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Li C, Tian H, Li R, Jia F, Wang L, Ma X, Yang L, Zhang Q, Zhang Y, Yao K, Zhuo C. Molecular mechanisms of quetiapine bidirectional regulation of bipolar depression and mania based on network pharmacology and molecular docking: Evidence from computational biology. J Affect Disord 2024; 355:528-539. [PMID: 38518857 DOI: 10.1016/j.jad.2024.03.096] [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: 02/05/2024] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Quetiapine monotherapy is recommended as the first-line option for acute mania and acute bipolar depression. However, the mechanism of action of quetiapine is unclear. Network pharmacology and molecular docking were employed to determine the molecular mechanisms of quetiapine bidirectional regulation of bipolar depression and mania. METHODS Putative target genes for quetiapine were collected from the GeneCard, SwissTargetPrediction, and DrugBank databases. Targets for bipolar depression and bipolar mania were identified from the DisGeNET and GeneCards databases. A protein-protein interaction (PPI) network was generated using the String database and imported into Cytoscape. DAVID and the Bioinformatics platform were employed to perform the Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses of the top 15 core targets. The drug-pathway-target-disease network was constructed using Cytoscape. Finally, molecular docking was performed to evaluate the interactions between quetiapine and potential targets. RESULTS Targets for quetiapine actions against bipolar depression (126 targets) and bipolar mania (81 targets) were identified. Based on PPI and KEGG pathway analyses, quetiapine may affect bipolar depression by targeting the MAPK and PI3K/AKT insulin signaling pathways via BDNF, INS, EGFR, IGF1, and NGF, and it may affect bipolar mania by targeting the neuroactive ligand-receptor interaction signaling pathway via HTR1A, HTR1B, HTR2A, DRD2, and GRIN2B. Molecular docking revealed good binding affinity between quetiapine and potential targets. LIMITATIONS Pharmacological experiments should be conducted to verify and further explore these results. CONCLUSIONS Our findings suggest that quetiapine affects bipolar depression and bipolar mania through distinct biological core targets, and thus through different mechanisms. Furthermore, our results provide a theoretical basis for the clinical use of quetiapine and possible directions for new drug development.
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Affiliation(s)
- Chao Li
- Computational Biology Centre (CBC), Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Medical University Affiliated Tianjin Anding Hospital, Tianjin 300222, China; Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China
| | - Hongjun Tian
- Animal Imaging Center (AIC) of Tianjin Fourth Center Hospital, Nankai University Affiliated Tianjin Fourth Center Hospital, Tianjin 300140, China
| | - Ranli Li
- Computational Biology Centre (CBC), Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Medical University Affiliated Tianjin Anding Hospital, Tianjin 300222, China
| | - Feng Jia
- Computational Biology Centre (CBC), Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Medical University Affiliated Tianjin Anding Hospital, Tianjin 300222, China
| | - Lina Wang
- Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China
| | - Xiaoyan Ma
- Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China
| | - Lei Yang
- Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China
| | - Qiuyu Zhang
- Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China
| | - Ying Zhang
- Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China
| | - Kaifang Yao
- Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China
| | - Chuanjun Zhuo
- Computational Biology Centre (CBC), Tianjin Anding Hospital, Nankai University Affiliated Tianjin Anding Hospital, Tianjin Medical University Affiliated Tianjin Anding Hospital, Tianjin 300222, China; Laboratory of Psychiatric-Neuroimaging-Genetic and Co-morbidity (PGNP_Lab), Tianjin Anding Hospital, Tianjin Mental Health Center of Tianjin Medical University, Tianjin 300222, China.
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Nizon D, Abdel Ahad P, Chauviré V, Godier E, Gohier B, Kazour F. Treatment with pimavanserin of Lewy body dementia related psychosis with previous clozapine intolerance - A case report. L'ENCEPHALE 2024; 50:358-359. [PMID: 38311485 DOI: 10.1016/j.encep.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/16/2023] [Accepted: 11/06/2023] [Indexed: 02/06/2024]
Affiliation(s)
- Dorian Nizon
- Department of Adult Psychiatry and Addictology, Angers University Hospital, CHU of Angers, 4, rue Larrey, 49100 Angers, France
| | - Pierre Abdel Ahad
- Department of Adult Psychiatry and Addictology, Angers University Hospital, CHU of Angers, 4, rue Larrey, 49100 Angers, France
| | - Valérie Chauviré
- Department of Neurology, Angers University Hospital, CHU of Angers, Angers, France
| | - Edouard Godier
- Department of Adult Psychiatry and Addictology, Angers University Hospital, CHU of Angers, 4, rue Larrey, 49100 Angers, France
| | - Bénédicte Gohier
- Department of Adult Psychiatry and Addictology, Angers University Hospital, CHU of Angers, 4, rue Larrey, 49100 Angers, France
| | - François Kazour
- Department of Adult Psychiatry and Addictology, Angers University Hospital, CHU of Angers, 4, rue Larrey, 49100 Angers, France.
