol, and aprepitant administration. CONCLUSION More research on CHS is needed to enhance knowledge translation, education, and create awareness in the medical community on the side effects of cannabinoids and to propose the best treatment options.
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Affiliation(s)
- Helen Senderovich
- Department of Family and Community Medicine, Geriatrics and Palliative Care, Baycrest Health Sciences, University of Toronto, Toronto, Ontario, Canada
- *Helen Senderovich,
| | - Preet Patel
- University of Waterloo, Waterloo, Ontario, Canada
| | | | - Sarah Waicus
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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19
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Bugarski-Kirola D, Nunez R, Odetalla R, Liu IY, Turner ME. Effects of adjunctive pimavanserin and current antipsychotic treatment on QT interval prolongation in patients with schizophrenia. Front Psychiatry 2022; 13:892199. [PMID: 36147980 PMCID: PMC9486460 DOI: 10.3389/fpsyt.2022.892199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pimavanserin prolongs the QT interval, with mean increases in corrected QT (QTc) of 5-8 ms, and is currently being investigated for the treatment of negative symptoms of schizophrenia. OBJECTIVES To assess QT interval prolongation in 3 studies investigating once-daily pimavanserin as an adjunct to current antipsychotic treatment in patients with schizophrenia. METHODS Electrocardiograms were unblinded from trials in which pimavanserin or placebo was added to main antipsychotics over 6 weeks (ENHANCE), 26 weeks (ADVANCE), and up to 78 weeks (ongoing 52-week, open-label extension study [study 035]) of treatment. Antipsychotic treatment was permitted throughout these studies. The 3 most frequently used antipsychotic treatments were examined-aripiprazole (including long-acting injectable), risperidone (including long-acting injectable), and olanzapine. QT intervals were corrected (QTc) using Fridericia's method, with elevated risk defined as either postbaseline value maximum of >500 ms or change from baseline to postbaseline maximum of >60 ms. RESULTS Of patients treated with adjunctive pimavanserin in ENHANCE, there were no postbaseline QTc values >481 ms; one patient in each of the risperidone and aripiprazole groups had change from baseline to postbaseline maximum >60 ms. More patients had change from baseline to postbaseline maximum ranging from 31 to 60 ms in the risperidone plus adjunctive placebo group (n = 5; 6.6%) than those in the risperidone plus adjunctive pimavanserin group (n = 3, 4.1%). In the pimavanserin plus antipsychotic group of ADVANCE, one patient had postbaseline QTc value >481 ms, and one patient treated with aripiprazole had change from baseline to postbaseline maximum of >60 ms. In study 035, a change from double-blind baseline to overall postbaseline maximum >60 ms occurred in one patient treated with aripiprazole and pimavanserin and in one patient treated with risperidone and pimavanserin. Similar proportions of patients had changes from double-blind baseline to post double-blind baseline maximum between 31 and 60 ms across treatments. No adverse events associated with an increase in the QTc interval were reported. CONCLUSIONS Adjunctive pimavanserin with background antipsychotic treatment showed no evidence of QTc prolongation >500 ms postbaseline, consistent with previously reports on QT prolongation with pimavanserin.
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Affiliation(s)
| | - Rene Nunez
- Acadia Pharmaceuticals Inc., San Diego, CA, United States
| | | | - I-Yuan Liu
- Acadia Pharmaceuticals Inc., San Diego, CA, United States
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20
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Delic V, Karp J, Klein J, Stalnaker KJ, Murray KE, Ratliff WA, Myers CE, Beck KD, Citron BA. Pyridostigmine bromide, chlorpyrifos, and DEET combined Gulf War exposure insult depresses mitochondrial function in neuroblastoma cells. J Biochem Mol Toxicol 2021; 35:e22913. [PMID: 34528356 PMCID: PMC8678325 DOI: 10.1002/jbt.22913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 06/21/2021] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Abstract
Gulf War Illness (GWI) is defined by the Centers for Disease Control and Prevention (CDC) as a multi-symptom illness having at least one symptom from two of three factors, which include: fatigue, mood-cognition problems, and musculoskeletal disorders. The cluster of long-term symptoms is unique to military personnel from coalition countries including United States, Australia, and the United Kingdom that served in Operation Desert Storm from 1990 to 1991. Reporting of these symptoms is much lower among soldiers deployed in other parts of the world like Bosnia during the same time period. The exact cause of GWI is unknown, but combined exposure to N,N-diethyl-m-toluamide (DEET), organophosphates like chlorpyrifos (CPF), and pyridostigmine bromide (PB), has been hypothesized as a potential mechanism. Mitochondrial dysfunction is known to occur in most neurodegenerative diseases that share symptoms with GWI and has therefore been implicated in GWI. Although exposure to these and other toxicants continues to be investigated as potential causes of GWI, their combined impact on mitochondrial physiology remains unknown. In this study, the effects of combined GWI toxicant exposure on mitochondrial function were determined in a commonly used and readily available immortalized cell line (N2a), whose higher rate of oxygen consumption resembles that of highly metabolic neurons in vivo. We report that combined exposure containing pesticide CPF 71 μM, insect repellants DEET 78 μM, and antitoxins PB 19 μM, causes profound mitochondrial dysfunction after a 4-h incubation resulting in decreased mitochondrial respiratory states in the absence of proapoptotic signaling, proton leak, or significant increase in reactive oxygen species production.
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Affiliation(s)
- Vedad Delic
- Laboratory of Molecular Biology, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
- Department of Pharmacology, Physiology, and Neuroscience, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Joshua Karp
- Laboratory of Molecular Biology, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
- Rutgers School of Graduate Studies, Newark, New Jersey, USA
| | - Julian Klein
- Laboratory of Molecular Biology, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
- Rutgers School of Graduate Studies, Newark, New Jersey, USA
| | - Katherine J. Stalnaker
- Laboratory of Molecular Biology, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
- NeuroBehavioral Research Laboratory, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
| | - Kathleen E. Murray
- Laboratory of Molecular Biology, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
- Rutgers School of Graduate Studies, Newark, New Jersey, USA
| | - Whitney A. Ratliff
- Laboratory of Molecular Biology, Bay Pines VA Healthcare System Research and Development, Bay Pines, Florida, USA
| | - Catherine E. Myers
- Department of Pharmacology, Physiology, and Neuroscience, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- NeuroBehavioral Research Laboratory, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
| | - Kevin D. Beck
- Department of Pharmacology, Physiology, and Neuroscience, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- NeuroBehavioral Research Laboratory, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
| | - Bruce A. Citron
- Laboratory of Molecular Biology, VA New Jersey Health Care System, Research & Development (Mailstop 15), East Orange, New Jersey, USA
- Department of Pharmacology, Physiology, and Neuroscience, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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21
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Weiss D, Höglinger G, Klostermann F, Weise D, Zeuner KE, Reichmann H. [Hallucinations in Patients with Idiopathic Parkinson's Disease]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 90:456-464. [PMID: 34844278 DOI: 10.1055/a-1670-7111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients with idiopathic Parkinson's disease develop symptoms of the hallucination-psychosis spectrum in more than 20%. Most common are visual hallucinations. The pathogenesis of hallucinations mainly depends on disease duration, the distribution and extent of alpha-synuclein pathology, and modulating effects of the dopaminergic therapy. When managing PD hallucinations both anti-delirogenic actions and medication management are important. However, decrease in dopaminergic medication may lead to critical worsening of akinesia. If appropriate neuroleptic medication - essentially quetiapin or clozapin - can be considered. Instead, anti-dopaminergic neuroleptics should not be used owing to their pro-akinetic side-effects. Here, we provide therapy recommendations to manage PD hallucinations based on an up-to-date targeted review of the literature and expert-based empirical evidence.
