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Baldaçara L, Diaz AP, Leite V, Pereira LA, Dos Santos RM, Gomes Júnior VDP, Calfat ELB, Ismael F, Périco CAM, Porto DM, Zacharias CEK, Cordeiro Q, da Silva AG, Tung TC. Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach. ACTA ACUST UNITED AC 2019; 41:324-335. [PMID: 30843960 PMCID: PMC6804299 DOI: 10.1590/1516-4446-2018-0177] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/18/2018] [Indexed: 01/07/2023]
Abstract
Objective: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. Methods: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. Conclusion: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. Systematic review registry number: CRD42017054440.
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Affiliation(s)
- Leonardo Baldaçara
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Universidade Federal do Tocantins (UFT), Palmas, TO, Brazil.,Secretaria de Estado de Saúde do Tocantins, Palmas, TO, Brazil
| | - Alexandre P Diaz
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina (UNISUL), Palhoça, SC, Brazil
| | - Verônica Leite
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Secretaria de Estado de Saúde do Tocantins, Palmas, TO, Brazil.,Secretaria de Saúde do Município de Palmas, Palmas, TO, Brazil
| | - Lucas A Pereira
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Universidade Salvador (UNIFACS), Salvador, BA, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, BA, Brazil.,Faculdade de Tecnologia e Ciências (FTC), Salvador, BA, Brazil
| | - Roberto M Dos Santos
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brazil.,Pronto Atendimento em Saúde Mental, João Pessoa, PB, Brazil
| | - Vicente de P Gomes Júnior
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Associação Psiquiátrica do Piauí (APPI), Teresina, PI, Brazil
| | - Elie L B Calfat
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil.,Centro de Atenção Integrada à Saúde Mental, Franco da Rocha, SP, Brazil
| | - Flávia Ismael
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina do ABC, Santo André, SP, Brazil.,Coordenadoria de Saúde Mental, São Caetano do Sul, SP, Brazil.,Universidade de São Caetano do Sul, São Caetano do Sul, SP, Brazil
| | - Cintia A M Périco
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina do ABC, Santo André, SP, Brazil.,Coordenadoria de Saúde Mental, São Bernardo do Campo, SP, Brazil
| | - Deisy M Porto
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Instituto de Psiquiatria de Santa Catarina, São José, SC, Brazil.,Coordenação Estadual de Saúde Mental, Florianópolis, SC, Brazil
| | - Carlos E K Zacharias
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Secretaria de Estado da Saúde de São Paulo, São Paulo, SP, Brazil.,Secretaria de Saúde do Município de Sorocaba, São Paulo, SP, Brazil
| | - Quirino Cordeiro
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil.,Coordenação-Geral de Saúde Mental, Álcool e Outras Drogas, Ministério da Saúde, Brazil
| | - Antônio Geraldo da Silva
- Asociación Psiquiátrica de América Latina (APAL)Asociación Psiquiátrica de América Latina (APAL).,ABP, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina, Universidade do Porto/Conselho Federal de Medicina (CFM), Porto, Portugal
| | - Teng C Tung
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
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Kumar P B S, Pandey RS, Thirthalli J, Kumar P T S, Kumar C N. A Comparative Study of Short Term Efficacy of Aripiprazole and Risperidone in Schizophrenia. Curr Neuropharmacol 2018; 15:1073-1084. [PMID: 28088913 PMCID: PMC5725539 DOI: 10.2174/1570159x15666170113100611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 05/13/2016] [Accepted: 11/03/2016] [Indexed: 12/20/2022] Open
Abstract
Objective: To compare the short term anti-schizophrenic efficacy and side effect profile of aripiprazole with risperidone. Methodology: The study was a non-randomized, naturalistic, rater blinded, prospective, 8-12 weeks, comparative trial between the risperidone and aripiprazole in patients with schizophrenia. Patients already getting treatment with aripiprazole (10 to 30 mg/day) or risperidone (3 to 8mg/day) were recruited. Mini International Neuropsychiatric Interview (MINI) Plus, Positive and Negative Syndrome Scale (PANSS), Abnormal Involuntary Movement Scale (AIMS), Simpson Angus Scale (SAS), Udvalg for Klinske Undersogelser (UKU) Scale, Clinical Global Impression-severity scales were administered by principal investigator on the day of recruitment. Anthropometric measurements (height, weight, BMI, waist, hip, waist circumference) blood pressure and pulse rate were measured on day 1 and during follow up. All tests except MINI plus were administered again after 8-12weeks. Results: Both aripiprazole and risperidone treated patients have shown significant improvement on positive and negative symptoms but there was no statistically significant difference between the two groups. Mean improvement in patient rated improvement scale score showed a trend towards significance favoring aripiprazole. Common adverse events (seen in ≥ 5% of patients) as assessed by the UKU Scale occurred more frequently in the risperidone group than in the aripiprazole group. Drug induced extra pyramidal symptoms were more common in risperidone treated patients. Aripiprazole showed less treatment emerged weight gain. Conclusion: Aripiprazole is equally efficacious and better tolerated than risperidone in patients with schizophrenia over a short-term period of eight weeks. Aripiprazole showed better patient satisfaction and side effect profile.