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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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Friedman JH. Parkinson's disease psychosis management: an evidence based, experience informed, pragmatic approach. Expert Opin Pharmacother 2024; 25:149-156. [PMID: 38344806 DOI: 10.1080/14656566.2024.2316135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/05/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION Psychotic symptoms in people with Parkinson's disease (PD) have attracted increasing. Recommendations on treating psychosis often fail to take into account what psychotic symptoms require treatment, which has been complicated by the increasing number of reports documenting the frequency of 'minor' hallucinations. AREAS COVERED This article focuses both on the phenomenology of psychotic symptoms and their management. EXPERT OPINION Understanding the nature and implications of the types of psychotic symptoms in PD is the key to proper treatment. Evidence and experience-based data on the effect of anti-psychotic medications will be reviewed and how the various clinical settings should determine the treatment approach. The evidence base consists of all reported blinded trials recorded in PubMed and the experience-based studies are those chosen by the author from PubMed as illustrative. Specific recommendations for the treatment of psychosis will be listed for specific situations. Pimavanserin is the first-line choice for mild symptoms; quetiapine for symptoms that require improvement in a short period and clozapine for urgent problems or those which fail the other approaches.
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Affiliation(s)
- Joseph H Friedman
- Butler Hospital, Movement Disorders Program, Warren Alpert Medical School of Brown University, Providence, RI, 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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Seritan AL. Advances in the Diagnosis and Management of Psychotic Symptoms in Neurodegenerative Diseases: A Narrative Review. J Geriatr Psychiatry Neurol 2023; 36:435-460. [PMID: 36941085 PMCID: PMC10578041 DOI: 10.1177/08919887231164357] [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] [Indexed: 03/23/2023]
Abstract
Background: Approximately 15% of older adults may experience psychotic phenomena. Primary psychiatric disorders that manifest with psychosis (delusions, hallucinations, and disorganized thought or behavior) account for less than half. Up to 60% of late-life psychotic symptoms are due to systemic medical or neurological conditions, particularly neurodegenerative diseases. A thorough medical workup including laboratory tests, additional procedures if indicated, and neuroimaging studies is recommended. This narrative review summarizes current evidence regarding the epidemiology and phenomenology of psychotic symptoms encountered as part of the neurodegenerative disease continuum (including prodromal and manifest stages). Results: Prodromes are constellations of symptoms that precede the onset of overt neurodegenerative syndromes. Prodromal psychotic features, particularly delusions, have been associated with an increased likelihood of receiving a neurodegenerative disease diagnosis within several years. Prompt prodrome recognition is crucial for early intervention. The management of psychosis associated with neurodegenerative diseases includes behavioral and somatic strategies, although evidence is scarce and mostly limited to case reports, case series, or expert consensus guidelines, with few randomized controlled trials. Conclusion: The complexity of psychotic manifestations warrants management by interprofessional teams that provide coordinated, integrated care.
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Affiliation(s)
- Andreea L. Seritan
- University of California, San Francisco Department of Psychiatry and UCSF Weill Institute for Neurosciences, CA, USA
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7
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Baker M, Song W, Fusick A. Pimavanserin Use in Lewy Body Dementia: A Case Report Demonstrating the Medication's Efficacy. Cureus 2023; 15:e46356. [PMID: 37920617 PMCID: PMC10619331 DOI: 10.7759/cureus.46356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 11/04/2023] Open
Abstract
Pimavanserin is an antipsychotic that is approved for use in Parkinson's disease psychosis. Working as a serotonin 2A inverse agonist, pimavanserin allows patients to improve their psychotic symptoms without worsening the motor symptoms of Parkinson's. This mechanism is mediated via serotonin receptors and may allow for pimavanserin to be considered for use in other disease processes that present with psychosis. Here, the authors describe the case of a 75-year-old man with Lewy Body Dementia (LBD) who was started on pimavanserin. The response of the patient to the medication was measured over a six-week time course using the Scales for the Assessment of Positive Symptoms of Schizophrenia (SAPS). Overall, pimavanserin was shown to be effective in this patient with LBD. The authors also provide a review of the sparse literature attesting to other off-label uses for this unique antipsychotic.