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Affiliation(s)
- Daniel Weiss
- Neurologische Klinik mit Schwerpunkt Neurodegenerative Erkrankungen und Hertie-Institut für Klinische Hirnforschung, Universitätsklinikum Tübingen, Deutschland
| | - Günter Höglinger
- Klinik für Neurologie mit Klinischer Neurophysiologie, Medizinisch Hochschule Hannover, Deutschland
| | - Fabian Klostermann
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - David Weise
- Klinik für Neurologie, Schmerztherapie und Schlafmedizin, Asklepios Fachklinikum Stadtroda, Deutschland
| | - Kirsten E Zeuner
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Deutschland
| | - Heinz Reichmann
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus Dresden, Deutschland
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22
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Brandt N, Kales HC, Saffel D. Safe Management of Dementia-Related Psychosis in Long-Term Care: Empowering Consultant Pharmacists. Sr Care Pharm 2021; 36:1-25. [PMID: 34465414 DOI: 10.4140/tcp.s.2021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Nicole Brandt
- Executive Director, Peter Lamy Center on Drug Therapy and Aging, Professor, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy Baltimore, Maryland
| | - Helen C Kales
- Professor and Joe P. Tupin Chair, Department of Psychiatry and Behavioral Science, University of California, Davis Health, Sacramento, California
| | - Dana Saffel
- Board Director, ASCP, President and CEO, PharmaCare Strategies, Inc, Santa Rosa Beach, Florida
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23
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Zarotti N, Eccles FJR, Foley JA, Paget A, Gunn S, Leroi I, Simpson J. Psychological interventions for people with Parkinson's disease in the early 2020s: Where do we stand? Psychol Psychother 2021; 94:760-797. [PMID: 33174688 DOI: 10.1111/papt.12321] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/27/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To explore the heterogeneity of the literature on psychological interventions for psychological difficulties in people with Parkinson's disease (PD). METHODS A scoping review was performed across five major databases (MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library) up to June 2020. RESULTS From an initial return of 4911 citations, 56 studies were included, of which 21 were RCTs. A relatively wide range of therapeutic models have been adopted with people with PD, from common therapies such as cognitive behavioural therapy (CBT) and mindfulness, to less frequent approaches, for example, acceptance and commitment therapy (ACT) and psychodrama. The clinical implications of the findings are discussed, and suggestions are provided for future research on intervention studies and key psychological outcomes. CONCLUSIONS CBT appears to be effective in treating depression and sleep disorders in people with PD, while psychoeducation programmes alone should be avoided. The use of CBT to improve anxiety, quality of life, and impulse control, as well mindfulness-based interventions, should be undertaken with some caution because of insufficient research and inconsistent results. As we enter the new decade, more high-quality evidence is required for psychological interventions in people with PD in general and to corroborate preliminary positive findings on the adoption of less frequent approaches such as ACT. PRACTITIONER POINTS Parkinson's disease is a progressive neurodegenerative condition associated with several psychological difficulties which be targeted by psychological interventions. Currently, cognitive behavioural therapy (CBT) can be recommended to treat depression and sleep disorders in people with Parkinson's, while psychoeducation alone should be avoided. Caution is advised regarding the use of CBT and mindfulness-based interventions to improve anxiety, quality of life, and impulse control. Further evidence is required for less common approaches, such as acceptance and commitment therapy, psychodrama, and EMDR.
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Affiliation(s)
- Nicolò Zarotti
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, UK
| | - Fiona J R Eccles
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, UK
| | - Jennifer A Foley
- Department of Neuropsychology, National Hospital of Neurology & Neurosurgery, London, UK.,UCL Queen Square Insitute of Neurology, Queen Square, London, UK
| | - Andrew Paget
- Department of Neuropsychology, National Hospital of Neurology & Neurosurgery, London, UK.,UCL Queen Square Insitute of Neurology, Queen Square, London, UK
| | - Sarah Gunn
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, UK
| | - Iracema Leroi
- Global Brain Health Institute, Trinity College Dublin, Ireland
| | - Jane Simpson
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, UK
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Rein-Hedin E, Sjöberg F, Waters S, Sonesson C, Waters N, Huss F, Tedroff J. First-in-Human Study to Assess the Safety, Tolerability, and Pharmacokinetics of Pirepemat, a Cortical Enhancer, in Healthy Volunteers. Clin Pharmacol Drug Dev 2021; 10:1485-1494. [PMID: 34118179 DOI: 10.1002/cpdd.959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/10/2021] [Indexed: 11/10/2022]
Abstract
Pirepemat (IRL752) is a cortical enhancer being developed for the prevention of falls in patients with Parkinson disease. This first-in-human, randomized, double-blind, placebo-controlled phase 1 study evaluated safety, tolerability, and pharmacokinetics (PK) of pirepemat administered as oral single ascending doses (10, 35, 75, 175, 350 mg) and multiple ascending doses (100 and 250 mg 3 times daily) for 7 days to healthy male volunteers. Twenty and 24 subjects were randomly assigned in the single ascending dose and multiple ascending doses parts of the study, respectively. Pirepemat was generally well tolerated, although an increased frequency of adverse events of mild intensity within nervous system disorders (headache and dizziness) was seen after administration of 350 mg as a single dose and after multiple doses of 100 and 250 mg. PK of pirepemat showed a linear relationship over the dose range studied and exhibited dose proportionality after multiple-dose administration. Accumulation after 7 days of multiple dosing was minor. Absorption was rapid, with a median time to maximum concentration of 2.0 hours on day 1 and day 7 (100 and 250 mg) and a mean terminal half-life between 3.7 and 5.2 hours. Food intake had no (obvious) impact on PK. The results support 3-times-daily dosing and further clinical development.
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Affiliation(s)
- Erik Rein-Hedin
- CTC Clinical Trial Consultants AB, Uppsala, Sweden.,Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - Folke Sjöberg
- CTC Clinical Trial Consultants AB, Uppsala, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Susanna Waters
- Integrative Research Laboratories Sweden AB, Gothenburg, Sweden
| | - Clas Sonesson
- Integrative Research Laboratories Sweden AB, Gothenburg, Sweden
| | - Nicholas Waters
- Integrative Research Laboratories Sweden AB, Gothenburg, Sweden
| | - Fredrik Huss
- CTC Clinical Trial Consultants AB, Uppsala, Sweden.,Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - Joakim Tedroff
- Integrative Research Laboratories Sweden AB, Gothenburg, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Dhingra A, Janjua AU, Hack L, Waserstein G, Palanci J, Hermida AP. Exploring Nonmotor Neuropsychiatric Manifestations of Parkinson Disease in a Comprehensive Care Setting. J Geriatr Psychiatry Neurol 2021; 34:181-195. [PMID: 32242493 DOI: 10.1177/0891988720915525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Parkinson disease (PD) is a debilitating neurological condition that includes both motor symptoms and nonmotor symptoms (NMS). Psychiatric complaints comprise NMS and are collectively referred to as neuropsychiatric manifestations. Common findings include atypical depressive symptoms, anxiety, psychosis, impulse control disorder, deterioration of cognition, and sleep disturbances. Quality of life (QoL) of patients suffering from NMS is greatly impacted and many times can be more debilitating than motor symptoms of PD. We expand on knowledge gained from treatment models within a comprehensive care model that incorporates multidisciplinary specialists working alongside psychiatrists to treat PD. Insight into background, clinical presentations, and treatment options for patients suffering from neuropsychiatric manifestations of PD are discussed. Identifying symptoms early can help improve QoL, provide early symptom relief, and can assist tailoring treatment plans that limit neuropsychiatric manifestations.
