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Miura G, Tanaka K, Kemuriyama T, Misawa F, Uchida H, Mimura M, Takeuchi H. Clinical Outcomes after Clozapine Discontinuation in Patients with Schizophrenia: A Systematic Review. PHARMACOPSYCHIATRY 2022; 55:181-192. [PMID: 35512817 DOI: 10.1055/a-1811-7318] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Clozapine is the gold standard of treatment for patients with treatment-resistant schizophrenia. However, approximately 60% of those patients do not respond to clozapine; moreover, clinical outcomes after clozapine discontinuation are unclear so far. Therefore, we conducted a systematic review to clarify the outcomes after clozapine discontinuation. METHODS A systematic literature search was conducted, using MEDLINE and Embase with the following keywords: (clozapine AND (cessation* OR cease* OR withdraw* OR discontinu* OR halt* OR stop* OR switch*) AND (schizophreni* OR schizoaffective)). RESULTS A total of 28 clinical studies from 27 articles were identified and included in this systematic review. Three randomized controlled trials reported worsening of psychiatric symptoms. In 10 single-arm studies, the results of worsening and improving psychiatric symptoms were inconsistent. In one large retrospective cohort study, clozapine rechallenge, olanzapine, and antipsychotic polypharmacy had lower rehospitalization rates compared to no medication after clozapine discontinuation. In the other 14 retrospective studies, the vast majority showed worsening of clinical status after clozapine discontinuation. Among five studies on clinical outcomes after clozapine rechallenge, four reported improvements in clinical status in more than half of patients who rechallenged clozapine. The remaining study reported that the clozapine discontinuation-rechallenge group had a worse remission assessment score than the clozapine discontinuation-no rechallenge group. DISCUSSION Clinical outcomes generally worsen after clozapine discontinuation. Clozapine rechallenge and olanzapine may be considered following clozapine discontinuation. The outcomes after clozapine discontinuation in clozapine non-responders remain inconclusive; therefore, well-designed studies are warranted.
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Affiliation(s)
| | - Kouhei Tanaka
- Yamanashi Prefectural Kita Hospital, Yamanashi, Japan
| | | | | | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Blackman G, Oloyede E, Horowitz M, Harland R, Taylor D, MacCabe J, McGuire P. Reducing the Risk of Withdrawal Symptoms and Relapse Following Clozapine Discontinuation-Is It Feasible to Develop Evidence-Based Guidelines? Schizophr Bull 2021; 48:176-189. [PMID: 34651184 PMCID: PMC8781383 DOI: 10.1093/schbul/sbab103] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Clozapine is the only antipsychotic that is effective in treatment-resistant schizophrenia. However, in certain clinical situations, such as the emergence of serious adverse effects, it is necessary to discontinue clozapine. Stopping clozapine treatment poses a particular challenge due to the risk of psychotic relapse, as well as the development of withdrawal symptoms. Despite these challenges for the clinician, there is currently no formal guidance on how to safely to discontinue clozapine. We assessed the feasibility of developing evidence-based recommendations for (1) minimizing the risk of withdrawal symptoms, (2) managing withdrawal phenomena, and (3) commencing alternatives treatment when clozapine is discontinued. We then evaluated the recommendations against the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. We produced 19 recommendations. The majority of these recommendation were evidence-based, although the strength of some recommendations was limited by a reliance of studies of medium to low quality. We discuss next steps in the refinement and validation of an evidence-based guideline for stopping clozapine and identify key outstanding questions.
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Affiliation(s)
- Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK,To whom correspondence should be addressed; Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK; tel: 44-20-7848-5228, fax: 44-20-7848-0976, e-mail:
| | - Ebenezer Oloyede
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK,Institute of Pharmaceutical Science, King’s College London, London, UK
| | - Mark Horowitz
- Division of Psychiatry, University College London, London, UK,North East London NHS Foundation Trust, London, UK
| | - Robert Harland
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Taylor
- Institute of Pharmaceutical Science, King’s College London, London, UK
| | - James MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
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Seppälä A, Pylvänäinen J, Lehtiniemi H, Hirvonen N, Corripio I, Koponen H, Seppälä J, Ahmed A, Isohanni M, Miettunen J, Jääskeläinen E. Predictors of response to pharmacological treatments in treatment-resistant schizophrenia - A systematic review and meta-analysis. Schizophr Res 2021; 236:123-134. [PMID: 34496316 DOI: 10.1016/j.schres.2021.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/30/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND As the burden of treatment-resistant schizophrenia (TRS) on patients and society is high it is important to identify predictors of response to medications in TRS. The aim was to analyse whether baseline patient and study characteristics predict treatment response in TRS in drug trials. METHODS A comprehensive search strategy completed in PubMed, Cochrane and Web of Science helped identify relevant studies. The studies had to meet the following criteria: English language clinical trial of pharmacological treatment of TRS, clear definition of TRS and response, percentage of response reported, at least one baseline characteristic presented, and total sample size of at least 15. Meta-regression techniques served to explore whether baseline characteristics predict response to medication in TRS. RESULTS 77 articles were included in the systematic review. The overall sample included 7546 patients, of which 41% achieved response. Higher positive symptom score at baseline predicted higher response percentage. None of the other baseline patient or study characteristics achieved statistical significance at predicting response. When analysed in groups divided by antipsychotic drugs, studies of clozapine and other atypical antipsychotics produced the highest response rate. CONCLUSIONS This meta-analytic review identified surprisingly few baseline characteristics that predicted treatment response. However, higher positive symptoms and the use of atypical antipsychotics - particularly clozapine -was associated with the greatest likelihood of response. The difficulty involved in the prediction of medication response in TRS necessitates careful monitoring and personalised medication management. There is a need for more investigations of the predictors of treatment response in TRS.