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Affiliation(s)
- Sajeev Kumar P B
- Department of Psychiatry, Kannur Medical College, Kannur, Kerala, India
| | - Ravi S Pandey
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Siva Kumar P T
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Naveen Kumar C
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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Ostinelli EG, Jajawi S, Spyridi S, Sayal K, Jayaram MB. Aripiprazole (intramuscular) for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2018; 1:CD008074. [PMID: 29308601 PMCID: PMC6491326 DOI: 10.1002/14651858.cd008074.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND People experiencing psychosis may become aggressive. Antipsychotics, such as aripiprazole in intramuscular form, can be used in such situations. OBJECTIVES To evaluate the effects of intramuscular aripiprazole in the treatment of psychosis-induced aggression or agitation (rapid tranquillisation). SEARCH METHODS On 11 December 2014 and 11 April 2017, we searched the Cochrane Schizophrenia Group's Study-based Register of Trials which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. SELECTION CRITERIA All randomised controlled trials (RCTs) that randomised people with psychosis-induced aggression or agitation to receive either intramuscular aripiprazole or another intramuscular intervention. DATA COLLECTION AND ANALYSIS We independently inspected citations and, where possible, abstracts, ordered papers and re-inspected and quality assessed these. We included studies that met our selection criteria. At least two review authors independently extracted data from the included studies. We chose a fixed-effect model. We analysed dichotomous data using risk ratio (RR) and the 95% confidence intervals (CI). We analysed continuous data using mean differences (MD) and their CIs. We assessed risk of bias for included studies and used GRADE to create 'Summary of findings' tables. MAIN RESULTS Searching found 63 records referring to 21 possible trials. We could only include three studies, all completed over the last decade, with 885 participants, of which 707 were included for quantitative analyses in this systematic review. Due to limited comparisons, small size of trials and a paucity of investigated and reported 'pragmatic' outcomes, evidence was mostly graded as low or very low quality. No trials reported useful data for one of our primary outcomes of tranquil or asleep by 30 minutes. Economic outcomes were also not reported in the trials.When compared with placebo, fewer people in the aripiprazole group needed additional injections compared to the placebo group (2 RCTs, n = 382, RR 0.69, 95% CI 0.56 to 0.85, very low-quality evidence). Clinically important improvement in agitation at two hours favoured the aripiprazole group (2 RCTs, n = 382, RR 1.50, 95% CI 1.17 to 1.92, very low-quality evidence). The numbers of non-responders after the first injection also favoured aripiprazole (1 RCT, n = 263, RR 0.49, 95% CI 0.34 to 0.71, low-quality evidence). Although no effect was found, more people in the aripiprazole compared to the placebo group experienced adverse effects (1 RCT, n = 117, RR 1.51, 95% CI 0.93 to 2.46, very low-quality evidence).Aripiprazole required more injections compared to haloperidol (2 RCTs, n = 477, RR 1.28, 95% CI 1.00 to 1.63, very low-quality evidence), with no significant difference in agitation (2 RCTs, n = 477, RR 0.94, 95% CI 0.80 to 1.11, very low-quality evidence), and similar non-responders after first injection (1 RCT, n = 360, RR 1.18, 95% CI 0.78 to 1.79, low-quality evidence). Aripiprazole and haloperidol did not differ when taking into account the overall number of people that experienced at least one adverse effect (1 RCT, n = 113, RR 0.91, 95% CI 0.61 to 1.35, very low-quality evidence).Compared to aripiprazole, olanzapine was better at reducing agitation (1 RCT, n = 80, RR 0.77, 95% CI 0.60 to 0.99, low-quality evidence) and had a more favourable effect on global state change scores (1 RCT, n = 80, MD 0.58, 95% CI 0.01 to 1.15, low-quality evidence), both at two hours. No differences were found in terms of experiencing at least one adverse effect during the 24 hours after treatment (1 RCT, n = 80, RR 0.75, 95% CI 0.45 to 1.24, very low-quality evidence). However, participants allocated to aripiprazole experienced less somnolence (1 RCT, n = 80, RR 0.25, 95% CI 0.08 to 0.82, low-quality evidence). AUTHORS' CONCLUSIONS The available evidence is of poor quality but there is some evidence aripiprazole is effective compared to placebo and haloperidol, but not when compared to olanzapine. However, considering that evidence comes from only three studies, caution is required in generalising these results to real-world practice. This review firmly highlights the need for more high-quality trials on intramuscular aripiprazole in the management of people with acute aggression or agitation.