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Affiliation(s)
| | - Wenxin Song
- Mental Health, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Adam Fusick
- Mental Health and Behavioral Services, James A Haley Veteran Affairs, Tampa, USA
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Rothenberg KG, McRae SG, Dominguez-Colman LM, Shutes-David A, Tsuang DW. Pimavanserin Treatment for Psychosis in Patients with Dementia with Lewy Bodies: A Case Series. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e939806. [PMID: 37775968 PMCID: PMC10549935 DOI: 10.12659/ajcr.939806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 08/11/2023] [Accepted: 07/27/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Many patients with dementia with Lewy bodies (DLB) experience cholinesterase inhibitor- and antipsychotic-resistant psychosis. The new second-generation antipsychotic pimavanserin has been used with some success in the treatment of psychosis in other forms of dementia, including Alzheimer disease and Parkinson disease dementia. It is possible that pimavanserin may also be useful in the treatment of psychosis in DLB. We sought to describe the disease course and treatment of psychosis in 4 patients with DLB who were prescribed pimavanserin after other medications failed to reduce the frequency or severity of hallucinations and delusions. CASE REPORT This is a case series of 4 male patients (ages 56 to 74 at the beginning of the reports) who developed DLB and psychosis (eg, visual illusions, visual and olfactory hallucinations, and paranoid delusions). All 4 patients were prescribed cholinesterase inhibitors (eg, donepezil or rivastigmine) prior to pimavanserin, and only 1 patient experienced improved psychosis while on cholinesterase inhibitors. All 3 patients who were prescribed first-generation antipsychotics (eg, haloperidol) or traditional second-generation antipsychotics (eg, olanzapine, risperidone, or quetiapine) experienced initial or lasting side effects with no improvement of psychosis. Conversely, all 4 patients tolerated pimavanserin well, and 3 of the 4 patients experienced significant improvement of psychosis (eg, fewer hallucinations, fewer delusions, reduced paranoia, and/or reduced distress or agitation related to hallucinations and delusions) when prescribed pimavanserin. CONCLUSIONS This case series suggests that pimavanserin is tolerable in older males with DLB and that it may be useful for the reduction of distressful hallucinations, delusions, and paranoia in patients with DLB.
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Affiliation(s)
- Kasia Gustaw Rothenberg
- Lou Ruvo Center for Brain Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sharon G. McRae
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Liza M. Dominguez-Colman
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Andrew Shutes-David
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Debby W. Tsuang
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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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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Alipour‐Haris G, Armstrong MJ, Okun M, Brown JD. Comparison of Pimavanserin Versus Quetiapine for Hospitalization and Mortality Risk Among Medicare Beneficiaries with Parkinson's Disease Psychosis. Mov Disord Clin Pract 2023; 10:406-414. [PMID: 36949798 PMCID: PMC10026272 DOI: 10.1002/mdc3.13652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/30/2022] [Accepted: 12/17/2022] [Indexed: 12/30/2022] Open
Abstract
Background Pimavanserin is currently the only antipsychotic approved for Parkinson's disease (PD) psychosis, yet its relative safety compared with treatment alternatives has not been thoroughly assessed. Objectives This study aimed to compare hospitalization and mortality risk in Medicare beneficiaries with PD receiving new prescriptions of pimavanserin or quetiapine for PD psychosis. Methods The study identified new users of pimavanserin and quetiapine from a 15% national sample of Medicare fee-for-service claims collected between May 1, 2016, and December 30, 2018. All-cause hospitalization and mortality were assessed in time-to-event regression models. Standardized mortality ratio weighting balanced pimavanserin and quetiapine users on baseline characteristics. Follow-up was censored at discontinuation, switch, disenrollment, or the end of the study period. Results There were 844 new pimavanserin users and 2505 new quetiapine users. The adjusted hazard ratios (95% confidence intervals [CIs]) for hospitalization at 30, 90, 180, and 365 days for pimavanserin versus quetiapine users were 0.59 (0.43-0.81), 0.56 (0.44-0.72), 0.63 (0.52-0.77), and 0.70 (0.60-0.83). The most common reasons for hospitalization were traumatic injury and sepsis. Hospitalizations for heart-related issues were higher with pimavanserin (P < 0.05). The adjusted hazard ratios (95% CIs) for all-cause mortality at 90, 180, and 365 days for pimavanserin versus quetiapine users were 0.73 (0.48-1.13), 0.80 (0.58-1.10), and 0.94 (0.74-1.19). Conclusions Risk of hospitalization was lower in pimavanserin users compared with quetiapine, and no difference in mortality was observed between pimavanserin and quetiapine. An active comparator analyses with treatment alternatives provided the most clinically relevant information for patients and physicians.