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Affiliation(s)
- Annika Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Jenni Pylvänäinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Heli Lehtiniemi
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Noora Hirvonen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Information Studies, Faculty of Humanities, University of Oulu, Oulu, Finland
| | - Iluminada Corripio
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, CIBERSAM G21, U.A.B (Autonomous University of Barcelona), Barcelona, Spain
| | - Hannu Koponen
- University of Helsinki and Helsinki University Hospital, Psychiatry, Helsinki, Finland
| | - Jussi Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Department of Mental Health and Substance Use Disorders, South Carelia Social and Health Care District, Lappeenranta, Finland
| | - Anthony Ahmed
- Department of Psychiatry, Weill Cornell Medicine, Cornell University, White Plains, USA
| | - Matti Isohanni
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jouko Miettunen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Erika Jääskeläinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of Psychiatry, University Hospital of Oulu, Finland
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Jo YT, Joo SW, Ahn S, Choi Y, Lee J. Use of olanzapine compared with clozapine for treatment-resistant schizophrenia in a real-world setting: nationwide register-based study. BJPsych Open 2021; 7:e142. [PMID: 34342261 PMCID: PMC8358972 DOI: 10.1192/bjo.2021.964] [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] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Clozapine is generally considered as the treatment of choice for patients with treatment-resistant schizophrenia (TRS). However, its superiority has recently been questioned because olanzapine has been suggested as non-inferior to clozapine in its effectiveness. AIMS We aimed to investigate the current status of clozapine prescriptions to identify any disparity between clinical guidelines and real-world practices. METHOD In this study, we utilised the Health Insurance Review Agency database in the Republic of Korea to investigate the real-world effectiveness of clozapine for patients with TRS. We compared differences in patient variables before and after clozapine administration, and we also performed survival analyses for both psychiatric admissions and emergency room visits among patients who used clozapine or olanzapine. RESULTS This study investigated an incident cohort of 64 442 patients, and 2338 patients have been prescribed clozapine. Of these, 998 patients had TRS. In survival analysis, clozapine showed a worse survival rate for psychiatric admissions than olanzapine (hazard ratio 0.615). We also identified that clinicians tended to try a number of antipsychotics, as recommended, before starting patients on clozapine. CONCLUSIONS In conclusion, we found that olanzapine led to higher survival rates for psychiatric admissions than clozapine. Thus, considering the risk of serious adverse effects, clozapine may be used conservatively. Considering several studies advocating superior efficacy of clozapine, further studies with extensive data are recommended.
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Affiliation(s)
- Young Tak Jo
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Sung Woo Joo
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Soojin Ahn
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Youngjae Choi
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Jungsun Lee
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
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Blackman G, Oloyede E. Clozapine discontinuation withdrawal symptoms in schizophrenia. Ther Adv Psychopharmacol 2021; 11:20451253211032053. [PMID: 34552710 PMCID: PMC8450618 DOI: 10.1177/20451253211032053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/23/2021] [Indexed: 12/14/2022] Open
Abstract
Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia. Whilst clozapine is highly effective, there are some clinical scenarios, such as the emergence of severe side effects, that necessitate its discontinuation. There is an emerging literature suggesting that discontinuing antipsychotics, in particular clozapine, can cause an array of withdrawal symptoms. We review the evidence for the existence of clozapine-induced withdrawal symptoms, and in particular focus on withdrawal-associated psychosis, cholinergic rebound, catatonia and serotonergic discontinuation symptoms. To date, there has been surprisingly little clinical guidance on how to minimise the likeliness of withdrawal symptoms in patients who are stopped on clozapine abruptly or gradually. We discuss the key outstanding questions in this area and why there is a need for guidance on the management of withdrawal symptoms associated with clozapine discontinuation.