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Affiliation(s)
- Edoardo G Ostinelli
- Università degli Studi di MilanoDepartment of Health SciencesVia Antonio di Rudinì 8MilanItaly20142
| | - Salwan Jajawi
- Rotherham, Doncaster and South Humber NHS TrustDepartment of PsychiatryRotherhamUK
| | - Styliani Spyridi
- Cyprus University of TechnologyDepartment of Rehabilitation Sciences, Faculty of Health Sciences30 Archbishop Kyprianou StreetLemesosCyprus3036
- Psychiatry ‐ UK LLPPO Box 329DewsburyWest YorkshireUKWF13 9DN
| | - Kamlaj Sayal
- Cygnet Hospital DerbyWyvern Locked Rehabilitation Unit100 City GateLondon RoadDerbyUKDE24 8WZ
| | - Mahesh B Jayaram
- Melbourne Neuropsychiatry CentreDepartment of PsychiatryUniversity of MelbourneMelbourneAustralia
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Ostinelli EG, Brooke‐Powney MJ, Li X, Adams CE. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2017; 7:CD009377. [PMID: 28758203 PMCID: PMC6483410 DOI: 10.1002/14651858.cd009377.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Haloperidol used alone is recommended to help calm situations of aggression or agitation for people with psychosis. It is widely accessible and may be the only antipsychotic medication available in limited-resource areas. OBJECTIVES To examine whether haloperidol alone is an effective treatment for psychosis-induced aggression or agitation, wherein clinicians are required to intervene to prevent harm to self and others. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (26th May 2016). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register. SELECTION CRITERIA Randomised controlled trials (RCTs) involving people exhibiting aggression and/or agitation thought to be due to psychosis, allocated rapid use of haloperidol alone (by any route), compared with any other treatment. Outcomes of interest included tranquillisation or asleep by 30 minutes, repeated need for rapid tranquillisation within 24 hours, specific behaviours (threat or injury to others/self), adverse effects. We included trials meeting our selection criteria and providing useable data. DATA COLLECTION AND ANALYSIS We independently inspected all citations from searches, identified relevant abstracts, and independently extracted data from all included studies. For binary data we calculated risk ratio (RR), for continuous data we calculated mean difference (MD), and for cognitive outcomes we derived standardised mean difference (SMD) effect sizes, all with 95% confidence intervals (CI) and using a fixed-effect model. We assessed risk of bias for the included studies and used the GRADE approach to produce 'Summary of findings' tables which included our pre-specified main outcomes of interest. MAIN RESULTS We found nine new RCTs from the 2016 update search, giving a total of 41 included studies and 24 comparisons. Few studies were undertaken in circumstances that reflect real-world practice, and, with notable exceptions, most were small and carried considerable risk of bias. Due to the large number of comparisons, we can only present a summary of main results.Compared with placebo, more people in the haloperidol group were asleep at two hours (2 RCTs, n=220, RR 0.88, 95%CI 0.82 to 0.95, very low-quality evidence) and experienced dystonia (2 RCTs, n=207, RR 7.49, 95%CI 0.93 to 60.21, very low-quality evidence).Compared with aripiprazole, people in the haloperidol group required fewer injections than those in the aripiprazole group (2 RCTs, n=473, RR 0.78, 95%CI 0.62 to 0.99, low-quality evidence). More people in the haloperidol group experienced dystonia (2 RCTs, n=477, RR 6.63, 95%CI 1.52 to 28.86, very low-quality evidence).Four trials (n=207) compared haloperidol with lorazepam with no significant differences with regard to number of participants asleep at one hour (1 RCT, n=60, RR 1.05, 95%CI 0.76 to 1.44, very low-quality of evidence) or those requiring additional injections (1 RCT, n=66, RR 1.14, 95%CI 0.91 to 1.43, very low-quality of evidence).Haloperidol's adverse effects were not offset by addition of lorazepam (e.g. dystonia 1 RCT, n=67, RR 8.25, 95%CI 0.46 to 147.45, very low-quality of evidence).Addition of promethazine was investigated in two trials (n=376). More people in the haloperidol group were not tranquil or asleep by 20 minutes (1 RCT, n=316, RR 1.60, 95%CI 1.18 to 2.16, moderate-quality evidence). Acute dystonia was too common in the haloperidol alone group for the trial to continue beyond the interim analysis (1 RCT, n=316, RR 19.48, 95%CI 1.14 to 331.92, low-quality evidence). AUTHORS' CONCLUSIONS Additional data from new studies does not alter previous conclusions of this review. If no other alternative exists, sole use of intramuscular haloperidol could be life-saving. Where additional drugs are available, sole use of haloperidol for extreme emergency could be considered unethical. Addition of the sedating promethazine has support from better-grade evidence from within randomised trials. Use of an alternative antipsychotic drug is only partially supported by fragmented and poor-grade evidence. Adding a benzodiazepine to haloperidol does not have strong evidence of benefit and carries risk of additional harm.After six decades of use for emergency rapid tranquillisation, this is still an area in need of good independent trials relevant to real-world practice.
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Affiliation(s)
- Edoardo G Ostinelli
- Università degli Studi di MilanoDepartment of Health SciencesVia Antonio di Rudinì 8MilanItaly20142
| | - Melanie J Brooke‐Powney
- The University of ManchesterDepartment of Clinical Psychology2nd Floor, Zochonis BuildingBrunswick StreetManchesterUKM13 9PL
| | - Xue Li
- Systematic Review Solutions LtdNottinghamUK
| | - Clive E Adams
- The University of NottinghamCochrane Schizophrenia GroupInstitute of Mental HealthInnovation Park, Triumph Road,NottinghamUKNG7 2TU
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Garriga M, Pacchiarotti I, Kasper S, Zeller SL, Allen MH, Vázquez G, Baldaçara L, San L, McAllister-Williams RH, Fountoulakis KN, Courtet P, Naber D, Chan EW, Fagiolini A, Möller HJ, Grunze H, Llorca PM, Jaffe RL, Yatham LN, Hidalgo-Mazzei D, Passamar M, Messer T, Bernardo M, Vieta E. Assessment and management of agitation in psychiatry: Expert consensus. World J Biol Psychiatry 2016; 17:86-128. [PMID: 26912127 DOI: 10.3109/15622975.2015.1132007] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.