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Affiliation(s)
- Golnoosh Alipour‐Haris
- Center for Drug Evaluation & Safety and The Department of Pharmaceutical Outcomes & PolicyUniversity of Florida College of PharmacyGainesvilleFloridaUSA
| | - Melissa J. Armstrong
- Norman Fixel Institute for Neurological Diseases and the Department of NeurologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Michael Okun
- Norman Fixel Institute for Neurological Diseases and the Department of NeurologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Joshua D. Brown
- Center for Drug Evaluation & Safety and The Department of Pharmaceutical Outcomes & PolicyUniversity of Florida College of PharmacyGainesvilleFloridaUSA
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Kurhan F, Akın M. A New Hope in Alzheimer's Disease Psychosis: Pimavanserin. Curr Alzheimer Res 2023; 20:403-408. [PMID: 37641988 DOI: 10.2174/1567205020666230825124922] [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] [Received: 02/15/2023] [Revised: 06/04/2023] [Accepted: 06/30/2023] [Indexed: 08/31/2023]
Abstract
Alzheimer's disease (AD) ranks first among the causes of dementia worldwide. AD can develop a psychotic manifest at a significant rate. AD prognosis worsens by added psychosis clinic. There is no treatment approved by the United States Food and Drug Administration (FDA) among antipsychotics for Alzheimer's disease Psychosis (ADP). However, pimavanserine, an atypical antipsychotic, has been approved by the FDA for Parkinson's psychosis. It is predicted that pimavanserin, a new antipsychotic, will fill an important gap in this area. In clinical trials, it appears to be effective in the treatment of delusions and hallucinations at psychosis in both Parkinson's and AD. In this systematic review, we evaluated the analysis of current literature data on pimavanserin used in ADP. We searched the existing literature on clinical studies on pimavanserin therapy used in ADP. Data were determined by systematically searching PubMed, MEDLINE, EMBASE, and Google Scholar until December 2022. A total of 35 citations were found and uploaded on the Mendeley program. Abstracts and full texts of literature data were examined. Pimavanserin was observed, and satisfactory results were obtained in treating ADP. Pimavanserin has a unique mechanism of action. Pimavanserin, an atypical antipsychotic drug, has a low affinity for 5-HT2C receptors and has selective 5-HT2A reverse agonist/antagonist action. Pimavanserin has no clinically significant affinity for dopaminergic, histaminergic, muscarinic or adrenergic receptors. This agent may also achieve significant positive results in resistant psychosis treatments.
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Affiliation(s)
- Faruk Kurhan
- Department of Psychiatry, Faculty of Medicine, Van Yuzuncu Yil University, 65100, Van, Turkey
| | - Mustafa Akın
- Department of Psychiatry, Faculty of Medicine, Van Yuzuncu Yil University, 65100, Van, Turkey
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Should patients with Parkinson’s disease only visit a neurologist’s office? - a narrative review of neuropsychiatric disorders among people with Parkinson’s disease. CURRENT PROBLEMS OF PSYCHIATRY 2022. [DOI: 10.2478/cpp-2022-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Abstract
Introduction: Parkinson’s disease is a neurodegenerative disease that is often accompanied by disorders such as depression, psychotic disorders, cognitive disorders, anxiety disorders, sleep disorders, impulse control disorders. The aim of the study was to review the literature and present the characteristics of neuropsychiatric disorders occurring in people suffering from Parkinson’s disease, with the specification of the above-mentioned disorders.
Material and method: The literature available on the PubMed platform from 1986 to 2022 was reviewed using the following keywords: Parkinson’s disease, depression, anxiety disorders, psychotic disorders, sleep disorders, cognitive disorders, impulse control disorders. Original studies, reviews, meta-analyzes and internet sources were analyzed.
Results: The above-mentioned neuropsychiatric disorders appear with different frequency among people suffering from Parkinson’s disease and occur at different times of its duration or even precede its onset for many years. The non-motor symptoms in the form of depressed mood, energy loss or changes in the rhythm of the day may result in a delay of appropriate therapy and thus in complications. Neuropathological changes in the course of Parkinson’s disease as well as dopaminergic drugs used in its therapy influence the development of neuropsychiatric disorders.
Conclusions: In order to avoid misdiagnosis, practitioners should use, e.g. scales intended for patients with Parkinson’s disease. To prevent the consequences of the aforementioned disease entities, methods of early diagnosis, determination of risk factors and standardization of the treatment process must be determined. Consistent care for patients with Parkinson’s disease is significant, not only in the neurological field, but also in the psychiatric one.
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Abadir A, Dalton R, Zheng W, Pincavitch J, Tripathi R. Neuroleptic Sensitivity in Dementia with Lewy Body and Use of Pimavanserin in an Inpatient Setting: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2022; 23:e937397. [PMID: 36282782 PMCID: PMC9619381 DOI: 10.12659/ajcr.937397] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/20/2022] [Accepted: 09/08/2022] [Indexed: 11/04/2023]
Abstract
BACKGROUND Antidopaminergic medications, including antipsychotics, are known to worsen motor and neuropsychiatric symptoms, including cognition and psychosis, in patients with dementia with Lewy body (DLB). The intensity of worsened clinical symptoms may vary and can result in mortality in certain situations. There have been some reports supporting clozapine, quetiapine and pimavanserin use in psychosis control in this population. CASE REPORT We describe the case of 75-year-old man with diagnosis of DLB and the post-treatment outcome with olanzapine for psychosis during hospitalization. He experienced worsened cognitive and motor functions. Discontinuation of olanzapine resulted in resolution of the clinical worsening. Further, re-initiation of Pimavanserin helped treat his hallucinations. He returned back to his baseline during a follow-up visit in the clinic at 1 month after discharge. Further, we incorporated the use of Best Practice Alert (BPA) as a part of the electronic health record (EHR) system to help providers identify patients prone to neuroleptic sensitivity and help select appropriate medications to treat psychosis in this patient population. CONCLUSIONS Administration of antipsychotics in patients with parkinsonism, especially DLB, requires close clinical monitoring and judicious use. Awareness of morbidity and mortality associated with such use is of importance, especially during hospitalization. From our experience, we incorporated use of BPA, which can help providers make judicious choices while treating this patient population. Pimavanserin, which is FDA-approved for psychosis in Parkinson's disease, could be a potential safe and effective treatment option in this patient population.