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Affiliation(s)
- Amitha Dhingra
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Laura Hack
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Gabriella Waserstein
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Justin Palanci
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
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Isaacson SH, Ballard CG, Kreitzman DL, Coate B, Norton JC, Fernandez HH, Ilic TV, Azulay JP, Ferreira JJ, Abler V, Stankovic S. Efficacy results of pimavanserin from a multi-center, open-label extension study in Parkinson's disease psychosis patients. Parkinsonism Relat Disord 2021; 87:25-31. [PMID: 33933853 DOI: 10.1016/j.parkreldis.2021.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/26/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Pimavanserin, a selective 5-HT2A inverse agonist/antagonist, was approved for hallucinations and delusions associated with Parkinson's disease psychosis (PDP). We present durability of response with pimavanserin in patients with PDP for an additional 4 weeks of treatment. METHODS This was an open-label extension (OLE) study in patients previously completing one of three double-blind, placebo-controlled (Core) studies. All patients received pimavanserin 34 mg once daily. Efficacy assessments included the Scale for the Assessment of Positive Symptoms (SAPS) PD and H + D scales, Clinical Global Impression (CGI) Improvement and Severity scales and Caregiver Burden Scale (CBS), through 4 weeks in the OLE. Safety assessments were conducted at each visit. RESULTS Of 459 patients, 424 (92.4%) had a Week 4 efficacy assessment. At Week 4 (10 weeks total treatment), SAPS-PD mean (standard deviation) change from OLE baseline was -1.8 (5.5) and for SAPS-H + D was -2.1 (6.2) with pimavanserin 34 mg. Patients receiving placebo during the Core studies had greater improvements (SAPS-PD -2.9 [5.6]; SAPS-H + D -3.5 [6.3]) during the OLE. For participants treated with pimavanserin 8.5 or 17 mg during the Core studies, further improvement was observed during the OLE with pimavanserin 34 mg. The mean change from Core Study baseline for SAPS-PD score was similar among prior pimavanserin 34 mg and prior placebo-treated participants (-7.1 vs. -7.0). The CGI-I response rate (score of 1 or 2) at Week 4 was 51.4%. Adverse events were reported by 215 (46.8%) patients during the first 4 weeks of OLE. The most common AEs were fall (5.9%), hallucination (3.7%), urinary tract infection (2.8%), insomnia (2.4%), and peripheral edema (2.2%) CONCLUSIONS: Patients previously on pimavanserin 34 mg during three blinded core studies had durability of efficacy during the subsequent 4 week OLE SAPS-PD assessment. Patients previously on blinded placebo improved after 4 weeks of OL pimavanserin treatment. These results in over 400 patients from 14 countries support the efficacy of pimavanserin for treating PDP.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA.
| | | | - David L Kreitzman
- Parkinson's Disease and Movement Disorders Center of Long Island, Commack, NY, USA
| | - Bruce Coate
- ACADIA Pharmaceuticals Inc., San Diego, CA, USA
| | | | - Hubert H Fernandez
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Tihomir V Ilic
- Medical Faculty of Military Medical Academy, Belgrade, Serbia
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Pimavanserin Treatment for Parkinson's Disease Psychosis in Clinical Practice. PARKINSONS DISEASE 2021; 2021:2603641. [PMID: 33489083 PMCID: PMC7801085 DOI: 10.1155/2021/2603641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 01/04/2023]
Abstract
Background Parkinson's disease psychosis (PDP) is a common, nonmotor symptom of Parkinson's disease (PD), which may affect up to 60% of patients and is associated with impaired quality of life, increased healthcare costs, and nursing home placement, among other adverse outcomes. Characteristic symptoms of PDP include illusions; visual, auditory, tactile, and olfactory hallucinations; and delusions. PDP symptoms typically progress over its course from being mild, infrequent, and often untroubling to complex, sometimes constant, and potentially highly disturbing. PDP has traditionally been treated with atypical antipsychotics (e.g., clozapine and quetiapine) although these are not approved for this indication and clozapine requires frequent white blood cell count monitoring due to the risk of agranulocytosis. Pimavanserin is a newer atypical antipsychotic with highly selective binding to serotonergic receptors, no evidence for worsening motor symptoms in PD, and no need for white blood cell count monitoring. It is currently the only approved medication indicated for PDP treatment. However, because it was approved relatively recently (2016), clinical experience with pimavanserin is limited. Case Presentations. A wide variety of representative clinical scenarios are presented, each with distinct variables and complications. Issues addressed include distinguishing PDP from similar symptoms caused by other disorders such as dementia, coordinating pimavanserin with other PD medications and with deep brain stimulation, adapting pimavanserin dosing for optimal benefit and tolerability, and recognizing variability of PDP symptoms due to patients' changing life circumstances. Conclusions These scenarios provide multiple insights regarding PDP management and the role of pimavanserin. Effective treatment of PDP may reduce disturbing symptoms of psychosis, thus improving patient function and quality of life. In addition, effective pharmacotherapy for PDP may also facilitate the use of other medications needed to treat neurological symptoms of PD (e.g., tremor, bradykinesia, and dyskinesia), although they may also have adverse effects that contribute to symptoms of PDP.
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Luo F, Ye M, Lv T, Hu B, Chen J, Yan J, Wang A, Chen F, He Z, Ding Z, Zhang J, Qian C, Liu Z. Efficacy of Cognitive Behavioral Therapy on Mood Disorders, Sleep, Fatigue, and Quality of Life in Parkinson's Disease: A Systematic Review and Meta-Analysis. Front Psychiatry 2021; 12:793804. [PMID: 34966313 PMCID: PMC8710613 DOI: 10.3389/fpsyt.2021.793804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/19/2021] [Indexed: 02/06/2023] Open
Abstract
Objective: The aim of this study was to perform a quantitative analysis to evaluate the efficacy of cognitive behavioral therapy (CBT) on mood disorders, sleep, fatigue, and its impact on quality of life (QOL) in Parkinson's Disease (PD). Methods: We searched for randomized controlled trials in three electronic databases. Fourteen studies, including 507 patients with PD, met the inclusion criteria. We determined the pooled efficacy by standard mean differences and 95% confidence intervals, using I 2 to reveal heterogeneity. Results: The result showed CBT had a significant effect on depression [-0.93 (95%CI, -1.19 to -0.67, P < 0.001)] and anxiety [-0.76 (95%CI, -0.97 to -0.55, P < 0.001)]. Moderate effect sizes were noted with sleep disorders [-0.45 (95% CI, -0.70 to -0.20, P = 0.0004)]. There was no evident impact of CBT on fatigue or QOL. We found an intervention period >8 weeks was advantageous compared with <8 weeks, and CBT implemented in non-group was more effective than in group. Between the delivery methods, no significant difference was found. Conclusion: We found that CBT in patients with PD was an efficacious therapy for some non-motor symptoms in PD, but not efficacious for fatigue and QOL. These results suggest that CBT results in significant improvement in PD and should be used as a conventional clinical intervention.
