Zotepine in the treatment of acute hospitalized schizophrenic episodes

Zotepine for behavioural and psychological symptoms in dementia: an open-label study

OBJECTIVE

To provide initial information on the safety and efficacy of the atypical antipsychotic zotepine in the treatment of behavioural and psychological symptoms of dementia (BPSD).

METHODS

This was an open-label, single-centre field study. Twenty-four patients with BPSD associated with Alzheimer's disease (n=12) or other forms of dementia (n=12) were included. During the 8-week observation period, the patients received zotepine (Nipolept) [12.5-150 mg/day] for the psychotic components of BPSD; no other treatment interventions for BPSD were allowed. At baseline, day 28 and day 56, patients were evaluated using the Clinical Global Impressions (CGI) scale; the Mini-Mental State Examination (MMSE), the Syndrome Brief Test (SKT) and the Age Concentration Test (AKT) to assess cognition; and the Neuropsychiatric Inventory (NPI) and the Cohen-Mansfield Agitation Inventory (CMAI) to assess BPSD. General adverse effects and, more specifically, the emergence of extrapyramidal symptoms were also assessed.

RESULTS

There was no change from baseline to day 56 in the CGI score and the caregiver burden (as indicated by the caregiver-related section of the NPI). There was also no change in cognition (as assessed by the MMSE, SKT and AKT). The neuropsychiatric symptom score according to part 1 of the NPI (especially key psychotic symptoms, aggression and disinhibition) and the CMAI scores improved by 36% and 15%, respectively, between baseline and the end of the study in a highly statistically significant fashion. No significant differences in treatment response or adverse effect profile were noted between the 12 patients with Alzheimer's disease and the 12 patients with other types of dementia. Zotepine was well tolerated, with tiredness and sedation (five and four cases, respectively) being the most frequent complaints. No clinically significant emergence of extrapyramidal symptoms was seen.

CONCLUSIONS

Zotepine appears to be well tolerated and effective in treating BPSD, consistent with the performance of other atypical antipsychotic drugs in this condition. Larger, controlled studies are warranted.

Stimulus properties of the “atypical” antipsychotic zotepine in rats: comparisons with clozapine and quetiapine

The stimulus properties of the "atypical" antipsychotic zotepine were assessed in three studies in rats. In Study 1, the ability of zotepine to generalise to clozapine was studied. Two groups of rats were trained to discriminate clozapine at 2 and 5 mg/kg. Clozapine induced full generalisation in both groups, with the generalisation curves shifted significantly to the left in the low dose group. In generalisation tests clozapine did not suppress responding. Zotepine induced dose-related generalisation in both groups, with full generalisation in the low dose group and 50% maximal generalisation in the high dose group at the highest dose that could be tested. In contrast to clozapine, zotepine induced substantial (50% or more) substitution for clozapine only at doses which suppressed responding. In Study 2 zotepine was investigated in rats trained to discriminate quetiapine (10 mg/kg). Quetiapine induced full generalisation and zotepine only induced 54% generalisation at the highest dose that could be tested. Generalisation was accompanied by response suppression induced by both quetiapine and zotepine. In Study 3 an attempt was made to train a zotepine discrimination (1 mg/kg increased to 2 mg/kg). Even after 150 training sessions it proved impossible to obtain reliable discriminative responding with zotepine. These data suggest that: (i) The actions of zotepine in discrimination assays are similar to, but not identical with, those of clozapine and quetiapine; (ii) The differences among the actions of clozapine, quetiapine and zotepine may be related to either the unique ability of zotepine to block noradrenaline (NA) uptake, or to its more marked affinity for D(2) receptors; (iii) The finding that zotepine only mimicked quetiapine up to a level of 54% was unexpected, since quetiapine and clozapine generalise reciprocally and zotepine generalised fully to (low dose) clozapine. This finding may also be related either to zotepine's ability to inhibit NA uptake or its relatively high D(2) affinity; (iv) Although zotepine clearly possesses discriminative properties, it is not possible to train it as a reliable stimulus, in contrast to clozapine and quetiapine. This may be due to its more marked D(2) receptor affinity. Collectively, these data demonstrate both similarities and differences between zotepine and other novel atypical antipsychotics in drug discrimination assays.

Antipsychotic treatment in schizophrenia: atypical options and NICE guidance

Following the reintroduction of clozapine, several atypical antipsychotics have become available for the treatment of schizophrenia. These drugs are at least as effective as conventional treatment. Although each has an individual pattern of affinities, new work suggests that the hallmark of atypicality is fast dissociation at the dopamine-2 receptor. Numerous novel drugs are in development, but it is not clear how these conform to this theory of therapeutic effect. Atypical antipsychotics cause less extrapyramidal side effects than conventional treatment, but other effects such as hyperprolactinaemia, weight gain, glucose dysregulation and prolonged QTc interval remain problematic for some. Current antipsychotic prescribing practice is far from ideal: the NICE guidance stresses that atypical treatments should be considered unless symptoms are well controlled and side effects are acceptable, or depot formulation is indicated. There is a welcome emphasis on drug treatment as part of an integrated package of care negotiated with patients and their carers.

Zotepine in Huntington's disease

The authors report a patient with Huntington's disease (HD) presenting with severe chorea. The motor scale of the unified HD rating scale (UHDRS-I) revealed 81 points. Motor function clearly improved with zotepine, until she reached an UHDRS-I of 34 points on day 7 of treatment. The patient was stable for at least 12 weeks. The improvement includes all seven categories of the UHDRS-I, especially chorea, gait and oral function. This is the first description of zotepine in HD. Our findings suggest that zotepine is useful in the treatment of HD chorea. Controlled trials of its use in HD would be welcome.