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Affiliation(s)
- Marina Garriga
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Isabella Pacchiarotti
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Siegfried Kasper
- c Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | | - Michael H Allen
- e University of Colorado Depression Center , Denver , CO 80045 , USA
| | - Gustavo Vázquez
- f Research Center for Neuroscience and Neuropsychology, Department of Neuroscience , University of Palermo , Buenos Aires , Argentina
| | | | - Luis San
- h CIBERSAM, Parc Sanitari Sant Joan De Déu , Barcelona , Catalonia , Spain
| | - R Hamish McAllister-Williams
- i Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Northumberland Tyne and Wear NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Konstantinos N Fountoulakis
- j 3rd Department of Psychiatry, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Philippe Courtet
- k Department of Emergency Psychiatry and Post Acute Care , Hôpital Lapeyronie , CHU Montpellier , France
| | - Dieter Naber
- l Department for Psychiatry and Psychotherapy , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Esther W Chan
- m Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine , the University of Hong Kong , Hong Kong , China
| | - Andrea Fagiolini
- n School of Medicine, Department of Molecular Medicine , University of Siena , Siena , Italy
| | - Hans Jürgen Möller
- o Department of Psychiatry and Psychotherapy , Ludwig Maximilian University , Munich , Germany
| | - Heinz Grunze
- p Paracelsus Medical University , Salzburg , Austria
| | - Pierre Michel Llorca
- q Service De Psychiatrie B , CHU De Clermont-Ferrand , Clermont-Ferrand , France
| | | | - Lakshmi N Yatham
- s Mood Disorders Centre, Department of Psychiatry , University of British Columbia , Vancouver , British Columbia , Canada
| | - Diego Hidalgo-Mazzei
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Marc Passamar
- t Centre Hospitalier Pierre-Jamet, SAUS , Albi , France
| | - Thomas Messer
- u Danuvius Klinik GmbH, Pfaffenhofen an Der Ilm , Germany
| | - Miquel Bernardo
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Eduard Vieta
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
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Charpeaud T, Samalin L, Llorca PM. [Efficacy of aripiprazole for the treatment of schizophrenia: what dose is required?]. Encephale 2014; 40:62-73. [PMID: 24445245 DOI: 10.1016/j.encep.2013.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Problem of the choice of antipsychotic dose is a key issue in clinical practice. It determines the efficacy and safety of treatment. Aripiprazole is recommended at a dose of between 10 and 15 mg/day in the treatment of schizophrenia, with a dose range considered to be effective, between 10 and 30 mg/day. This wide therapeutic range prompted us to investigate the existence of a possible dose-effect relationship for aripiprazole in the treatment of schizophrenia. METHOD We conducted a literature review from PubMed and EMBASE database, with the keywords: aripiprazole, schizophrenia. We limited it to studies published in English and French, with the main objective to assess the efficacy of aripiprazole in patients with schizophrenia. We selected only randomized clinical trials, double-blind, controlled against placebo or against an active comparator. Studies in which aripiprazole was studied added to another antipsychotic were not retained. RESULTS Twenty-two randomized, double-blind, controlled studies were selected. Three studies assessed the efficacy of aripiprazole on agitation symptoms in patients with schizophrenia and for which a dose of aripiprazole between 1 and 15mg showed significant efficacy compared to placebo. Seven clinical trials focused on the effect of aripiprazole short term (less than 12weeks). For the primary endpoint (PANSS scores), aripiprazole was superior to placebo or equivalent to active comparators (risperidone, olanzapine or haloperidol). These short-term studies revealed a range of effective doses from 10 mg/day to 20 mg/day. Five studies, lasting between 16 and 52 weeks, with a primary endpoint being the time to discontinuation for any cause for two studies, the time before relapse in one study, and the improvement in PANSS scores for the two other studies. On these different endpoints, aripiprazole was effective at average doses between 15 and 28.1 mg/day. The safety of aripiprazole was particularly favourable in these trials. Finally, we listed seven post-hoc analyses. In support of these long-term analyses on different endpoints, aripiprazole showed significant efficacy at higher doses (20 and 30 mg/day) than those used in the agitation treatment. CONCLUSIONS No study was designed to compare aripiprazole doses in schizophrenia. Nevertheless, efficacy on agitation and hostility components had been observed for doses of 10mg/day, or lower; whereas the antipsychotic effect in acute or maintenance phase appeared optimal for doses ranging from 10 to 25 mg/day. Only one study retained a minimum effective dose of 10mg/day on the PANSS scores. This literature review reveals an effective dose range between 10 and 25 mg/day for aripiprazole in schizophrenia. Less than 10 mg/day did not show significant efficacy on symptoms of schizophrenia, apart from a specific short-term effect on agitation, at very low doses (starting at 1mg). Optimization of treatment, at doses above 25 mg/day, cannot be the subject of evidence-based recommendations.