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Affiliation(s)
- Fangyi Luo
- Department of Psychiatry, Shaoxing Seventh People's Hospital, Affiliated Mental Health Center, Medical College of Shaoxing University, Shaoxing, China.,Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Mengfei Ye
- Department of Psychiatry, Shaoxing Seventh People's Hospital, Affiliated Mental Health Center, Medical College of Shaoxing University, Shaoxing, China
| | - Tingting Lv
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Baiqi Hu
- Department of Neurology, Shaoxing Hospital, China Medical University, Shaoxing, China
| | - Jiaqi Chen
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Junwei Yan
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Anzhe Wang
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Feng Chen
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Ziyi He
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Zhinan Ding
- Laboratory of Forensic Toxicology, Judicial Identification Center of Shaoxing University, Shaoxing, China
| | - Jian Zhang
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China
| | - Chao Qian
- Department of Psychiatry, Shaoxing Seventh People's Hospital, Affiliated Mental Health Center, Medical College of Shaoxing University, Shaoxing, China
| | - Zheng Liu
- Department of Behavioral Neurosciences, Science Research Center of Medical College, Shaoxing University, Shaoxing, China.,Laboratory of Forensic Toxicology, Judicial Identification Center of Shaoxing University, Shaoxing, China
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Coerver KA, Subramanian PS. Visual hallucinations in psychiatric, neurologic, and ophthalmologic disease. Curr Opin Ophthalmol 2020; 31:475-482. [PMID: 33009079 DOI: 10.1097/icu.0000000000000701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Recent studies have increased our understanding of the biochemical and structural bases of visual hallucinations in patients with a variety of underlying causes. RECENT FINDINGS Visual hallucinations may be related to disruption of functional connectivity networks, with underlying biochemical dysfunction such as decreased in cholinergic activity. Structural abnormalities in primary and higher order visual processing areas also have been found in patients with visual hallucinations. The occurrence of visual hallucinations after vision loss, the Charles Bonnet syndrome, may have more functional similarity to psychiatric and neurodegenerative causes than previously suspected despite retained insight into the unreal nature of the phenomena. SUMMARY Visual hallucinations are common, and patients may not report them if specific inquiries are not made. Presence or absence of hallucinations may be of diagnostic and therapeutic importance, especially in patients with neurodegenerative conditions that have overlapping features. Treatment of visual hallucinations remains challenging and must be tailored to each patient based on the underlying cause and comorbid conditions.
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Affiliation(s)
| | - Prem S Subramanian
- Department of Ophthalmology
- Department of Neurology
- Department of Neurosurgery, University of Colorado School of Medicine
- Sue Anschutz-Rodgers UCHealth Eye Center, Aurora, Colorado, USA
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Takamiya A, Seki M, Kudo S, Yoshizaki T, Nakahara J, Mimura M, Kishimoto T. Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis. Mov Disord 2020; 36:50-58. [PMID: 33280168 DOI: 10.1002/mds.28335] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 08/27/2020] [Accepted: 09/21/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a well-established treatment for psychiatric disorders, including depression and psychosis. ECT has been reported to be effective in treating such psychiatric symptoms in patients with Parkinson's disease (PD) and has been also reported to be effective in treating motor symptoms. The aim of the study is to summarize previous clinical studies investigating the efficacy of ECT for symptoms in patients with PD. METHODS A systematic review and meta-analysis of any study designs assessing motor and/or non-motor symptoms in patients with PD before and after ECT. Co-primary outcomes were set as motor manifestations assessed using the Unified Parkinson's Disease Rating Scale or other rating scales, and non-motor symptoms included depression and psychosis. Secondary outcomes were wearing-off phenomenon and cognitive function. The impact of ECT on those symptoms was examined by comparing the severity of the symptoms before and after ECT using a random effect model and was expressed in standardized mean difference. RESULTS Of 1219 identified citations, 14 studies (n = 129; 1 randomized controlled study, 9 prospective observational studies, and 4 retrospective studies) were analyzed. The findings were as follows: ECT significantly improved motor manifestations in patients with PD, and the improvement was significant in the subpopulation without psychiatric symptoms; ECT significantly improved depression and psychosis; and ECT significantly relieved wearing-off phenomenon and did not worsen cognitive functioning. CONCLUSION The current meta-analysis suggests the potential benefit of ECT on motor and non-motor symptoms in presumably complicated and difficult-to-treat subgroups. © 2020 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Akihiro Takamiya
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Morinobu Seki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kudo
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takahito Yoshizaki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Taishiro Kishimoto
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Chekani F, Holmes HM, Johnson ML, Chen H, Sherer JT, Aparasu RR. Risk of Mortality Associated With Atypical Antipsychotic use: A National Cohort Study of Older Adults With Depression and Parkinson's Disease. Am J Geriatr Psychiatry 2020; 28:1079-1088. [PMID: 32147383 DOI: 10.1016/j.jagp.2020.01.193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study examined the risk of all-cause-mortality in patients with Parkinson's Disease (PD) and comorbid depression using inappropriate atypical antipsychotics (AAPs), based on the 2015 American Geriatrics Society Beers criteria. METHODS A retrospective analysis of 2007-2010 Minimum Data Set linked Medicare data was conducted using a propensity-matched approach. The cohort included PD patients aged 65 years or older without schizophrenia or bipolar disorder who started AAPs. All patients had a diagnosis of comorbid depression. Risk of 6-month all-cause-mortality was compared across appropriate AAPs (aripiprazole, clozapine, or quetiapine) and inappropriate AAPs (olanzapine, asenapine, brexpiprazole, iloperidone, lurasidone, paliperidone, risperidone, or ziprasidone) using robust Cox regression models involving the matched cohort. RESULTS All-cause mortality rate was 15.65% in appropriate AAP group (n = 6,038) and 16.91% in inappropriate AAP group (n = 6,038) over 6-month follow-up in the matched cohort. The robust Cox proportional hazards models revealed increased risk of all-cause mortality (hazard ratio [HR] 1.13 [95% confidence interval {CI}: 1.01-1.28)] for patients who used inappropriate compared to appropriate AAPs. Risk of death was also higher for risperidone compared to quetiapine (HR: 1.20 [95% CI: 1.03-1.40]) in sensitivity analysis. However, there was a significant relationship between pneumonia and death in all analyses. The impact of inappropriate AAP use on mortality was not significant when pneumonia was modeled as a mediator. CONCLUSIONS Inappropriate AAP use is associated with a higher risk of all-cause-mortality in older patients with PD which is mainly mediated by pneumonia. Therefore, inappropriate AAP use should be avoided to improve quality of care in PD.
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Affiliation(s)
- Farid Chekani
- Department of Pharmaceutical Health Outcomes and Policy (FC, MLJ, HC, RRA), College of Pharmacy, University of Houston, Houston, TX
| | - Holly M Holmes
- The University of Texas Health Science Center (HMH), Houston, TX; Division of Geriatric and Palliative Medicine (HMH), McGovern Medical School, Houston, TX
| | - Michael L Johnson
- Department of Pharmaceutical Health Outcomes and Policy (FC, MLJ, HC, RRA), College of Pharmacy, University of Houston, Houston, TX
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy (FC, MLJ, HC, RRA), College of Pharmacy, University of Houston, Houston, TX
| | - Jeffrey T Sherer
- Department of Pharmaceutical Health Outcomes and Policy (FC, MLJ, HC, RRA), College of Pharmacy, University of Houston, Houston, TX
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy (FC, MLJ, HC, RRA), College of Pharmacy, University of Houston, Houston, TX.