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Affiliation(s)
- Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Camberwell, London, SE5 8AF, UK
| | - Ebenezer Oloyede
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Evaluation of a few discrete clinical markers may predict categorization of actively symptomatic non-acute schizophrenia patients as treatment resistant or responders: A study by ROC curve analysis and multivariate analyses. Psychiatry Res 2018; 269:481-493. [PMID: 30195742 DOI: 10.1016/j.psychres.2018.08.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 07/04/2018] [Accepted: 08/24/2018] [Indexed: 02/07/2023]
Abstract
Here, we used Receiver Operating Characteristic (ROC) curve analysis to determine whether clinical factors may aid predicting the categorization of schizophrenia patients as Treatment Resistant (TRS) or antipsychotic responsive schizophrenia (ARS). Patients with an established condition of TRS or ARS were assessed for: clinical presentation and course; neurological soft signs (NES); psychopathology by PANSS; cognitive performances; quality of life scale (QLS); functional capacity; social functioning (PSP and SLOF scales). In ROC curve analysis, significance indicated that the Area under curve (AUC) allowed distinguishing between TRS and ARS. Multivariate analyses were additionally used to provide independent predictive analysis. Multiple clinical variables showed significant AUCs. The largest significant AUCs were found for: NES total score; SLOF Area2; QLS subscale; antipsychotic doses. The highest sensitivity was found for NES total score, the highest specificity for previous hospitalizations. The highest Odds Ratio of being included within the TRS category were found for: NES total score (7.5); QLS total score (5.49); and previous hospitalizations (4.76). This same circumscribed group of variables was also found to be predictive of TRS when adopting stepwise logistic regression or discriminant analysis. We concluded that the evaluation of few clinical factors may provide reliable and accurate predictions on whether one schizophrenia patient may be categorized as a TRS.
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Optimal Dosing of Risperidone and Olanzapine in the Maintenance Treatment for Patients With Schizophrenia and Related Psychotic Disorders: A Retrospective Multicenter Study. J Clin Psychopharmacol 2017; 37:296-301. [PMID: 28306616 DOI: 10.1097/jcp.0000000000000689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aims to determine the optimal tolerability dose ranges of risperidone (RIS) and olanzapine (OLZ) administered during schizophrenia maintenance phase. METHODS Two-year continuation rates of prescription at discharge were examined using a retrospective cohort study method. Adult patients with schizophrenia and related psychotic disorders, receiving antipsychotic monotherapy with RIS or OLZ at discharge, were included. The primary outcome measures were the time to treatment discontinuation and 2-year continuation rates at 4 modal dose ranges of each drug. We estimated the optimal tolerability dose ranges by comparing the continuation rates at various modal doses. RESULTS Of 648 patients, 344 received RIS and 304 received OLZ. The RIS 2-year continuation rates at 4 daily modal dose ranges were significantly different (0.5-2.5 mg: 46.0%, 3.0-5.0 mg: 40.0%, 5.5-7.5 mg: 30.0%, and 8.0-10.0 mg: 28.0%), with the difference favoring RIS at lower doses (0.5-5.0 mg) more than higher doses (5.5-10.0 mg). In contrast, there were no significant differences among OLZ 4 modal dose ranges (2.5-7.5 mg: 49.1%, 10.0-15.0 mg: 42.6%, 17.5-22.5 mg: 40.9%, and 25.0-30.0 mg: 39.0%). The time to treatment discontinuation significantly favored OLZ over RIS. However, it did not significantly differ between RIS and OLZ at lower doses. CONCLUSIONS It is suggested that the optimal tolerability dose range during maintenance treatment is 0.5 to 5.0 mg/d for RIS and 2.5 to 30 mg/d for OLZ, and that RIS at lower doses is comparable with OLZ at lower doses.
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9
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Citrome L, Kantrowitz JT. Olanzapine dosing above the licensed range is more efficacious than lower doses: fact or fiction? Expert Rev Neurother 2014; 9:1045-58. [DOI: 10.1586/ern.09.54] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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Withdrawal symptoms and rebound syndromes associated with switching and discontinuing atypical antipsychotics: theoretical background and practical recommendations. CNS Drugs 2013; 27:545-72. [PMID: 23821039 DOI: 10.1007/s40263-013-0079-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
With the widespread use of atypical or second-generation antipsychotics, switching treatment has become current practice and more complicated, as the pharmacological profiles of these agents differ substantially despite their similarity in being 'atypical'. All share the ability to block dopamine D₂ receptors, and most of them also block serotonin 5-HT2A receptors. Apart from these common features, some atypical antipsychotics are also able to block or stimulate other dopamine or serotonin receptors, as well as histaminergic, muscarinergic or adrenergic receptors. As a result of the varying receptor affinities, in switching or discontinuing compounds several possible pitfalls have to be considered, including the occurrence of withdrawal and rebound syndromes. This article reviews the pharmacological background of functional blockade or stimulation of receptors of interest in regard to atypical antipsychotics and the implicated potential withdrawal and rebound phenomena. A MEDLINE search was carried out to identify information on withdrawal or rebound syndromes occurring after discontinuation of atypical antipsychotics. Using the resulting literature, we first discuss the theoretical background to the functional consequences of atypical antipsychotic-induced blockade or stimulation of neurotransmitter receptors and, secondly, we highlight the clinical consequences of this. We then review the available clinical literature on switching between atypical antipsychotics, with respect to the occurrence of withdrawal or rebound symptoms. Finally, we offer practical recommendations based on the reviewed findings. The systematic evaluation of withdrawal or rebound phenomena using randomized controlled trials is still understudied. Knowledge of pharmacological receptor-binding profiles may help clinicians in choosing adequate switching or discontinuation strategies for each agent. Results from large switching trials indicate that switching atypical antipsychotics can be performed in a safe manner. Treatment-emergent adverse events during or after switching are not always considered to be, at least in part, associated with the pre-switch antipsychotic. Further studies are needed to substantiate the evidence gained so far on different switching strategies. The use of concomitant medication, e.g., benzodiazepines or anticholinergic drugs, may help to minimize symptoms arising from the discontinuation or switching of antipsychotic treatment.