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Affiliation(s)
- Anthony Abadir
- Department of Psychiatry, West Virginia University, Morgantown, WV, USA
| | - Ryder Dalton
- West Virginia School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Wanhong Zheng
- Department of Psychiatry, West Virginia University, Morgantown, WV, USA
| | - Jami Pincavitch
- Department of Orthopedics, West Virginia University, Morgantown, WV, USA
| | - Richa Tripathi
- Department of Neurology, West Virginia University, Morgantown, WV, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
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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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15
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Zhang S, Ma Y. Emerging role of psychosis in Parkinson's disease: From clinical relevance to molecular mechanisms. World J Psychiatry 2022; 12:1127-1140. [PMID: 36186499 PMCID: PMC9521528 DOI: 10.5498/wjp.v12.i9.1127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/12/2022] [Accepted: 08/18/2022] [Indexed: 02/05/2023] Open
Abstract
Parkinson’s disease (PD) is the second most common neurodegenerative disease. Psychosis is one of the common psychiatric presentations in the natural course of PD. PD psychosis is an important non-motor symptom, which is strongly correlated with a poor prognosis. Increasing attention is being given to PD psychosis. In this opinion review, we summarized and analyzed the identification, screening, epidemiology, mechanisms, risk factors, and therapeutic approaches of PD psychosis based on the current clinical evidence. PD psychosis tends to have a negative effect on patients' quality of life and increases the burden of family caregiving. Screening and identification in the early stage of disease is crucial for establishing tailored therapeutic strategies and predicting the long-term outcome. Development of PD psychosis is believed to involve a combination of exogenous and endogenous mechanisms including imbalance of neurotransmitters, structural and network changes, genetic profiles, cognitive impairment, and antiparkinsonian medications. The therapeutic strategy for PD psychosis includes reducing or ceasing the use of dopaminergic drug, antipsychotics, cholinesterase inhibitors, and non-pharmacological interventions. Ongoing clinical trials are expected to provide new insights for tailoring therapy for PD psychosis. Future research based on novel biomarkers and genetic factors may help inform individualized therapeutic strategies.
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Affiliation(s)
- Shuo Zhang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Yan Ma
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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16
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Mosholder AD, Ma Y, Akhtar S, Podskalny GD, Feng Y, Lyu H, Liao J, Wei Y, Wernecke M, Leishear K, Nelson LM, MaCurdy TE, Kelman JA, Graham DJ. Mortality Among Parkinson's Disease Patients Treated With Pimavanserin or Atypical Antipsychotics: An Observational Study in Medicare Beneficiaries. Am J Psychiatry 2022; 179:553-561. [PMID: 35702829 DOI: 10.1176/appi.ajp.21090876] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Pimavanserin, a serotonin 5-HT2 antagonist, is indicated for treatment of hallucinations and delusions associated with Parkinson's disease psychosis. In premarketing trials in patients with Parkinson's disease psychosis, 11% of patients died during open-label pimavanserin treatment. Antipsychotics, which are used off-label in Parkinson's disease psychosis, increase mortality in dementia patients. The authors compared mortality with pimavanserin and atypical antipsychotics in a large database. METHODS This was a retrospective new-user cohort study of Medicare beneficiaries with Parkinson's disease initiating pimavanserin (N=3,227) or atypical antipsychotics (N=18,442) from April 2016 to March 2019. All-cause mortality hazard ratios and 95% confidence intervals were estimated for pimavanserin compared with atypical antipsychotics, using segmented proportional hazards regression over 1-180 and 181+ days of treatment. Potential confounding was addressed through inverse probability of treatment weighting (IPTW). RESULTS Pimavanserin users had a mean age of approximately 78 years, and 45% were female. Before IPTW, some comorbidities were more prevalent in atypical antipsychotic users; after IPTW, comorbidities were well balanced between groups. In the first 180 days of treatment, mortality was approximately 35% lower with pimavanserin than with atypical antipsychotics (hazard ratio=0.65, 95% CI=0.53, 0.79), with approximately one excess death per 30 atypical antipsychotic-treated patients; however, during treatment beyond 180 days, there was no additional mortality advantage with pimavanserin (hazard ratio=1.05, 95% CI=0.82, 1.33). Pimavanserin showed no mortality advantage in nursing home patients. CONCLUSIONS Pimavanserin use was associated with lower mortality than atypical antipsychotic use during the first 180 days of treatment, but only in community-dwelling patients, not nursing home residents.