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Ford A, Almeida OP. Effect of biological treatments on psychotic symptoms in lewy body disease: A systematic review and meta-analysis of randomized controlled trials. Int J Geriatr Psychiatry 2020; 35:1083-1096. [PMID: 32662076 DOI: 10.1002/gps.5376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Parkinson disease and dementia with Lewy bodies (collectively termed Lewy body disease) are common neurodegenerative conditions of later life and are frequently associated with distressing psychotic symptoms. The best approach to manage these symptoms is yet to be established and current treatments carry the risk of serious adverse effects. METHODS We performed a systematic review and meta-analysis of 19 randomized controlled trials investigating the efficacy of biological treatments for psychotic symptoms in Lewy body disease. RESULTS The summary effect estimate did not show a statistically significant benefit of biological treatments for psychotic symptoms in Lewy body disease (SMD -0.48, 95%CI -1.01 to 0.04). This was irrespective of the choice of intervention (SMD -0.53, 95%CI -1.20 to 0.14 for antipsychotic trials) or disease status (SMD -0.59, 95%CI -1.24 to 0.05 for trials of Parkinson disease). There was a significant effect for biological treatments compared with placebo in trials that lasted at least 6 weeks (SMD -0.25, 95%CI -0.43 to -0.08) and those with sample sizes greater than 100 participants (SMD of -0.28 95%CI -0.45 to -0.11). CONCLUSIONS In this systematic review and meta-analysis, treatment of psychotic symptoms by biological means did not improve symptoms compared with placebo. Small sample sizes, modest treatment durations, and other methodological differences across the trials do make it difficult to draw firm conclusions. Longer, adequately powered trials utilizing established and novel treatments are needed to provide more definitive evidence to guide clinicians in the best choice of agent to treat these distressing and often persistent symptoms.
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Affiliation(s)
- Andrew Ford
- WA Centre for Health and Ageing, Medical School, University of Western Australia, Perth, Australia
| | - Osvaldo P Almeida
- WA Centre for Health and Ageing, Medical School, University of Western Australia, Perth, Australia
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Isaacson SH, Coate B, Norton J, Stankovic S. Blinded SAPS-PD Assessment After 10 Weeks of Pimavanserin Treatment for Parkinson's Disease Psychosis. JOURNAL OF PARKINSONS DISEASE 2020; 10:1389-1396. [PMID: 32716320 PMCID: PMC7683065 DOI: 10.3233/jpd-202047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Parkinson's disease psychosis (PDP) is a common nonmotor symptom that affects up to 60% of patients. Pimavanserin, a selective 5-HT2A inverse agonist/antagonist, is approved for treating hallucinations and delusions associated with PDP. OBJECTIVE Evaluate the efficacy and tolerability of pimavanserin in an open-label extension (OLE) study. METHODS Patients completing a pivotal 6-week placebo-controlled trial (Core Study) could enroll in the OLE. All patients pimavanserin 34 mg once daily, blinded to previous treatment allocation. Prespecified blinded assessments at Week 4 were the Scale for the Assessment of Positive Symptoms (SAPS) PD version and SAPS H + D scales, Caregiver Burden Scale (CBS), and Clinical Global Impression (CGI) Improvement and Severity scales. RESULTS Of 171 who entered the OLE, 148 (87%) completed Week 4. Among patients who received placebo in the Core Study, mean (SD) change from OLE baseline to OLE Week 4 for the SAPS-PD was - 3.4 (6.3); p < 0.0001. Mean change from Core Study baseline to OLE Week 4 for SAPS-PD was similar among prior pimavanserin- and placebo-treated patients (-6.9 vs. -6.3). Improvement was similar with CGI-I, CGI-S, CBS, and SAPS-H + D in patients previously treated with placebo. Adverse events occurred in 92 (53.8%) patients during the 4-week OLE. CONCLUSION Improvements at OLE Week 4 from pretreatment baseline were similar with placebo and pimavanserin in the Core Study. The beneficial effects observed with pimavanserin in the 6-week Core Study were maintained for 4 weeks in the blinded OLE, supporting the durability of response with pimavanserin 34 mg for PDP over 10 weeks.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
| | - Bruce Coate
- ACADIA Pharmaceuticals Inc., San Diego, CA, USA
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Hjorth S, Waters S, Waters N, Tedroff J, Svensson P, Fagerberg A, Edling M, Svanberg B, Ljung E, Gunnergren J, McLean S, Grayson B, Idris N, Neill J, Sonesson C. (3S)‐3‐(2,3‐difluorophenyl)‐3‐methoxypyrrolidine (IRL752) —a Novel Cortical-Preferring Catecholamine Transmission- and Cognition-Promoting Agent. J Pharmacol Exp Ther 2020; 374:404-419. [DOI: 10.1124/jpet.120.000037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/25/2020] [Indexed: 12/30/2022] Open
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Ezzeldin E, Iqbal M, Asiri YA, Ali AA, El-Nahhas T. A rapid, simple and highly sensitive UPLC-MS/MS method for quantitation of pimavanserin in plasma and tissues: Application to pharmacokinetics and brain uptake studies in mice. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1143:122015. [DOI: 10.1016/j.jchromb.2020.122015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/04/2020] [Accepted: 01/31/2020] [Indexed: 11/17/2022]
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Morana P, Mucci F, Baroni S, Della Vecchia A, Piccinni A, Morana B, Marazziti D. Effectiveness of clozapine, oxcarbazepine and rivastigmine combination in a bipolar disorder patient with initial cerebral atrophy. Clin Case Rep 2020; 8:254-257. [PMID: 32128167 PMCID: PMC7044366 DOI: 10.1002/ccr3.2462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 12/26/2022] Open
Abstract
This paper reports the case of a 46-year-old woman suffering from bipolar disorder of type I with mixed features with initial fronto-temporal atrophy. Although considered treatment-resistant to conventional strategies, she successfully responded to a combination of rivastigmine, clozapine, and oxcarbazepine.
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Affiliation(s)
| | - Federico Mucci
- Dipartimento di Medicina Clinica e SperimentaleSection of PsychiatryUniversity of PisaItaly
| | - Stefano Baroni
- Dipartimento di Medicina Clinica e SperimentaleSection of PsychiatryUniversity of PisaItaly
| | | | - Armando Piccinni
- Brain Research Foundation (BRF)LuccaItaly
- UNICamillus University of health medical sciencesRomaItaly
| | | | - Donatella Marazziti
- Dipartimento di Medicina Clinica e SperimentaleSection of PsychiatryUniversity of PisaItaly
- Brain Research Foundation (BRF)LuccaItaly
- UNICamillus University of health medical sciencesRomaItaly
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Chekani F, Holmes HM, Johnson ML, Chen H, Sherer JT, Aparasu RR. Use of Atypical Antipsychotics in Long-Term Care Residents with Parkinson's Disease and Comorbid Depression. Drug Healthc Patient Saf 2020; 12:23-30. [PMID: 32099480 PMCID: PMC6999551 DOI: 10.2147/dhps.s226486] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/15/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE According to the 2015 American Geriatrics Society (AGS) Beers criteria, most antipsychotics are inappropriate in Parkinson's disease (PD) patients due to the risk of worsening Parkinsonian symptoms. This study examined the incidence and predictors of inappropriate antipsychotic use among long-term care residents with PD and comorbid depression. PATIENTS AND METHODS This retrospective cohort study utilized 2007-2009 Minimum Data Set (MDS) linked to Chronic Condition Warehouse (CCW) Medicare data files involving patients with PD and comorbid depression. Using a 12-month baseline and a 24-month follow-up, the study examined incidence of inappropriate atypical antipsychotics, namely asenapine, brexpiprazole, iloperidone, lurasidone, olanzapine, paliperidone, risperidone, or ziprasidone as specified in the 2015 AGS Beers criteria. Appropriate atypical antipsychotic included aripiprazole, clozapine, or quetiapine. Multivariable logistic regression was used to examine various sociodemographic and clinical factors associated with inappropriate antipsychotic use in PD based on the Andersen Behavioral Model. RESULTS The incidence of atypical antipsychotic use was 17.50% (13,352/76,294) among PD patients over a 2-year follow-up. The percentage of inappropriate use among atypical antipsychotic users was 36.32%. The likelihood of inappropriate antipsychotic use was higher for patients who had dementia (OR=1.22, 95% CI: 1.12-1.33) or Chronic Obstructive Pulmonary Disease ((OR=1.13, 95% CI: 1.03-1.24). However, patients who were taking levodopa (OR=0.62, 95% CI: 0.57-0.67), dopamine agonists (OR=0.90, 95% CI: 0.82-0.98), Catechol-O-methyltransferase (COMT) inhibitors (OR=0.77, 95% CI: 0.68-0.86), Monoamine Oxidase (MAO) inhibitors type B (OR=0.72, 95% CI: 0.60-0.86), or amantadine (OR=0.84, 95% CI: 0.71-0.98) were less likely to receive inappropriate antipsychotics. CONCLUSION More than one-third of PD patients used inappropriate antipsychotics among those who were treated with atypical antipsychotic medications. Various socio-demographics and clinical factors were associated with inappropriate antipsychotic use in older patients with PD. Concerted efforts are needed to reduce inappropriate atypical antipsychotic use among PD patients.