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Affiliation(s)
- T Charpeaud
- EA U7280, université d'Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France.
| | - L Samalin
- EA U7280, université d'Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - P-M Llorca
- EA U7280, université d'Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
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Abstract
BACKGROUND Haloperidol was developed in the late 1950s for use in the field of anaesthesia. Research subsequently demonstrated effects on hallucinations, delusions, aggressiveness, impulsiveness and states of excitement and led to the introduction of haloperidol as an antipsychotic. OBJECTIVES To evaluate the clinical effects of haloperidol for the management of schizophrenia and other similar serious mental illnesses compared with placebo. SEARCH METHODS Initially, we electronically searched the databases of Biological Abstracts (1985-1998), CINAHL (1982-1998), The Cochrane Library (1998, Issue 4), The Cochrane Schizophrenia Group's Register (December 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1998), and SCISEARCH. We also checked references of all identified studies for further trial citations and contacted the authors of trials and pharmaceutical companies for further information and archive material.For the 2012 update, on 15 May 2012, we searched the Cochrane Schizophrenia Group's Trials Register. SELECTION CRITERIA We included all relevant randomised controlled trials comparing the use of haloperidol (any oral dose) with placebo for those with schizophrenia or other similar serious, non-affective psychotic illnesses (however diagnosed). Our main outcomes of interest were death, loss to follow-up, clinical and social response, relapse and severity of adverse effects. DATA COLLECTION AND ANALYSIS We evaluated data independently and extracted, re-inspected and quality assessed the data. We analysed dichotomous data using risk ratio (RR) and calculated their 95% confidence intervals (CI). For continuous data, we calculated mean differences (MD). We excluded continuous data if loss to follow-up was greater than 50% and inspected data for heterogeneity. We used a fixed-effect model for all analyses. For the 2012 update, we assessed risk of bias of included studies and used the GRADE approach to create a 'Summary of findings' table. MAIN RESULTS Twenty-five trials randomising 4651 people are now included in this review. We chose seven main outcomes of interest for the 'Summary of findings' table. More people allocated haloperidol improved in the first six weeks of treatment than those given placebo (4 RCTs n = 472, RR 0.67 CI 0.56 to 0.80, moderate quality evidence). A further eight trials also found a difference favouring haloperidol across the six weeks to six months period (8 RCTs n = 307 RR 0.67 CI 0.58 to 0.78, moderate quality evidence). Relapse data from two trials favoured haloperidol at < 52 weeks but the evidence was very low quality (2 RCTs n = 70, RR 0.69 CI 0.55 to 0.86). Moderate quality evidence showed about half of those entering studies failed to complete the short trials (six weeks to six months), although, at up to six weeks, 16 studies found a difference that marginally favoured haloperidol (n = 1812, RR 0.87 CI 0.80 to 0.95). Adverse effect data does, nevertheless, support clinical impression that haloperidol is a potent cause of movement disorders, at least in the short term. Moderate quality evidence indicates that haloperidol caused parkinsonism (5 RCTs n = 485, RR 5.48 CI 2.68 to 11.22), akathisia (6 RCTs n = 695, RR 3.66 CI 2.24 to 5.97, and acute dystonia (5 RCTs n = 471, RR 11.49 CI 3.23 to 10.85). Discharge from hospital was equivocal between groups (1 RCT n = 33, RR 0.85 CI 0.47 to 1.52, very low quality evidence). Data were not reported for death and patient satisfaction. AUTHORS' CONCLUSIONS Haloperidol is a potent antipsychotic drug but has a high propensity to cause adverse effects. Where there is no treatment option, use of haloperidol to counter the damaging and potentially dangerous consequences of untreated schizophrenia is justified. However, where a choice of drug is available, people with schizophrenia and clinicians may wish to prescribe an alternative antipsychotic with less likelihood of adverse effects such as parkinsonism, akathisia and acute dystonias. Haloperidol should be less favoured as a control drug for randomised trials of new antipsychotics.