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Abstract
Between one-third and one-half of the individuals who meet diagnostic criteria for schizophrenia remain actively ill despite optimal pharmacological treatment. These individuals tend to progressively deteriorate in terms of social and vocational functioning despite major public and private investments in their rehabilitation. For patients who do not respond to the first prescribed antipsychotic drug, current clinical practice is to switch to a second and a third drug, and eventually to clozapine, the only antipsychotic drug proven to be effective in treatment-refractory schizophrenia (TRS). Occasionally, two antipsychotics are given concomitantly or psychotropic drugs are added to antipsychotic drugs; however, very few empirical data exist to support this practice. Although there are many exceptions, patients who do not benefit from the first prescribed drug will not benefit from any pharmacological intervention. Therefore, efforts are under way to determine the reason for lack of response to available treatments and devise novel, more effective treatments. To be successful these efforts must result in a more specific definition of TRS, as well as in a better understanding of the illness pathophysiology and the mechanism of action of the drugs.
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Affiliation(s)
- Asaf Caspi
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hasan A, Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Thibaut F, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry 2012; 13:318-78. [PMID: 22834451 DOI: 10.3109/15622975.2012.696143] [Citation(s) in RCA: 382] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This first part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia.
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Affiliation(s)
- Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University of Goettingen, Goettingen, Germany.
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Suzuki T, Remington G, Mulsant BH, Rajji TK, Uchida H, Graff-Guerrero A, Mamo DC. Treatment resistant schizophrenia and response to antipsychotics: a review. Schizophr Res 2011; 133:54-62. [PMID: 22000940 DOI: 10.1016/j.schres.2011.09.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 08/24/2011] [Accepted: 09/17/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND There remains a lack of agreement regarding criteria for treatment-resistant schizophrenia (TRS) and definition of response. METHOD A literature search was conducted to identify clinical studies of antipsychotics in TRS using PubMed, EMBASE and PsycINFO (last search 31 July 2011). Psychopharmacological studies with the number of participants of ≥ 40 were evaluated in terms of definitions for TRS and subsequent treatment response. RESULTS Thirty-three studies of antipsychotics in TRS were reviewed. TRS has been defined mainly by severity in symptoms. Many studies based TRS with at least 2 failed adequate antipsychotic trials (at chlorpromazine equivalent doses of ≥ 1000 mg/day for ≥ 6 weeks), but some studies adopted prospective treatment arm to be certain of sample refractoriness. Treatment response has been defined by a relative change in the representative scales (most commonly ≥ 20% decrease in the Positive and Negative Syndrome Scale), but it sometimes included the absolute criteria such as post-treatment score of ≤ 35 in the Brief Psychiatric Rating Scale or Clinical Global Impression-severity score of ≤ 3 (mild or less severe). Social functioning has not been a primary outcome measure in past pivotal trials, and other important domains of the illness such as cognition and subjective perspectives have not been incorporated into definitions of treatment resistance or response. However, adopting various assessment scales can be time-consuming and complicated, with an additional possibility of disagreement among raters. CONCLUSION Defining outcomes in schizophrenia is a challenging task. It is imperative that the field agrees on how this population is better defined and what constitutes treatment response.
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Affiliation(s)
- Takefumi Suzuki
- Centre for Addiction and Mental Health, Geriatric Mental Health Program, Toronto, Ontario, Canada.
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Abstract
This article summarizes the current knowledge base on the diagnosis and management of treatment resistant schizophrenia. While the prevalence of treatment resistant schizophrenia is definition dependent, estimates have ranged from 30% to up to 60%. This article first looks into the various diagnostic criteria of treatment resistant schizophrenia. Then the literature is reviewed about the pharmacotherapeutics of its management. Clozapine emerges to be the gold standard. In addition risperidone and high dose olanzapine also emerge as clinically useful options. Other emerging adjunctive treatment options are equally addressed.
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Affiliation(s)
- R K Solanki
- Department of Psychiatry, Psychiatry Center, SMS Medical College, Jaipur, India
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Lang UE, Willbring M, von Golitschek R, Schmeisser A, Matschke K, Malte Tugtekin S. Clozapine-induced myocarditis after long-term treatment: case presentation and clinical perspectives. J Psychopharmacol 2008; 22:576-80. [PMID: 18308817 DOI: 10.1177/0269881107082136] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Clozapine is the drug of choice for treatment-resistant schizophrenia. Prompted by a patient who developed reversible clozapine-induced myocarditis after long-term treatment with clozapine for several years for chronic-resistant schizophrenia, we undertook a review of the relevant literature. Concerning the myocarditis, the patient recovered rapidly by withdrawal of clozapine and with supportive management. Psychiatric stabilisation of the patient was at least possible with a combination of quetiapine (600 mg) and amisulpride (800 mg). Well-designed studies with the aim to specifically investigate treatment options after clozapine are limited and clinical possibilities are discussed in this paper. Olanzapine and combinations using non-clozapine atypical neuroleptics have partly shown improvement, whereas evidence for successful augmentation with mood stabilisers, anticonvulsants or electroconvulsive therapy in treatment-resistant schizophrenia is limited.