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Affiliation(s)
- Andrew D Mosholder
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Yong Ma
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Sandia Akhtar
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Gerald D Podskalny
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Yuhui Feng
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Hai Lyu
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Jiemin Liao
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Yuqin Wei
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Michael Wernecke
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Kira Leishear
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Lorene M Nelson
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Thomas E MaCurdy
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - Jeffrey A Kelman
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
| | - David J Graham
- Division of Epidemiology 1 (Mosholder, Leishear), Division of Neurology 1 (Podskalny), Office of Pharmacovigilance and Epidemiology (Graham), and Division of Biometrics 7 (Ma), U.S. Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Md.; Acumen LLC, Burlingame, Calif. (Akhtar, Feng, Lyu, Liao, Wei, Wernecke, Nelson, MaCurdy); Guardant Health, Redwood City, Calif. (Liao); Department of Epidemiology and Population Health (Nelson) and Department of Economics (MaCurdy), Stanford University, Stanford, Calif.; Centers for Medicare and Medicaid Services, Washington, DC (Kelman)
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17
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Limitations of access to antipsychotics in Canada: loss of the old and unavailability of the new options. Int J Clin Pharm 2022; 44:1083-1086. [PMID: 35699861 DOI: 10.1007/s11096-022-01426-3] [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: 11/13/2021] [Revised: 04/23/2022] [Accepted: 05/06/2022] [Indexed: 11/05/2022]
Abstract
Schizophrenia is a severe, debilitating disorder that is associated with a significant burden of illness. Antipsychotic medications remain the mainstay of treatment for schizophrenia and related disorders. In recent years, a number of new psychotropic medications have been introduced to the market, with some potential differences in the mechanism of action compared to the previous ones. In this paper, we discuss the issue of lack of access to the newer antipsychotics in Canada, and the discontinuation of some of the older options from the market, leaving clinicians and patients with a limited number of available options. While the aim of this paper is to increase awareness of the current state of availability and accessibility of options, we further discuss some potential solutions.
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Agüera-Ortiz L, Babulal GM, Bruneau MA, Creese B, D'Antonio F, Fischer CE, Gatchel JR, Ismail Z, Kumar S, McGeown WJ, Mortby ME, Nuñez NA, de Oliveira FF, Pereiro AX, Ravona-Springer R, Rouse HJ, Wang H, Lanctôt KL. Psychosis as a Treatment Target in Dementia: A Roadmap for Designing Interventions. J Alzheimers Dis 2022; 88:1203-1228. [PMID: 35786651 PMCID: PMC9484097 DOI: 10.3233/jad-215483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Psychotic phenomena are among the most severe and disruptive symptoms of dementias and appear in 30% to 50% of patients. They are associated with a worse evolution and great suffering to patients and caregivers. Their current treatments obtain limited results and are not free of adverse effects, which are sometimes serious. It is therefore crucial to develop new treatments that can improve this situation. We review available data that could enlighten the future design of clinical trials with psychosis in dementia as main target. Along with an explanation of its prevalence in the common diseases that cause dementia, we present proposals aimed at improving the definition of symptoms and what should be included and excluded in clinical trials. A review of the available information regarding the neurobiological basis of symptoms, in terms of pathology, neuroimaging, and genomics, is provided as a guide towards new therapeutic targets. The correct evaluation of symptoms is transcendental in any therapeutic trial and these aspects are extensively addressed. Finally, a critical overview of existing pharmacological and non-pharmacological treatments is made, revealing the unmet needs, in terms of efficacy and safety. Our work emphasizes the need for better definition and measurement of psychotic symptoms in dementias in order to highlight their differences with symptoms that appear in non-dementing diseases such as schizophrenia. Advances in neurobiology should illuminate the development of new, more effective and safer molecules for which this review can serve as a roadmap in the design of future clinical trials.