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Affiliation(s)
- Clive E Adams
- Cochrane Schizophrenia Group, The University of Nottingham, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road,, Nottingham, UK, NG7 2TU
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Powney MJ, Adams CE, Jones H. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2012; 11:CD009377. [PMID: 23152276 DOI: 10.1002/14651858.cd009377.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Haloperidol, used alone is recommended to help calm situations of aggression with people with psychosis. This drug is widely accessible and may be the only antipsychotic medication available in areas where resources are limited. OBJECTIVES To investigate whether haloperidol alone, administered orally, intramuscularly or intravenously, is effective treatment for psychosis-induced agitation or aggression. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (1st June 2011). SELECTION CRITERIA Randomised controlled trials (RCTs) involving people exhibiting agitation or aggression (or both) thought to be due to psychosis, allocated rapid use of haloperidol alone (by any route), compared with any other treatment. Outcomes included tranquillisation or asleep by 30 minutes, repeated need for rapid tranquillisation within 24 hours, specific behaviours (threat or injury to others/self), adverse effects. DATA COLLECTION AND ANALYSIS We independently selected and assessed studies for methodological quality and extracted data. 'Summary of findings' tables were produced for each comparison grading the evidence and calculating, where possible and appropriate, a range of absolute effects. MAIN RESULTS We included 32 studies comparing haloperidol with 18 other treatments. Few studies were undertaken in circumstances that reflect real world practice, and, with notable exceptions, most were small and carried considerable risk of bias.Compared with placebo, more people in the haloperidol group were asleep at two hours (2 RCTs, n = 220, risk ratio (RR) 0.88, 95% confidence interval (CI) 0.82 to 0.95). Dystonia was common (2 RCTs, n = 207, RR 7.49, CI 0.93 to 60.21). Compared with aripiprazole, people in the haloperidol group required fewer injections than those in the aripiprazole group (2 RCTs, n = 473, RR 0.78, CI 0.62 to 0.99). More people in the haloperidol group experienced dystonia (2 RCTs, n = 477, RR 6.63, CI 1.52 to 28.86).Despite three larger trials with ziprasidone (total n = 739), data remain patchy, largely because of poor design and reporting. Compared with zuclopenthixol acetate, more people who received haloperidol required more than three injections (1 RCT, n = 70, RR 2.54, CI 1.19 to 5.46).Three trials (n = 205) compared haloperidol with lorazepam. There were no significant differences between the groups with regard to the number of participants asleep at one hour (1 RCT, n = 60, RR 1.05, CI 0.76 to 1.44). However, by three hours, significantly more people were asleep in the lorazepam group compared with the haloperidol group (1 RCT, n = 66, RR 1.93, CI 1.14 to 3.27). There were no differences in numbers requiring more than one injection (1 RCT, n = 66, RR 1.14, CI 0.91 to 1.43).Haloperidol's adverse effects were not offset by addition of lorazepam (e.g. dystonia 1 RCT, n = 67, RR 8.25, CI 0.46 to 147.45; required antiparkinson medication RR 2.74, CI 0.81 to 9.25). Addition of promethazine was investigated in one larger and better graded trial (n = 316). More people in the haloperidol group were not tranquil or asleep by 20 minutes (RR 1.60, CI 1.18 to 2.16). Significantly more people in the haloperidol alone group experienced one or more adverse effects (RR 11.28, CI 1.47 to 86.35). Acute dystonia for those allocated haloperidol alone was too common for the trial to continue beyond the interim analysis (RR 19.48, CI 1.14 to 331.92). AUTHORS' CONCLUSIONS If no other alternative exists, sole use of intramuscular haloperidol could be life-saving. Where additional drugs to offset the adverse effects are available, sole use of haloperidol for the extreme emergency, in situations of coercion, could be considered unethical. Addition of the sedating promethazine has support from better-grade evidence from within randomised trials. Use of an alternative antipsychotic drug is only partially supported by fragmented and poor-grade evidence. Evidence for use of newer generation antipsychotic alternatives is no stronger than that for older drugs. Adding a benzodiazepine to haloperidol does not have strong evidence of benefit and carries a risk of additional harm.After six decades of use for emergency rapid tranquillisation, this is still an area in need of good independent trials relevant to real world practice.
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Affiliation(s)
- Melanie J Powney
- Department of Clinical Psychology, The University ofManchester,Manchester, UK.
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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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[Psychomotor agitation, pharmaceutical sedation and psychiatric emergency in psychotic patients]. Encephale 2011; 37:448-56. [PMID: 22137217 DOI: 10.1016/j.encep.2011.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/28/2011] [Indexed: 11/20/2022]
Abstract
Psychomotor agitation, very common among psychiatric emergencies, raises the question of pharmaceutical sedation, its indications, and its issues, notably with regard to the observance in postemergency. A new approach to sedation places it within its therapeutic aim and also takes into account the sometimes harmful impact on the course of the patient's care. A pretherapeutical, analysis both clinical and environmental is crucial. The time spent on the initial meeting and assessment is essential. The evolution of professional practices in mental health allows us to distinguish three kinds of sedation (vigilance, behaviour and psychical) that guide the choice and the mode of psychotropic drug use. The harmful effects of an ever-increasing use of sedation is debated. The use of atypical antipsychotics and injectable forms is argued. Early psychical sedation is preferable to the obsolete practice of vigilance sedation and to behavioural sedation with its limited indications. The use of excessive or prolonged sedation might have a detrimental effect on the care offered after psychiatric emergency treatment.