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Affiliation(s)
- U E Lang
- Department of Psychiatry and Psychotherapy, Charité Medicine Berlin, Campus Mitte, Berlin, Germany.
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Abstract
This article opens with a brief history of pharmacologic treatment of schizophrenia. It then discusses the definition and treatment of treatment-resistant schizophrenia, with particular attention to clinical, biological and neuroimaging correlates, as well as the best treatment options, including the use of clozapine in patients who meet the definition of treatment-resistant schizophrenia.
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Tollefson GD, Taylor CC. Olanzapine: Preclinical and Clinical Profiles of a Novel Antipsychotic Agent. CNS DRUG REVIEWS 2006. [DOI: 10.1111/j.1527-3458.2000.tb00155.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia. World J Biol Psychiatry 2005; 6:132-91. [PMID: 16173147 DOI: 10.1080/15622970510030090] [Citation(s) in RCA: 228] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
These guide lines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBO). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.
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Affiliation(s)
- Peter Falkai
- Department of Psychiatry and Psychotherapy, University of Saarland, Homburg/Saar, Germany
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Abstract
The introduction of antipsychotics in the 1950s revolutionised the treatment of schizophrenia, but it soon became apparent that a substantial number of patients demonstrated a suboptimal response to these antipsychotics. Clozapine proved to be beneficial in patients whose symptoms were treatment resistant, but it too had limitations, with as many as 40-70% of those treated with clozapine demonstrating inadequate response to this drug as well. The availability of other 'atypical' antipsychotics offers options, but clozapine appears to remain the most effective option in treatment-resistant schizophrenia. This, of course, raises the question of what to do when clozapine is only partially effective. To address the issue of treatment in patients who have demonstrated a suboptimal response to clozapine, efforts have focused on a variety of augmentation strategies, including numerous medications and electroconvulsive therapy. The current body of evidence consists largely of data from smaller open trials and case series/reports, although data from a limited number of controlled studies are now available. Not surprisingly, the evidence drawn from the former is more supportive of augmentation strategies, although the controlled trials are not without positive findings. The available information is certainly not so overwhelming as to endorse any single augmentation approach. Indeed, it argues for more controlled data and cautions us regarding the cost-benefit ratio in adopting this strategy. Over and above the added adverse effects of another treatment, there is evidence to indicate that actual clinical worsening can occur. Without compelling evidence, clinicians must resort to guiding principles. The potential benefits of augmentation cannot be ruled out, but it should be approached with caution and in a systematic fashion. Factors compromising clozapine response should first be ruled out, and any augmentation trials should be guided by existing evidence and a treatment plan that incorporates a clear understanding of target symptoms. A means of evaluating outcome effectively needs to be in place, and the trial should be circumscribed to prevent needless polypharmacy. A priori, an endpoint needs to be established and the trial discontinued unless results firmly support added benefits.
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Affiliation(s)
- Gary Remington
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
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Goodnick PJ. Higher than Physician’s Desk Reference (US) doses on atypical antipsychotics. Expert Opin Drug Saf 2005; 4:653-68. [PMID: 16011445 DOI: 10.1517/14740338.4.4.653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Physician's Desk Reference (PDR) was established to provide for the practicing of a complete listing of all medications with the FDA-approved labelling, including dosage recommendations. Perhaps in order to maximise individual usage of medications, pharmaceutical companies have frequently targeted lowest possible doses for FDA approval. However, many patients with a variety of illnesses due to resistance and/or multiple illnesses, may need higher than these dose ranges to maximise therapeutic response. In terms of regularly prescribed atypical antipsychotics released over the past 10 years, only risperidone initially obtained approval for a dose for psychosis (16 mg) higher than that suggested currently (maximum of 8 mg). The dose that was approved for mania was lower: a maximum of 6 mg. The others: respectfully, olanzapine (schizophrenia: 15 mg, mania: 20 mg), quetiapine (schizophrenia: 750 mg; mania: 800 mg), ziprasidone (schizophrenia and mania: 160 mg) and aripiprazole (schizophrenia and mania: 30 mg) obtained approvals for psychosis that may limit adverse events but, at the same time, limit benefits. Other data from various sources (double-blind trials, open-label trials, reviews and case reports) have found safety and/or efficacy for the following maximum doses: olanzapine (40 mg), quetiapine (1600 mg), ziprasidone (320 mg) and aripiprazole (75 mg). Reports above those doses are included, but either are insufficient in numbers or bring up questions on safety. In many situations, feared increase in adverse events were not magnified by use of higher doses.
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Affiliation(s)
- Paul J Goodnick
- Department of Psychiatry & Behavioural Sciences, Carrier Clinic, UMDNJ Robert Wood Johnson School of Medicine, 252 CR 601, Belle Mead, NJ 08502, USA.