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Affiliation(s)
- Luis Agüera-Ortiz
- Department of Psychiatry, Instituto de Investigación Sanitaria (imas12), Hospital Universitario 12 de Octubre, & Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Ganesh M Babulal
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Department of Psychology, Faculty of Humanities, University of Johannesburg, South Africa
| | - Marie-Andrée Bruneau
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Quebec, Canada.,Geriatric Institute of Montreal Research Center, Montreal, Quebec, Canada
| | - Byron Creese
- Medical School, College of Medicine and Health, University of Exeter, UK
| | | | - Corinne E Fischer
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Department of Psychiatry, Toronto, Ontario, Canada
| | - Jennifer R Gatchel
- Harvard Medical School; Massachusetts General Hospital, Boston MA, USA.,McLean Hospital, Belmont MA, USA
| | - Zahinoor Ismail
- Hotchkiss Brain Institute & O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Sanjeev Kumar
- Adult Neurodevelopmental and Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - William J McGeown
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Moyra E Mortby
- School of Psychology, University of New South Wales, Sydney, Australia & Neuroscience Research Australia, Sydney, Australia
| | - Nicolas A Nuñez
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Fabricio F de Oliveira
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Arturo X Pereiro
- Facultade de Psicoloxía, Universidade de Santiago de Compostela, Spain
| | - Ramit Ravona-Springer
- Sheba Medical Center, Tel Hashomer, Israel & Sackler School of Medicine, Tel Aviv University, Israel
| | - Hillary J Rouse
- School of Aging Studies, University of South Florida, Tampa, FL, USA.,SiteRx, New York, NY, USA
| | - Huali Wang
- Dementia Care and Research Center, Peking University Institute of Mental Health; National & Clinical Research Center for Mental Disorders, Beijing, China
| | - Krista L Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute and Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, Ontario, Canada
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19
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MacDonald S, Shah AS, Tousi B. Current Therapies and Drug Development Pipeline in Lewy Body Dementia: An Update. Drugs Aging 2022; 39:505-522. [PMID: 35619045 DOI: 10.1007/s40266-022-00939-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
The term Lewy body dementia refers to either of two related diagnoses: dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD). Clinical management of Lewy body dementia is challenging. The current treatment options focus on relieving symptoms; no disease-modifying therapies are available. There are currently no US Food and Drug Administration (FDA) approved drugs for the treatment of DLB, and there are only a few for PDD. Cholinesterase inhibitors are shown to be beneficial in improving cognitive symptoms in Lewy body dementia. Rivastigmine was approved by the FDA to treat PDD. Donepezil was approved in Japan as a treatment for DLB. Levodopa may provide modest benefit in treating motor symptoms and zonisamide in adjunct to low-dose levodopa helps with parkinsonism. Treatment of autonomic symptoms are based on symptomatic treatment with off-label agents. Our main objective in this article is to present an overview of the current pharmacological options available to treat the clinical features of DLB and PDD. When evaluating the existing management options for Lewy body dementia, it is difficult to fully separate PDD from DLB. However, we have attempted to identify whether the cited studies include patients with PDD and/or DLB. Moreover, we have provided an overview of the current drug pipeline in Lewy body dementia. All currently active trials are in phase I or II and most are focused on disease modification rather than symptomatic treatment. Phase II trial results for neflamapimod show promising results. Due to heterogeneity of symptoms and underlying pathophysiology, there is a need for new biomarker strategies and improved definitions of outcome measures for Lewy body dementia drug trials.
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Affiliation(s)
- Steve MacDonald
- Cleveland Clinic Lou Ruvo Center for Brain Health, Cleveland, OH, USA
| | | | - Babak Tousi
- Cleveland Clinic Lou Ruvo Center for Brain Health, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.
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20
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Akbar U, Friedman JH. Long-term outcomes with pimavanserin for psychosis in clinical practice. Clin Park Relat Disord 2022; 6:100143. [PMID: 35479873 PMCID: PMC9036130 DOI: 10.1016/j.prdoa.2022.100143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 11/27/2022] Open
Abstract
Psychosis in PD is a common problem, with limited treatment options. Pimavanserin is FDA approved for PDP, but long-term outcomes in clinical practice are lacking. While it has been proven to be effective in short-duration clinical trials, our clinical experiences, however, demonstrate less promising results in the long term.
Introduction Pimavanserin is the only medication FDA-approved for the treatment of Parkinson disease (PD) psychosis (PDP), but reports of long-term, real-world clinical experience are lacking. Methods A retrospective chart review of all patients treated with pimavanserin was conducted at our large Movement Disorders practice in Providence, Rhode Island, USA. Demographic and clinical data for each patient were collected and descriptive analyses were performed. Results We identified 54 patients (23 female) who initiated pimavanserin, whose median age was 70 years (range 44–87 years) and the median duration of pimavanserin therapy was 26 weeks. Initial improvement was seen in 47% of the entire group, and 50% of the DLB patients. Additional antipsychotic medication was needed concomitantly with pimavanserin to maintain a positive response for 40% of patients. Only 15% of the entire group had effective treatment of their condition with pimavanserin monotherapy over a median of 52 weeks. Among the initial responders, 32% continued on pimavanserin monotherapy. Among the non-responders, the mean trial period for patients who did not improve was 27 weeks, for patients who worsened was 16 weeks, and for those who experienced adverse effects was 1–2 weeks. Reported sex was similar across responders (60%), non-responders (56%), and the overall cohort (57%). Conclusion Our real-world experience shows that pimavanserin is safe and tolerable, with a lower response rate than reported in other publications. While it has been proven to be effective in short-duration clinical trials, our clinical experiences, however, demonstrate less promising results in the long term.