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Abstract
It seems that the efficacy of aripiprazole for treating schizophrenia is mediated through a combination of partial agonism at dopamine D2 and serotonin 5-HT1A receptors and antagonism at serotonin 5-HT2A receptors. Aripiprazole has also received approval for the treatment of bipolar disorder as adjunctive therapy or monotherapy (manic or mixed episodes) as well as an augmentation therapy of major depressive disorder (MDD) by the US FDA. The overall safety and tolerability of aripiprazole is favorable compared to other atypical antipsychotics across the approved indications. Aripiprazole showed a minimal propensity for clinically significant weight gain and metabolic disruption. However, extrapyramidal side effects, such as akathisia, are reported and may limit its clinical use in some cases, particularly in patients with bipolar disorder and MDD. This review focuses on the tolerability and safety of aripiprazole across a broad spectrum of psychiatric disorders while taking into consideration results from registrational studies as well as findings from studies in the naturalistic setting. In conclusion, whereas the comparative safety and tolerability of aripiprazole has not been systematically evaluated in comparator studies, tolerability and safety issues commonly associated with atypical antipsychotics such as weight gain and metabolic syndrome are less prominent with aripiprazole.
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Affiliation(s)
- Chi-Un Pae
- Catholic University of Korea College of Medicine, Holy Family Hospital, Department of Psychiatry, Sosa-Dong, Wonmi-Gu, Bucheon 420-717, Kyounggi-Do, Republic of Korea.
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Buchanan RW, Kreyenbuhl J, Kelly DL, Noel JM, Boggs DL, Fischer BA, Himelhoch S, Fang B, Peterson E, Aquino PR, Keller W. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36:71-93. [PMID: 19955390 PMCID: PMC2800144 DOI: 10.1093/schbul/sbp116] [Citation(s) in RCA: 613] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In light of the large number of studies published since the 2004 update of Schizophrenia Patient Outcomes Research Team psychopharmacological treatment recommendations, we conducted an extensive literature review to determine whether the current psychopharmacological treatment recommendations required revision and whether there was sufficient evidence to warrant new treatment recommendations for prespecified outcomes of interest. We reviewed over 400 articles, which resulted in 16 treatment recommendations: the revision of 11 previous treatment recommendations and 5 new treatment recommendations. Three previous treatment recommendations were eliminated. There were 13 interventions and/or outcomes for which there was insufficient evidence for a treatment recommendation, and a statement was written to summarize the current level of evidence and identify important gaps in our knowledge that need to be addressed. In general, there was considerable consensus among the Psychopharmacology Evidence Review Group and the expert consultants. Two major areas of contention concerned whether there was sufficient evidence to recommend specific dosage ranges for the acute and maintenance treatment of first-episode and multi-episode schizophrenia and to endorse the practice of switching antipsychotics for the treatment of antipsychotic-related weight gain. Finally, there continue to be major gaps in our knowledge, including limited information on (1) the use of adjunctive pharmacological agents for the treatment of persistent positive symptoms or other symptom domains of psychopathology, including anxiety, cognitive impairments, depressive symptoms, and persistent negative symptoms and (2) the treatment of co-occurring substance or medical disorders that occur frequently in individuals with schizophrenia.
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Affiliation(s)
- Robert W. Buchanan
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228,To whom correspondence should be addressed; tel: 410-402-7876, fax: 410-402-7198, e-mail:
| | - Julie Kreyenbuhl
- Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD,VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center, Baltimore, MD
| | - Deanna L. Kelly
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228
| | - Jason M. Noel
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
| | - Douglas L. Boggs
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228
| | - Bernard A. Fischer
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD 21228
| | - Seth Himelhoch
- Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - Beverly Fang
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - Eunice Peterson
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - Patrick R. Aquino
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
| | - William Keller
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
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Satterthwaite TD, Wolf DH, Rosenheck RA, Gur RE, Caroff SN. A meta-analysis of the risk of acute extrapyramidal symptoms with intramuscular antipsychotics for the treatment of agitation. J Clin Psychiatry 2008; 69:1869-79. [PMID: 19192477 PMCID: PMC4041731 DOI: 10.4088/jcp.v69n1204] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 05/19/2008] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We examined the evidence for a decreased risk of extrapyramidal symptoms (EPS) with intramuscular second-generation antipsychotics (SGAs) versus intramuscular haloperidol alone or in combination with an anticholinergic agent. DATA SOURCES We searched MEDLINE (1950 to the present), and EMBASE and the Cochrane Database through January 16, 2008, for studies published in English of intramuscular SGAs and intramuscular haloperidol alone or in combination with an anticholinergic agent using the following drug names: ziprasidone, Geodon, olanzapine, Zyprexa, aripiprazole, Abilify, haloperidol, and Haldol. We then searched this pool of studies for trials with the terms intramuscular, IM, or injectable. Initially, we included only randomized controlled trials (RCTs). To obtain more data comparing SGAs to the combination of haloperidol and an anticholinergic, we conducted a second analysis including studies of any methodology. STUDY SELECTION Seven RCTs that compared intramuscular SGAs to intramuscular haloperidol alone were identified. However, we found only one RCT of haloperidol plus an anticholinergic. In the second analysis, we identified 18 studies, including 4 using haloperidol combined with promethazine (an antihistamine with anticholinergic properties). DATA EXTRACTION The primary outcome measure was acute dystonia; secondary outcome measures included akathisia, parkinsonism, or the need for additional anticholinergic medication. For RCTs, risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each outcome. When all studies were included in the second analysis, we calculated the risk of acute dystonia. DATA SYNTHESIS Among RCTs (N = 2032), SGAs were associated with a significantly lower risk of acute dystonia (RR = 0.19, 95% CI = 0.10 to 0.39), akathisia (RR = 0.25, 95% CI = 0.14 to 0.44), and anticholinergic use (RR = 0.19, 95% CI = 0.09 to 0.43) compared with haloperidol alone. When all trials were considered (N = 3425), rates of acute dystonia were higher for haloperidol alone (4.7%) than for SGAs (0.6%) or for haloperidol plus promethazine (0.0%). CONCLUSIONS Intramuscular SGAs have a significantly lower risk of acute EPS compared to haloperidol alone. However, intramuscular haloperidol plus promethazine has a risk of acute dystonia comparable to intramuscular SGAs. The decision to use SGAs should consider other factors in addition to the reduction of EPS, which can be prevented by the use of an anticholinergic agent.
