Frequency, reasons, and factors associated with antipsychotic polypharmacy in Schizophrenia: A retrospective chart review in a tertiary hospital in India

Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review

It is important to examine the psychotropic prescription practices in schizophrenia, as it can inform regarding changing treatment choices and related patient profiles. No recent reviews have evaluated the global neuropsychopharmacological prescription patterns in adults with schizophrenia. A systematic search of the literature published from 2002 to 2023 found 88 empirical papers pertinent to the utilization of psychotropic agents. Globally, there were wide inter-country and inter-regional variations in the prescription of psychotropic agents. Overall, over time there was an absolute increase in the prescription rate of second-generation antipsychotics (up to 50%), mood stabilizers (up to 15%), and antidepressants (up to 17%), with an observed absolute decrease in the rate of antipsychotic polypharmacy (up to 15%), use of high dose antipsychotic (up to 12% in Asia), clozapine (up to 9%) and antipsychotic long-acting injectables (up to 10%). Prescription patterns were mainly associated with specific socio-demographic (such as age), illness (such as illness duration), and treatment factors (such as adherence). Further work, including more evidence in adjunctive neuropsychopharmacological treatments, pharmaco-economic considerations, and examination of cohorts in prospective studies, can proffer insights into changing prescription trends relevant to different treatment settings and predictors of such trends for enhancement of clinical management in schizophrenia.

Antipsychotic polypharmacy and associated factors among patients with schizophrenia: Multicenter cross-sectional study in Northwest Ethiopia

BACKGROUND

Antipsychotic polypharmacy (APP) remains common despite guideline recommendations to minimize combinations, except after repeated antipsychotic monotherapy trials. This study aimed to assess APP and its associated factors among schizophrenia patients at comprehensive specialized hospitals in Northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 422 schizophrenia patients at selected hospitals in Ethiopia from June to August 2022. The data were collected using a semi-structured questionnaire. Study participants were enrolled using systematic random sampling. Data entry and analysis were done with Epi-data version 4.6.1 and SPSS version 24, respectively. APP was determined by reviewing the number of medications based on relevant evidence. A multivariable logistic regression model was fitted to identify APP factors. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant.

RESULTS

From a total of 430 approached samples, 422 (98.1% response rate) eligible patients were included in the study. An overall APP prevalence was 22.7% (95% CI: 19-27). Duration of illness (AOR = 2.88; 95% CI: 1.49, 5.59); duration of treatment (AOR = 3.79; 95% CI: 1.05, 13.62); number of admissions (AOR = 4.93; 95% CI: 2.52, 9.64); and substance use (AOR = 2.58; 95% CI: 1.49, 4.47) were significantly associated with APP.

CONCLUSION AND RECOMMENDATION

In this study, APP was recorded in a considerable number of patients. Patients with a longer duration of illness and treatment, frequent admissions, and substance users need critical follow-up to minimize antipsychotic medication use.

Combination of two long-acting injectable antipsychotics in treatment-resistant schizophrenia: A retrospective 12-month mirror-image study

To evaluate the efficacy and tolerability of the combination of two long-acting injections of antipsychotics (dual-LAIs) in non-adherent and resistant schizophrenia. Efficacy and tolerability were assessed in 13 patients admitted to a French hospital, using a retrospective 12-month mirror-image design. The number and total duration of hospitalizations significantly decreased after introducing dual-LAIs (2.6 vs. 1.3, P = 0.017; 142 days vs. 95 days, P = 0.046). The average duration of each hospitalization did not differ. No significant differences were observed in tolerance outcomes (body mass index, agranulocytosis, lipid profile, sugar levels). Patients with treatment-resistant schizophrenia and poor medication adherence can derive significant clinical benefits from dual-LAIs.

Determining nonesterified and total docosahexaenoic acid and eicosapenaenoic acid concentrations by LC-MS/MS in the plasma of patients with schizophrenia

Background: Nonesterified, total docosahexaenoic acid (DHA) and eicosapenaenoic acid (EPA) plasma levels were evaluated in patients with schizophrenia on different medications compared with healthy individuals using validated LC-MS/MS methods. Methods: Samples for nonesterified DHA and EPA assay were extracted in n-hexane-dichloromethane-isopropyl alcohol (2:1:0.1, V/V/V) and hydrolyzed at 90°C for 2 h before total DHA and EPA determination. Methods were validated in surrogate matrix and plasma. Results: These methods generated similar recovery for plasma (>89%) and surrogate matrix (>87%) and negligible matrix effects. Linearity, lower limit of quantification, accuracy, precision and stability were also validated. Conclusions: This study successfully determined DHA and EPA plasma levels in patients with schizophrenia and healthy individuals using validated LC-MS/MS methods. Therefore, nonesterified DHA and total EPA levels could be used as schizophrenia biomarkers.