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Affiliation(s)
- Umer Akbar
- Department of Neurology, Brown University, Providence, RI, United States.,Rhode Island Hospital, Providence, RI, United States.,Butler Hospital, Providence, RI, United States
| | - Joseph H Friedman
- Department of Neurology, Brown University, Providence, RI, United States.,Butler Hospital, Providence, RI, United States
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21
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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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22
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Reynolds B, Mandelbaum R, Marks DS. An older man with visual hallucinations, tremor, and gait dysfunction. JAAPA 2021; 34:62-64. [PMID: 34813538 DOI: 10.1097/01.jaa.0000800292.29219.9d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Beverly Reynolds
- Beverly Reynolds is a student in the PA program at Northeastern University in Boston, Mass. Rosalind Mandelbaum and Donald S. Marks practice at Beth Israel Deaconess Hospital-Plymouth in Plymouth, Mass. Dr. Marks discloses that he receives funding for clinical trials research from Biogen, Eisai, Eli Lilly, and ATRI. The authors have disclosed no other potential conflicts of interest, financial or otherwise
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23
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Abstract
Introduction: Hallucinations in Parkinson's disease are common, can complicate medication management and significantly impact upon the quality of life of patients and their carers.Areas covered: This review aims to examine current evidence for the management of hallucinations in Parkinson's disease.Expert opinion: Treatment of hallucinations in Parkinson's disease should be both individualized and multifaceted. Screening, education, medication review and the avoidance of common triggers are important. For well-formed visual hallucinations, acetylcholinesterase inhibitors are recommended first-line. Refractory or severe symptoms may require the cautious use of atypical antipsychotics. Antidepressants may be beneficial in the appropriate setting. Unfortunately, current therapies for hallucinations offer only limited benefits and future research efforts are desperately required to improve the management of these challenging symptoms.
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Affiliation(s)
- Alice Powell
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia.,Department of Geriatric Medicine, Prince of Wales Hospital, Randwick, Australia
| | - Elie Matar
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia
| | - Simon J G Lewis
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia
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24
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Turra BO, Barbisan F, Azzolin VF, Teixeira CF, Flores T, Braun LE, de Oliveira Nerys DA, Rissi VB, de Oliveira Alves A, Assmann CE, da Cruz Jung IE, Marques LPS, da Cruz IBM. Unmetabolized quetiapine exerts an in vitro effect on innate immune cells by modulating inflammatory response and neutrophil extracellular trap formation. Biomed Pharmacother 2020; 131:110497. [PMID: 33152899 DOI: 10.1016/j.biopha.2020.110497] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 12/31/2022] Open
Abstract
Quetiapine is an antipsychotic drug that is used to treat psychiatric and neurological disorders. Despite its efficiency and low-toxicity, quetiapine administration has been associated with undesirable side effects such as the development of low-grade inflammatory disorders and neutropenia states. As the liver rapidly metabolizes quetiapine to metabolites, the non-metabolized part of this molecule might play a role in immune alterations. In an in vitro study, this hypothesis was tested by exposing activated and inactivated RAW-264.7 macrophages and human neutrophils to unmetabolized quetiapine (u-QUE). Based on our findings, u-QUE was not cytotoxic to these cells. u-QUE differentially modulates macrophages according to their activation states. In inactivated macrophages, u-QUE induced a proinflammatory state as observed by an increase in cellular proliferation; increased levels of oxidative molecules (nitric oxide and superoxide), protein levels, and gene overexpression of proinflammatory cytokines (IL-1β, IL-6, and TNF-α); and decreased levels of IL-10, an anti-inflammatory cytokine. Conversely, on phytohemagglutinin (PHA)-activated macrophages, u-QUE exerted an anti-inflammatory effect. u-QUE induced neutrophil extracellular trap (NET) formation and increased the sensitivity of the neutrophils previously activated by exposure to dead yeast cells for NET formation. These results confirm the effect of quetiapine on macrophage and neutrophil function, which may be associated with the side effects of this psychopharmaceutical agent.
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Affiliation(s)
- Bárbara Osmarin Turra
- Graduate Program of Pharmacology, Universidade Federal Santa Maria, Santa Maria, RS, Brazil
| | - Fernanda Barbisan
- Graduate Program in Gerontology, Universidade Federal Santa Maria, Santa Maria, RS, Brazil
| | | | | | - Thamara Flores
- Graduate Program of Pharmacology, Universidade Federal Santa Maria, Santa Maria, RS, Brazil
| | | | | | - Vitor Braga Rissi
- Biotechnology and Animal Reproduction Laboratory, Universidade Federal Santa Maria, Santa Maria, RS, Brazil
| | | | - Charles Elias Assmann
- Graduate Program of Biological Sciences, Universidade Federal Santa Maria, Santa Maria, RS, Brazil
| | | | | | - Ivana Beatrice Mânica da Cruz
- Graduate Program of Pharmacology, Universidade Federal Santa Maria, Santa Maria, RS, Brazil; Graduate Program in Gerontology, Universidade Federal Santa Maria, Santa Maria, RS, Brazil.
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