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Affiliation(s)
- Theodore D Satterthwaite
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market St., 2nd Floor, Philadelphia, PA 19104, USA.
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Abstract
Agitation can present as an emergency in the course of numerous psychiatric conditions including intoxication, schizophrenia, bipolar disorder, and delirium. This article reviews relevant literature regarding the definition, etiology, measurement, and management of episodic agitation and pays particular attention to intramuscular treatments. The impact of changes in methodology between the era of first- and second-generation antipsychotics, the implications of those changes for external validity of studies of second-generation studies, and the recent evolution of expert consensus are discussed.
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Abstract
BACKGROUND Haloperidol was developed in the late 1950s for use in the field of anaesthesia. Research subsequently demonstrated effects on hallucinations, delusions, aggressiveness, impulsiveness and states of excitement and led to the introduction of haloperidol as an antipsychotic. OBJECTIVES To evaluate the clinical effects of haloperidol for the management of schizophrenia and other similar serious mental illnesses compared to placebo. SEARCH STRATEGY We initially electronically searched the databases of Biological Abstracts (1985-1998), CINAHL (1982-1998), The Cochrane Library (1998, Issue 4), The Cochrane Schizophrenia Group's Register (December 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1998), and SCISEARCH. We also checked references of all identified studies for further trial citations and contacted the authors of trials and pharmaceutical companies for further information and archive material. For the 2005 update we searched The Cochrane Library (2005, Issue 6). SELECTION CRITERIA We included all relevant randomised controlled trials comparing the use of haloperidol (any oral dose) with placebo for those with schizophrenia or other similar serious, non-affective psychotic illnesses (however diagnosed). Our main outcomes of interest were death, loss to follow up, clinical and social response, relapse and severity of adverse effects. DATA COLLECTION AND ANALYSIS We evaluated data independently and analysed on an intention-to-treat basis, assuming that people who left the study early, or were lost to follow-up, had no improvement. Where possible and appropriate, we analysed dichotomous data using Relative Risk (RR) and calculated their 95% confidence intervals (CI). If appropriate, the number needed to treat (NNT) or number needed to harm (NNH) was estimated. For continuous data, we calculated weighted mean differences. We excluded continuous data if loss to follow up was greater than 50% and inspected data for heterogeneity. MAIN RESULTS Twenty-one trials randomising 1519 people are now included in this review. One new trial, Kane 2002 (n=414) has been added but it did not affect the overall results. More people allocated haloperidol improved in the first six weeks of treatment than those given placebo (3RCTs n=159, RR failing to produce a marked improvement 0.44 CI 0.3 to 0.6, NNT 3 CI 2 to 5). A further eight trials also found a difference favouring haloperidol across the 6-24 week period (8 RCTs n=308 RR no marked global improvement 0.68 CI 0.6 to 0.8 NNT 3 CI 2.5 to 5) but this may be an over estimate of effect as small negative studies were not identified. About half of those entering studies failed to complete the short trials, although, at 0-6 weeks, 11 studies found a difference that marginally favoured haloperidol (11 RCTs n=898, RR 0.8 CI 0.7 to 0.9, NNT 59 CI 38 to 200). Adverse effect data does, nevertheless, support clinical impression, that haloperidol is a potent cause of movement disorders, at least in the short term. Haloperidol promotes acute dystonia (3 RCTs n=93, RR 4.7 CI 1.7 to 44, NNH 5 CI 3 to 9), akathisia (4 RCTs n=333, RR 2.6 CI 1.4 to 4.8, NNH 7 CI 3 to 25) and parkinsonism (4 RCTs n=163, RR 11.7 CI 2.9 to 47, NNH 3 CI 2 to 5). AUTHORS' CONCLUSIONS Haloperidol is a potent antipsychotic drug but has a high propensity to cause adverse effects. Where there is no treatment option, use of haloperidol to counter the damaging and potentially dangerous consequences of untreated schizophrenia is justified. However, where a choice of drug is available, people with schizophrenia and clinicians may wish to prescribe an alternative antipsychotic with less likelihood of adverse effects such as parkinsonism, akathisia and acute dystonias. Haloperidol should not be a control drug of choice for randomised trials of new antipsychotics.
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Affiliation(s)
- C B Joy
- University of Leeds, Department of Psychiatry & Behavioural Sciences, 15-19 Hyde Terrace, Leeds, UK.
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