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Conley RR, Kelly DL, Nelson MW, Richardson CM, Feldman S, Benham R, Steiner P, Yu Y, Khan I, McMullen R, Gale E, Mackowick M, Love RC. Risperidone, Quetiapine, and Fluphenazine in the Treatment of Patients With Therapy-Refractory Schizophrenia. Clin Neuropharmacol 2005; 28:163-8. [PMID: 16062094 DOI: 10.1097/01.wnf.0000172993.89879.0f] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This 12-week, double-blind study evaluated the effectiveness of risperidone (4 mg/day), quetiapine (400 mg/day), or fluphenazine (12.5 mg/day) in a stringently defined treatment-resistant population of people with schizophrenia. No differences were noted in total Brief Psychiatric Rating Scale (BPRS) or Clinical Global Impression scores among the drug groups (n = 38). More subjects tended to complete the study on risperidone (69%) or quetiapine (58%) than those treated with fluphenazine (31%; P value not significant). Eighty-nine percent of those who discontinued on fluphenazine (8 of 9) were due to lack of efficacy. Discontinuation due to adverse effects was low, with only 2 subjects (both on quetiapine) stopping due to side effects. Three of 13 risperidone-treated subjects (23%) and 3 of 12 quetiapine-treated subjects (25%) met response criteria (decrease of 20% of total BPRS score), whereas 2 of 13 subjects (15%) responded to fluphenazine. Side effect occurrence was similar among drug groups and EPS ratings on the Simpson Angus Scale improved in all drug groups (quetiapine, 1.64; risperidone, 1.30; fluphenazine, 0.69; P value not significant). Despite the newer class of second-generation antipsychotic medications, this treatment-resistant population remains difficult to treat. Many people have only minimal to modest improvements with antipsychotic treatment and most continue to have residual psychotic symptoms. Treatment with first- and second-generation antipsychotics may demonstrate similar efficacy; however, patients treated with second-generation antipsychotics may be more likely to adhere to treatment.
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Affiliation(s)
- Robert R Conley
- Maryland Psychiatric Research Center, Treatment Research Unit, University of Maryland, Baltimore 21228, USA
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Edlinger M, Baumgartner S, Eltanaihi-Furtmüller N, Hummer M, Fleischhacker WW. Switching between second-generation antipsychotics: why and how? CNS Drugs 2005; 19:27-42. [PMID: 15651903 DOI: 10.2165/00023210-200519010-00003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The introduction of second-generation antipsychotics represents an important advance in the treatment of schizophrenia. Although these drugs are generally very effective, not all patients respond in the same way. Partial response with persistent positive and negative symptoms and residual symptoms may force physicians to change antipsychotic medication. As more and more second-generation antipsychotics are introduced, the need for practical guidelines on switching these medications becomes increasingly important. In this article we provide a short summary of the second-generation antipsychotics, focusing on efficacy, adverse effect profile and safety. Indications for switching antipsychotic medication are outlined, as well as recommendations when switching is disadvantageous. Three basic switching strategies (abrupt, gradual and overlapping switching) and their potential risks and benefits are described. We review the available evidence concerning techniques, problems and consequences when switching from one second-generation antipsychotic agent to another and discuss potential difficulties.
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Affiliation(s)
- Monika Edlinger
- Department of Biological Psychiatry, Innsbruck Medical University, Innsbruck, A-6020, Austria
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23
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Schäfer I, Lambert M, Naber D. [Atypical antipsychotics in therapy refractory schizophrenia]. DER NERVENARZT 2004; 75:79-91. [PMID: 14997870 DOI: 10.1007/s00115-003-1662-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Many studies have shown that treatment resistance is a substantial problem in schizophrenic patients, with 20-30% of patients responding only partially and about 7% showing no response to antipsychotic treatment. Clozapine has been consistently shown to be effective in this subgroup of schizophrenic patients. It is still the drug of choice, despite the restricted indication and the need for a careful evaluation of side effects. Recently, several double-blind studies of newer atypical antipsychotics have been conducted in therapy-resistant patients. Three studies compared risperidone with clozapine, one study zotepine with clozapine and two others olanzapine with dozapine. One study compared the efficacy of clozapine, olanzapine, risperidone with one another and with haloperidol. In these studies, dozapine showed increasing superiority the more restrictive the criteria for therapy-resistance chosen. Olanzapine was found to be as effective as clozapine and was better tolerated. However, the results of studies comparing different atypical anti-psychotics have to be interpreted carefully because of their limited number as well as methodological problems. Case studies also indicate the efficacy of combining different atypical antipsychotics, but no systematic research on this issue has been done so far.
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Affiliation(s)
- I Schäfer
- Klinik für Psychiatrie und Psychoterapie der Universitätsklinik Hamburg-Eppendorf.