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Affiliation(s)
- Farid Chekani
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX77204-5047, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX77030, USA
| | - Michael L Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX77204-5047, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX77204-5047, USA
| | - Jeffrey T Sherer
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX77204-5047, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX77204-5047, USA
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Hu K, Zhang M, Wu D, Xie Y, Ren J. A Novel Synthesis of Pimavanserin: A Selective Serotonin 5-HT2A Receptor Inverse Agonist. ORG PREP PROCED INT 2020. [DOI: 10.1080/00304948.2019.1697613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Kun Hu
- School of Pharmaceutical Engineering & Life Science, Changzhou University, Changzhou, Jiangsu, China
| | - Meiju Zhang
- School of Pharmaceutical Engineering & Life Science, Changzhou University, Changzhou, Jiangsu, China
| | - Dongdong Wu
- School of Pharmaceutical Engineering & Life Science, Changzhou University, Changzhou, Jiangsu, China
| | - Yuxuan Xie
- School of Pharmaceutical Engineering & Life Science, Changzhou University, Changzhou, Jiangsu, China
| | - Jie Ren
- School of Pharmaceutical Engineering & Life Science, Changzhou University, Changzhou, Jiangsu, China
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Mécanisme d’action de la pimavansérine : le nouvel antipsychotique pour traiter la psychose parkinsonienne. ANNALES MEDICO-PSYCHOLOGIQUES 2019. [DOI: 10.1016/j.amp.2019.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Risk of pneumonia associated with atypical antipsychotic use in nursing home residents with Parkinson's disease. J Psychiatr Res 2019; 117:116-121. [PMID: 31377483 DOI: 10.1016/j.jpsychires.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/12/2019] [Accepted: 07/25/2019] [Indexed: 12/26/2022]
Abstract
According to the American Geriatrics Society (AGS) Beers criteria, most atypical antipsychotic (AAPs) are inappropriate in patients with Parkinson's disease (PD) due to the risk of worsening Parkinsonian symptoms. This study evaluated the risk of pneumonia associated with inappropriate AAP use in elderly nursing home residents with PD. The study population encompassed older adults aged 65 years or older with a diagnosis of PD and with comorbid depression who started the AAP medication. Appropriate AAPs were defined as aripiprazole, clozapine or quetiapine according to 2015 Beers criteria, and inappropriate AAPs included olanzapine, asenapine, brexpiprazole, iloperidone, lurasidone, paliperidone, risperidone, or ziprasidone. Cox regression analyses involved propensity score-matched users of inappropriate and appropriate AAPs to examine the association between AAP use and risk of pneumonia. The mean age of patients in propensity-matched cohort (n = 12,076) was 82.15 years (SD = 6.97). The pneumonia incidence rates were 37.19 and 45.92 per person-year in appropriate and inappropriate AAP groups, respectively. Multivariable Cox regression analyses revealed increased risk of pneumonia [Hazard Ratio (HR) 1.20 (1.08-1.34)] for nursing home residents who were taking inappropriate compared to those taking appropriate AAP. In sensitivity analyses, the pneumonia risk was 1.28 (1.12-1.47) for risperidone vs. quetiapine and 1.29 (1.06-1.57) for olanzapine vs. quetiapine. The risk of pneumonia was significantly higher for patients with PD who used inappropriate AAP in comparison to appropriate AAP group in all analyses. This investigation warrants further attention regarding safety of atypical antipsychotics in PD.
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Abstract
PURPOSE OF REVIEW Neuropsychiatric syndromes (NPS) are common in neurodegenerative disorders (NDD). This review describes the role of NPS in the diagnosis of NDD, criteria for the diagnosis of NPS, management of NPS, and agents in clinical trials for NPS. RECENT FINDINGS NPS play an increasingly important role in the diagnosis of NDD. Consensus diagnostic criteria have evolved for psychosis, depression, agitation, and apathy in NDD. With one exception-pimavanserin is approved for the treatment of hallucinations and delusions in Parkinson's disease-there are no drugs approved by the FDA for treatment of NPS in NDD. Trials show that atypical antipsychotics reduce psychosis in AD and in Parkinson's disease, although side effect concerns have constrained their use. Antidepressants show benefit in treatment of Parkinson's disease with depression. Several agents are in clinical trials for treatment of NPS in NDD. Neuropsychiatric syndromes play a major role in NDD diagnosis. Clinical criteria allow recognition of NPS in NDD. Psychotropic medications are often useful in the treatment of NPS in NDD; efficacious, safe, and approved agents are needed.
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Affiliation(s)
- Jeffrey Cummings
- Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas (UNLV), 4505 S Maryland Pkwy, Las Vegas, NV, 89154, USA.
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W Bonneville Ave., Las Vegas, NV, 89106, USA.
| | - Aaron Ritter
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W Bonneville Ave., Las Vegas, NV, 89106, USA
| | - Kasia Rothenberg
- Cleveland Clinic Lou Ruvo Center for Brain Health, Cleveland, OH, USA
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Berardelli I, Belvisi D, Pasquini M, Fabbrini A, Petrini F, Fabbrini G. Treatment of psychiatric disturbances in hypokinetic movement disorders. Expert Rev Neurother 2019; 19:965-981. [PMID: 31241368 DOI: 10.1080/14737175.2019.1636648] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: We reviewed studies that assessed the treatment of psychiatric disturbances in Parkinson's disease and atypical parkinsonisms. Neuropsychiatric disturbances in these conditions are frequent and have a profound impact on quality of life of patients and of their caregivers. It is therefore important to be familiar with the appropriate pharmacological and non-pharmacological interventions for treating these disorders. Areas covered: The authors searched for papers in English in Pubmed using the following keywords: Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia, depression, apathy, anxiety, fatigue, sleep disorders, obsessive compulsive disorders, psychosis, hallucinations, delusions, impulse control disorders. Expert opinion: In Parkinson's disease, depression may benefit from the optimization of dopaminergic therapy, from the use of antidepressants acting on both the serotoninergic and noradrenergic pathways and from cognitive behavioral therapy. Psychosis in Parkinson's disease may improve with the use of clozapine; the serotonin inverse agonist pimavanserin has been shown to be effective. Treatment of impulse control disorders is primarily based on the removal of dopamine agonists. No controlled studies have investigated the treatment of neuropsychiatric disorders in multiple system atrophy, progressive supranuclear palsy or corticobasal degeneration. Acethylcholinesterase inhibitors may be used to treat hallucinations in Lewy body dementia.