Review: Influence of the CYP450 Genetic Variation on the Treatment of Psychotic Disorders

Second-generation antipsychotic metabolism is mainly carried out by the CYP450 superfamily, which is highly polymorphic. Therefore, knowing the influence of the different known CYP450 polymorphisms on antipsychotic plasmatic levels and, consequently, the biological effect could contribute to a deeper knowledge of interindividual antipsychotic treatment variability, prompting possible solutions. Considering this, this state of the art review aimed to summarize the current knowledge about the influence of the diverse characterized phenotypes on the metabolism of the most used second-generation antipsychotics. Forty studies describing different single nucleotide polymorphisms (SNPs) associated with the genes CYP1A2, CYP2D6, CYP3A4, CYP3A5, and ABCB1 and their influence on pharmacokinetics of olanzapine, clozapine, aripiprazole, risperidone, and quetiapine. Most of the authors concluded that although significant differences in the pharmacokinetic parameters between the different phenotypes could be observed, more thorough studies describing pharmacokinetic interactions and environmental conditions, among other variables, are needed to fully comprehend these pharmacogenetic interactions.

Case Report: Pharmacogenetics Applied to Precision Psychiatry Could Explain the Outcome of a Patient With a New CYP2D6 Genotype

Precision medicine applied to psychiatry provides new insight into the promising field of precision psychiatry. Psychotic disorders are heterogeneous, complex, chronic, and severe mental disorders. Not only does the prognosis and the course of the disease vary among patients suffering from psychotic disorders, but the treatment response varies as well. Although antipsychotic drugs are the cornerstone of the treatment of schizophrenia, many patients only partially respond to these drugs. Furthermore, patients often experience adverse events which can lead to poor treatment adherence. Interindividual variability in drug response could be related to age, gender, ethnicity, lifestyle factors, pharmacological interactions, obesity, and genetics, all of which influence the process of drug metabolism. Commonly prescribed antipsychotics are metabolized by cytochrome P450 (CYP450) enzymes, and CYP450 genes are highly polymorphic. Pharmacogenetic testing is increasingly being used to predict a patient's drug response and could help to find the most appropriate therapy for an individual patient. In this report, we describe a psychotic patient who did not receive adequate clinical follow-up and subsequently presented adverse events, which could be explained by his pharmacogenetic profile and the drug interactions resulting from the polypharmacy prescribed.

Defining polypharmacy: in search of a more comprehensive determination method applied in a tertiary psychiatric hospital

AIMS

This cross-sectional pharmacoepidemiologic study examined the prevalence of polypharmacy and psychotropic polypharmacy among inpatients in a tertiary psychiatric hospital in Belgium.

METHODS

Current prescriptions of all inpatients suffering from mental disorders were extracted from the hospital Computerized Physician Order Entry. Two methods were used to examine definitive polypharmacy (defined as the concomitant use of at least five medicines): number of medicines per active component and per prescription. Psychotropic polypharmacy was defined as the concomitant use of at least two psychotropic medicines, based on the first counting, i.e., per active component.

RESULTS

In 292 included patients, the prevalence of definitive polypharmacy was 65.8%, with a mean number of 6.8 ± 4.2 medicines per patient. The most prevalent medicines were related to the central nervous system (55.7%), followed by medicines related to the gastro-intestinal (17.6%) and cardiovascular (9.4%) systems. A prevalence of psychotropic polypharmacy of 78.1% was observed, with a mean of 3.0 ± 1.7 psychotropic medicines per patient. Psychotropic polypharmacy was classified in same-class (71.5%), multi-class (82.5%), augmentation (20.6%), and adjuvant (35.5%) polypharmacy.

CONCLUSION

These findings are consistent with previous reports of highly prevalent polypharmacy in patients with mental disorders. Although, in some cases, polypharmacy can be an important part of good clinical practice, the high prevalence of both polypharmacy and psychotropic polypharmacy emphasizes that attention must be paid to the potentially associated risks. Consensus on the definition and method of determination of polypharmacy is needed to support further research.

Application of a Pharmacogenetics-Based Precision Medicine Model (5SPM) to Psychotic Patients That Presented Poor Response to Neuroleptic Therapy

Antipsychotics are the keystone of the treatment of severe and prolonged mental disorders. However, there are many risks associated with these drugs and not all patients undergo full therapeutic profit from them. The application of the 5 Step Precision Medicine model(5SPM), based on the analysis of the pharmacogenetic profile of each patient, could be a helpful tool to solve many of the problematics traditionally associated with the neuroleptic treatment. In order to solve this question, a cohort of psychotic patients that showed poor clinical evolution was analyzed. After evaluating the relationship between the prescribed treatment and pharmacogenetic profile of each patient, a great number of pharmacological interactions and pharmacogenetical conflicts were found. After reconsidering the treatment of the conflictive cases, patients showed a substantial reduction on mean daily doses and polytherapy cases, which may cause less risk of adverse effects, greater adherence, and a reduction on economic costs.