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Conley RR, Kelly DL, Richardson CM, Tamminga CA, Carpenter WT. The efficacy of high-dose olanzapine versus clozapine in treatment-resistant schizophrenia: a double-blind crossover study. J Clin Psychopharmacol 2003; 23:668-71. [PMID: 14624201 DOI: 10.1097/01.jcp.0000096246.29231.73] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lambert M, Holzbach R, Moritz S, Postel N, Krausz M, Naber D. Objective and subjective efficacy as well as tolerability of olanzapine in the acute treatment of 120 patients with schizophrenia spectrum disorders. Int Clin Psychopharmacol 2003; 18:251-60. [PMID: 12920385 DOI: 10.1097/00004850-200309000-00001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of the present study was to evaluate the objective and subjective efficacy as well as tolerability of olanzapine in acute treatment of schizophrenia spectrum disorders under naturalistic non-selective conditions. Inpatients with schizophrenia spectrum disorders, consecutively admitted over an 18-month period, treated with olanzapine, were included. Diagnoses were made according to ICD-10 criteria based on repeated clinical assessments. Efficacy and tolerability of olanzapine were assessed at baseline and at the end of inpatient acute treatment including Positive and Negative Symptom Scale (PANSS), Clinical Global Impression, subjective assessments, UKU and biological investigations. One hundred and twenty non-selected patients who met ICD-10 criteria for schizophrenia (73%), schizophreniform disorder (14%) or schizoaffective disorder (13%) were treated with olanzapine 15.3+/-5.2 mg/day. Baseline severity (PANSS total mean score 102.2) was higher compared to various admittance studies (PANSS total mean score 86-90). In 32% of patients (n=38), olanzapine treatment was discontinued, mainly because of inefficacy for positive (89%, n=34) and/or negative (95%, n=36) symptoms and/or because of adverse events (37%, n=14). Response rates as improvement in PANSS total score (after > or =3 weeks of treatment) of > or =20%, 30% or 40% were 68%, 55% and 35%, respectively. Response rates in post-hoc defined treatment resistant patients were not significantly different from non-refractory patients. Sedation (26%) was the most common side-effect, followed by weight gain (22%). With regards to subjective efficacy, 30% of the patients were not satisfied with the efficacy of olanzapine, while only 6% of the patients reported a not satisfying subjective tolerability. According to duration of olanzapine treatment, the results for patients, who remained in hospital, revealed a faster increase of weight compared to admittance studies (7 kg in 14 weeks versus 7 kg in 38 weeks). Olanzapine has been found to be effective and tolerable, also under naturalistic acute treatment conditions. Compared to previous double-blind admittance studies, patients had a higher severity of illness at entry and a lower > or =40% PANSS total score response rate. By contrast to previous results, mean dose of olanzapine was similar for multiple- and first-episode patients, and weight gain was more severe. The results underline the need of Phase IV studies for the assessment of clinical antipsychotic efficacy and tolerability.
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Affiliation(s)
- Martin Lambert
- Department for Psychiatry and Psychotherapy, University of Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.
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26
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Ananth J, Ananth K, Burgoyne K, Sidhom T, Gunatilake S. Pharmacotherapy for refractory schizophrenia patients. Expert Rev Neurother 2003; 3:387-401. [PMID: 19810906 DOI: 10.1586/14737175.3.3.387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Most schizophrenic patients experience morbidity over the course of their illness, as the illness runs a chronic course and full remissions are infrequent. Therefore, defining treatment resistance among schizophrenia is problematic. Not all patients respond to antipsychotic medication treatment and an estimated 30-50% are considered resistant to treatment. Treatment resistance normally occurs along a continuum and most patients manifest varying degrees of resistance to antipsychotic medications. Essock and colleagues discovered that more than 60% of the patients in state hospitals met the criteria for clozapine therapy and, therefore, they may qualify for treatment resistance.
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Affiliation(s)
- Jambur Ananth
- University of California, Los Angeles, Harbor UCLA Medical Center, Torrance, CA 90502, USA.
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Casey DE, Carson WH, Saha AR, Liebeskind A, Ali MW, Jody D, Ingenito GG. Switching patients to aripiprazole from other antipsychotic agents: a multicenter randomized study. Psychopharmacology (Berl) 2003; 166:391-9. [PMID: 12610718 DOI: 10.1007/s00213-002-1344-3] [Citation(s) in RCA: 187] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2002] [Accepted: 11/06/2002] [Indexed: 10/26/2022]
Abstract
RATIONALE Switching patients from one antipsychotic to another can lead to tolerability problems or transient symptom exacerbations. It is important to compare switching strategies to determine which methods produce the best possible patient outcomes. OBJECTIVE To investigate the efficacy, safety and tolerability of three dosing strategies for switching chronic, stable patients with schizophrenia from current oral antipsychotic monotherapy to once-daily oral aripiprazole monotherapy. METHOD Patients in this 8-week, open-label, outpatient study were randomized to: 1). immediate initiation of 30 mg/day aripiprazole with simultaneous immediate discontinuation of current antipsychotic; 2). immediate initiation of 30 mg/day aripiprazole while tapering off current antipsychotic over 2 weeks; or 3). up-titrating aripiprazole to 30 mg/day over 2 weeks, while simultaneously tapering off current antipsychotic. Efficacy assessments included PANSS, CGI-S, and CGI-I scores. Safety assessments included: adverse events (AEs) recording, evaluation of extrapyramidal symptoms (EPS), vital signs, ECG, and clinical laboratory tests. RESULTS Efficacy with aripiprazole was maintained during the study with numerical improvements compared with baseline in all three groups. The overall incidence of AEs was broadly comparable across all groups, and AEs were generally mild to moderate in severity and time-limited. Discontinuations due to AEs were comparable across the groups. No deterioration in EPS occurred in any group. The reduction in body weight and plasma prolactin levels following switch to aripiprazole were comparable across the three groups. CONCLUSION Any of the three strategies evaluated can be used safely for switching patients to aripiprazole from antipsychotic monotherapy. Furthermore, patients' symptoms may continue to improve after switching to aripiprazole.