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Affiliation(s)
- Isabella Berardelli
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy
| | | | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome , Rome , Italy
| | - Andrea Fabbrini
- Department of Human Neurosciences, Sapienza University of Rome , Rome , Italy
| | - Federica Petrini
- Department of Neurosciences and Mental Health, Azienda Universitaria Policlinico Umberto I° , Rome , Italy
| | - Giovanni Fabbrini
- IRCCS Neuromed , Pozzilli , Italy.,Department of Human Neurosciences, Sapienza University of Rome , Rome , Italy
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Lyons KE, Pahwa R, Hermanowicz N, Davis T, Pagan F, Isaacson S. Changing the treatment paradigm for Parkinson’s disease psychosis with pimavanserin. Expert Rev Clin Pharmacol 2019; 12:681-691. [DOI: 10.1080/17512433.2019.1623669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Kelly E. Lyons
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Neal Hermanowicz
- Department of Neurology, University of California Irvine, Irvine, CA, USA
| | - Thomas Davis
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fernando Pagan
- Department of Neurology, Georgetown University Medical Center, Washington, DC, USA
| | - Stuart Isaacson
- Parkinson’s Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
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Rothenberg KG, Rajaram R. Advances in Management of Psychosis in Neurodegenerative Diseases. Curr Treat Options Neurol 2019; 21:3. [PMID: 30673880 DOI: 10.1007/s11940-019-0545-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF THE REVIEW Psychosis is broadly defined as a disengagement from reality. It describes syndromes that impair both thought content and thought process. Psychosis negatively impacts an individual's quality of life, in addition to the families caring for them. Psychosis with different types of hallucinations and delusions occurs in the context of delirium. Neuropsychiatric symptoms (NPS) are almost universal in the course of common neurodegenerative disorders (NDD) like Alzheimer's disease (AD) or Parkinson's disease (PD). In this paper, the authors took an effort to characterize AD and PD psychosis with a special focus on the most diagnostically reliable features. Effectiveness and limitations of pharmacological interventions are discussed. RECENT FINDINGS Consensus diagnostic criteria have evolved for psychosis secondary to AD as well as psychosis in PD. Psychotropic medications can be effective in the treatment of NPS in NDD; however, clinicians must be mindful of the side effects. There is a consensus on benefit of initiating any acetylcholinesterase inhibitor (ACHI: donepezil, rivastigmine, and galantamine) as a first line of treatment for psychosis in AD, as it may reduce and/or avoid the need for the use antipsychotics. Pimavanserin, a selective-serotonin inverse agonist that preferentially targets 5-HT2A receptors, while avoiding activity at dopamine and other receptors commonly targeted by antipsychotics had recently been approved by FDA to treat hallucinations and delusions in PD. Quetiapine is widely prescribed for the treatment of psychosis in different NDD, but the data remains equivocal. Psychosis with different types of hallucinations and delusions may occur in the context of delirium and is almost universal as a neuropsychiatric symptom in the course of PD and AD. Currently, pimavanserin remains the only pharmacologic agent approved for treatment of psychosis in PD. In cases of other NPS in other than Parkinson's diseases, atypical antipsychotics are commonly used off-label. More research is greatly needed to advance this field and address NPS especially psychosis in geriatric population.
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Affiliation(s)
- Kasia Gustaw Rothenberg
- Cleveland Clinic Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
| | - Ryan Rajaram
- Department of Psychiatry, Yale School of Medicine, 300 George St., Suite 901, New Haven, CT, 06511, USA
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Tampi RR, Young JJ, Tampi D. Behavioral symptomatology and psychopharmacology of Lewy body dementia. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:59-70. [PMID: 31727230 DOI: 10.1016/b978-0-444-64012-3.00005-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lewy body dementia (LBD) is an umbrella term for major neurocognitive disorders caused by Lewy body pathology. Parkinson's disease dementia (PDD) and Dementia with Lewy bodies (DLB) are the two main syndromes in LBD. LBDs typically present with cognitive impairment, cholinergic deficiency, neuropsychiatric symptoms such as visual hallucinations and paranoid delusions, as well as parkinsonian symptoms. Due to the urgency in diagnosing LBD early in the disease course to provide the most optimal management of these syndromes, it is important that clinicians elicit the most clinically significant symptoms during patient encounters. The focus of this chapter is to discuss current LBD classification systems and assessments, neuropathology of LBDs, behavioral symptomatology, contemporary management options, and possible future targets of treatment. PubMed was searched to obtain reviews and studies that pertain to classification, behavioral symptomatology, neurobiology, neuroimaging, and treatment of LBDs. Articles were chosen with a predilection to more recent clinical trials and systematic reviews or meta-analyses. Updates to diagnostic criteria have increased clinical diagnostic sensitivity and specificity. Current therapeutic modalities are limited as there is no current disease-modifying drug available. Cholinesterase inhibitors have been reported to be effective in decreasing neuropsychiatric and cognitive symptoms. Neuroleptics should be avoided unless clinically indicated. There is a paucity of studies investigating treatment options for mood symptoms. Current novel targets of treatment focus on decreasing α-synuclein burden. LBDs are a group of dementia syndromes that affect a significant portion of the elderly population. Early diagnosis and treatment is necessary to improve patient quality of life with current treatment options more focused on alleviating severe symptomatology rather than modifying disease pathology.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, United States; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States.
| | - Juan Joseph Young
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Deena Tampi
- Diamond Healthcare, Richmond, VA, United States
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Zhang H, Wang L, Fan Y, Yang L, Wen X, Liu Y, Liu Z. Atypical antipsychotics for Parkinson's disease psychosis: a systematic review and meta-analysis. Neuropsychiatr Dis Treat 2019; 15:2137-2149. [PMID: 31551655 PMCID: PMC6677378 DOI: 10.2147/ndt.s201029] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/09/2019] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To assess the present evidence regarding the efficiency, safety, and potential risks of pharmacotherapy used for Parkinson's disease psychosis (PDPsy) treatment. PATIENTS AND METHODS We searched the following databases: PubMed, the Cochrane Library, ISI Web of Science, and Embase using the following terms: atypical antipsychotics, pimavanserin, olanzapine, quetiapine, clozapine, Parkinson's disease and psychosis. We systematically reviewed all randomized placebo-controlled trials comparing an atypical antipsychotic with a placebo. RESULTS A total of 13 randomized placebo-controlled trials for a total 1142 cases were identified involving pimavanserin (n=4), clozapine (n=2), olanzapine (n=3), and quetiapine (n=4). For each atypical antipsychotic, a descriptive synthesis and meta-analyses was presented. Pimavanserin was associated with a significant improvement in psychotic symptoms compared to a placebo without worsening motor function. Clozapine was efficacious in alleviating psychotic symptoms and did not exacerbate motor function either. Quetiapine and Olanzapine did not demonstrate significant differences in reducing psychotic symptoms but may aggravate motor function. CONCLUSIONS There is strong evidence that pimavanserin is effective for the treatment of PDPsy. Clozapine is also recommended but should be used with caution due to its side effects. In the future, more well-designed randomized controlled trials (RCTs) are needed to confirm and update the findings reported in this meta-analysis.