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Affiliation(s)
- Daniel E Casey
- Mental Health Division (P3MIRECC), VA Medical Center, 3710 SW US Veterans Hospital Road, Portland, OR 97239, USA.
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28
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Elovic EP, Lansang R, Li Y, Ricker JH. The use of atypical antipsychotics in traumatic brain injury. J Head Trauma Rehabil 2003; 18:177-95. [PMID: 12802226 DOI: 10.1097/00001199-200303000-00008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of antipsychotic medication in treating individuals with traumatic brain injury (TBI) has been controversial. Much of the caution derives from animal studies (and limited human data) with regard to typical antipsychotics. Of note, however, is that similar assumptions have been made about the newer generation of atypical antipsychotics as well. Because these agents have different mechanisms of action as well as different neurotransmitter targets, this may very well be unwarranted. In this article, mechanisms of action of typical and atypical antipsychotics are discussed, with particular attention paid to their use in TBI. Indications and contraindications are presented, and recommendations are made for the responsible prescribing of antipsychotic medications after TBI.
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Affiliation(s)
- Elie Paul Elovic
- Traumatic Brain Injury Research, Kessler Medical Rehabilitation Research Education Corporation (KMRREC), West Orange, NJ, USA
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Karagianis JL, LeDrew KK, Walker DJ. Switching treatment-resistant patients with schizophrenia or schizoaffective disorder to olanzapine: a one-year open-label study with five-year follow-up. Curr Med Res Opin 2003; 19:473-80. [PMID: 14594518 DOI: 10.1185/030079903125002108] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether patients with treatment-resistant schizophrenia or schizoaffective disorder would respond when switched to olanzapine and whether they could maintain their response on this atypical antipsychotic. RESEARCH DESIGN AND METHODS In this single-center, observational, 1-year open-label study, a cohort of patients was switched to olanzapine due to failure on previous treatment. The patients were followed up (retrospectively) for an additional 5 years. Patients had schizophrenia or schizoaffective disorder and all but one were treatment-resistant. The starting dose was 10 mg/day, with dosage adjustments based on physician judgment. MAIN OUTCOME MEASURES The CGI-S and CGI-I scales were the primary outcome measures. During the observation period, positive and negative symptoms, hospital readmission rates and duration of hospitalization were measured, and treatment-emergent adverse events recorded. RESULTS Mean age of patients (n = 25) was 39.7 years; 19 were male, and all were Caucasian. The mean number of antipsychotics used prior to olanzapine was 4.6 with risperidone (76%) being the most common. The mean duration of olanzapine therapy was 8.6 months. The average number of hospital admissions per patient dropped from 1.32 during the year prior to olanzapine therapy to 0.39 after starting olanzapine. Total number of hospital days was 1042 the year before and 258 the year after olanzapine treatment. The mean CGI-S score improved from markedly ill at baseline to borderline/mildly ill at study end. The mean CGI-I score was rated much improved at study end. Few adverse events occurred during the study. Twelve patients remained on olanzapine monotherapy after 5 years of treatment (mean duration of 62 months). CONCLUSIONS Olanzapine may be a treatment option for patients who fail to respond to treatment with other antipsychotics. Importantly, this is one of the first reports showing that patients with schizophrenia can be maintained on atypical antipsychotic monotherapy for at least 5 years.
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Williams L, Newton G, Roberts K, Finlayson S, Brabbins C. Clozapine-resistant schizophrenia: a positive approach. Br J Psychiatry 2002; 181:184-7. [PMID: 12204919 DOI: 10.1192/bjp.181.3.184] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
A systematic approach to the evaluation and characterization of treatment resistance in schizophrenia has become increasingly important since the introduction of the second-generation antipsychotics. The need for accurate evaluation will increase further as other new antipsychotic medications are developed. Patients with schizophrenia may manifest poor response to therapy because of intolerance to medication, poor adherence, inappropriate dosing, as well as true resistance of their illness to antipsychotic drug therapy. Criteria for treatment-resistance are presented to help in standardizing treatment and clinical trials. As clinicians face the decision of when to change or augment antipsychotic medications, a clear understanding of the appropriate length of a treatment trial and which target symptoms respond to antipsychotic therapy is critical for maximizing response in patients with treatment-resistant schizophrenia.
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Affiliation(s)
- R R Conley
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore 21228, USA
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Abstract
Special patient populations with schizophrenia have received little attention. These populations include adolescents, the elderly, substance abusers, and patients who are considered treatment-resistant. Interest in these populations is rapidly growing, especially with regard to their treatment with second-generation antipsychotics. This article describes the treatment of special patient populations and summarizes the research that has been done in this field.
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Affiliation(s)
- R R Conley
- University of Maryland School of Medicine, Department of Psychiatry, Maryland Psychiatric Research Center, Baltimore, Md, USA
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