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Affiliation(s)
- Han Zhang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Limin Wang
- Department of Neurology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Neuroscience Institute, Guangzhou 510080, Guangdong Province, People's Republic of China
| | - Yafei Fan
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Lianhong Yang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Xiaojun Wen
- Department of Neurology, Guangzhou First Municipal People's Hospital, Guangzhou Medical University, Guangzhou-Birmingham University Brain and Cognition Center, Guangzhou 510180, People's Republic of China
| | - Yunyun Liu
- Department of Neurology, The Sixth Affiliated Hospital Sun Yat-Sen University, Guangzhou 510440, People's Republic of China
| | - Zhonglin Liu
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
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Tampi RR, Young J, Hoq R, Resnick K, Tampi DJ. Psychotic disorders in late life: a narrative review. Ther Adv Psychopharmacol 2019; 9:2045125319882798. [PMID: 31662846 PMCID: PMC6796200 DOI: 10.1177/2045125319882798] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/25/2019] [Indexed: 11/25/2022] Open
Abstract
Psychotic disorders are not uncommon in late life. These disorders often have varied etiologies, different clinical presentations, and are associated with significant morbidity and mortality among the older adult population. Psychotic disorders in late life develop due to the complex interaction between various biological, psychological, social, and environmental factors. Given the significant morbidity and mortality associated with psychotic disorders in late life, a comprehensive work-up should be conducted when they are encountered. The assessment should not only identify the potential etiologies for the psychotic disorders, but also recognize factors that predicts possible outcomes for these disorders. Treatment approaches for psychotic disorders in late life should include a combination of nonpharmacological management strategies with the judicious use of psychotropic medications. When antipsychotic medications are necessary, they should be used cautiously with the goal of optimizing outcomes with regular monitoring of their efficacy and adverse effects.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry and Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH 44307, USA
| | - Juan Young
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Rakin Hoq
- NeoMed/Summa Psychiatry Residency Program, Akron, OH, USA
| | - Kyle Resnick
- NeoMed/Summa Psychiatry Residency Program, Akron, OH, USA
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Sawada H, Oeda T, Kohsaka M, Umemura A, Tomita S, Park K, Mizoguchi K, Matsuo H, Hasegawa K, Fujimura H, Sugiyama H, Nakamura M, Kikuchi S, Yamamoto K, Fukuda T, Ito S, Goto M, Kiyohara K, Kawamura T. Early use of donepezil against psychosis and cognitive decline in Parkinson's disease: a randomised controlled trial for 2 years. J Neurol Neurosurg Psychiatry 2018; 89:1332-1340. [PMID: 30076270 PMCID: PMC6288700 DOI: 10.1136/jnnp-2018-318107] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/27/2018] [Accepted: 07/10/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Brain acetylcholine is decreased even in patients with cognitively preserved Parkinson's disease (PD). We investigated whether early and long-term use of donepezil prevents psychosis in non-demented PD patients. METHODS A double-blinded, placebo-controlled trial was conducted. A total of 145 non-demented PD patients were randomly assigned to receive 5 mg/day donepezil (n=72) or placebo (n=73) for 96 weeks. Medications for PD were not restricted, but antipsychotic drugs were not permitted throughout the study. The primary outcome measure was survival time to psychosis that was predefined by Parkinson's Psychosis Questionnaire (PPQ) B score ≥2 or C score ≥2. Secondary outcome measures included psychosis developing within 48 weeks, total PPQ score, Mini-Mental State Examination (MMSE), Wechsler Memory Scale (WMS) and subgroup analysis by apolipoprotein ε4 genotyping. RESULTS Kaplan-Meier curves for psychosis development were very similar between the two groups, and the Cox proportional hazard model revealed an adjusted HR of 0.87 (95%CI 0.48 to 1.60). The changes in MMSE and WMS-1 (auditory memory) were significantly better with donepezil than in placebo. In the subgroup analysis, donepezil provided an HR of 0.31 (0.11-0.86) against psychosis in 48 weeks for apolipoprotein ε4 non-carriers. CONCLUSIONS Although donepezil provided beneficial effects on PPQ, MMSE and auditory WMS score changes in 2 years, it had no prophylactic effect on development of psychosis in PD. Apolipoprotein ε4 may suppress the antipsychotic effect of donepezil. TRIAL REGISTRATION NUMBER UMIN000005403.
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Affiliation(s)
- Hideyuki Sawada
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Tomoko Oeda
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Masayuki Kohsaka
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Atsushi Umemura
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Satoshi Tomita
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Kwiyoung Park
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Kouichi Mizoguchi
- Department of Neurology, Shizuoka Medical Institute of Epilepsy and Neurological Disorders, Shizuoka City, Japan
| | - Hidenori Matsuo
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Kazuko Hasegawa
- Department of Neurology, Sagamihara National Hospital, Sagamihara, Japan
| | - Harutoshi Fujimura
- Clinical Research Center and Department of Neurology, Toneyama National Hospital, Toyonaka, Japan
| | - Hiroshi Sugiyama
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
- Department of Neurology, Minami-Kyoto National Hospital, Joyo, Japan
| | | | - Seishi Kikuchi
- Department of Neurology, Hokkaido Medical Center, Sapporo, Japan
| | - Kenji Yamamoto
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Toshiaki Fukuda
- Clinical Research Center and Department of Neurology, Utano National Hospital, Kyoto, Japan
| | - Suminobu Ito
- Clinical Research Center, National Hospital Organization, Meguro, Japan
| | - Masashi Goto
- Division of General Internal Medicine, Kyoto Medical Center, Kyoto, Japan
| | - Kosuke Kiyohara
- Department of Public Health, Tokyo Women's Medical University, Shinjuku-ku, Japan
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Cozac VV. [Modern approaches to treatment of psychosis in Parkinson's disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2018. [PMID: 28635863 DOI: 10.17116/jnevro2016116101103-109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Psychotic disorders in Parkinson's disease (PDPD) are common and significantly influence the quality of life and disability level. The pathogenesis of PDPD is complex and not yet fully understood. Taking into consideration the features of the Parkinson's disease (usually older patients with a risk of cognitive decline), and the pharmacodynamics of the antiparkinsonian and traditional antipsychotic drugs, the management of PDPD is a challenging issue of clinical neurology and psychiatry. In this systematic review, scientific publications for the period 2014-2016 were analyzed within two bibliographic databases: MEDLINE/PubMed and eLIBRARY.RU. Additionally, the guidelines of the International Parkinson and Movement Disorders Society, American Academy of Neurology and European Academy of Neurology were included in the analysis. Clozapine is recommended to use in the treatment of PDPD, quetiapine is possible to use, pimavanserin will probably become a remedy of choice. Nonpharmacological approaches have positive effects on the general condition of the patients with PDPD, however the efficacy of such approaches to treat psychosis is unclear.
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Affiliation(s)
- V V Cozac
- Hospital of the University of Basel, Basel, Switzerland
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Schubmehl S, Sussman J. FDA Approval of Pimavanserin: Response to Absence of Evidence Versus Evidence of Absence-Pimavanserin and the SAPS-PD. Am J Geriatr Psychiatry 2018; 26:1014. [PMID: 30100268 DOI: 10.1016/j.jagp.2018.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
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