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Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Ponsford M, Ponsford JL. Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials. J Neurotrauma 2023; 40:33-51. [PMID: 35833454 DOI: 10.1089/neu.2022.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are frequently used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety, and impact upon patient outcomes. The sedating and cognitive side effects of these agents are theorized to exacerbate confusion during PTA, leading to prolonged PTA duration and increased agitation. This study, conducted in a subacute inpatient rehabilitation setting, describes the results of a double-blind, randomized, placebo-controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group comparisons were additionally conducted, examining level of agitation; number of agitated days; agitation at discharge, duration, and depth of PTA; length of hospitalization; cognitive outcome; adverse events; and rescue medication use. Eleven agitated participants in PTA (mean [M] age = 39.82 years, standard deviation [SD] = 20.06; mean time post-injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every 3 to 4 days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37-0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5-20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. In group analyses, participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine, mean = 9.32, SD = 0.69; placebo, M = 10.68, SD = 0.30; p = .009, d = -2.16), and a trend toward longer PTA duration with large effect size (olanzapine, M = 71.96 days, SD = 20.31; placebo, M = 47.50 days, SD = 11.27; p = 0.072, d = 1.26). No further group comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so. Importantly, administration of olanzapine during PTA may lead to increased patient confusion, possibly prolonging PTA. When utilizing olanzapine, physicians must therefore balance the possible advantages of agitation management with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings and the efficacy and outcomes associated with the use of any pharmacological agent for the management of agitation during the PTA period.
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
| | - Adam McKay
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia.,Division of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
| | - John Olver
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, Melbourne, Australia
| | - Michael Ponsford
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
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Japanese Society of Neuropsychopharmacology: "Guideline for Pharmacological Therapy of Schizophrenia". Neuropsychopharmacol Rep 2021; 41:266-324. [PMID: 34390232 PMCID: PMC8411321 DOI: 10.1002/npr2.12193] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022] Open
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Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Hicks AJ, Mortimer D, Ponsford JL. Use of olanzapine to treat agitation in traumatic brain injury: study protocol for a randomised controlled trial. Trials 2020; 21:662. [PMID: 32690072 PMCID: PMC7370410 DOI: 10.1186/s13063-020-04553-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Agitation is common in the early stages of recovery from traumatic brain injury (TBI), when patients are in post-traumatic amnesia (PTA). Agitation is associated with risk of harm to patients and caregivers. Recent guidelines recommend that agitation during PTA is managed using environmental modifications. Agitation is also frequently treated pharmacologically, with the use of atypical antipsychotics such as olanzapine among the most common. This is despite a lack of well-designed studies to support the use of antipsychotics within this context. This study will be a double-blind, placebo-controlled randomised controlled trial. We will examine the efficacy, safety, cost-effectiveness and outcomes associated with the use of olanzapine for reducing agitation in patients in PTA following TBI over and above recommended environmental management. Methods Fifty-eight TBI rehabilitation inpatients who are in PTA and are agitated will receive olanzapine or placebo for the duration of PTA. All participants will additionally receive optimal environmental management for agitation. Measures of agitation, PTA and health will be undertaken at baseline. Treatment administration will begin at a dose of 5 mg daily and may be escalated to a maximum dose of 20 mg per day. Throughout the treatment period, agitation and PTA will be measured daily, and adverse events monitored weekly. Efficacy will be assessed by treatment group comparison of average Agitated Behaviour Scale scores during PTA. Participants will cease treatment upon emergence from PTA. Agitation levels will continue to be monitored for a further 2 weeks, post-treatment measures of health will be undertaken and cognitive and functional status will be assessed. Level of agitation and functional health will be assessed at hospital discharge. At 3 months post-discharge, functional outcomes and health service utilisation will be measured. Discussion This trial will provide crucial evidence to inform the management of agitation in patients in PTA following TBI. It will provide guidance as to whether olanzapine reduces agitation over and above recommended environmental management or conversely whether it increases or prolongs agitation and PTA, increases length of inpatient hospitalisation and impacts longer term cognitive and functional outcomes. It will also speak to the safety and cost-effectiveness of olanzapine use in this population. Trial registration ANZCTR ACTRN12619000284167. Registered on 25 February 2019
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Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia. .,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia. .,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia.
| | - Adam McKay
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia.,Department of Psychology, Epworth HealthCare, 29 Erin Street, Richmond, Victoria, 3121, Australia
| | - John Olver
- Rehabilitation Medicine, Epworth HealthCare, 89 Bridge Rd, Richmond, Victoria, 3121, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Level 1 North Block, Grattan Street, Parkville, Victoria, 3052, Australia.,Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, 3050, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade, Parkville, Victoria, 3052, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Level 1 North Block, Grattan Street, Parkville, Victoria, 3052, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, 31 Albert Rd, Melbourne, Victoria, 3004, Australia
| | - Amelia J Hicks
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia
| | - Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Building H, Level 5, Caulfield Campus, Clayton, Victoria, 3145, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Centre, 185-187 Hoddle Street, Richmond, Victoria, 3121, Australia.,School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Clayton, Victoria, 3800, Australia.,Turner Institute for Brain and Mental Health, Monash University, Level 5, 18 Innovation Walk, Clayton Campus, Clayton, Victoria, 3800, Australia
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Ward K, Citrome L. The treatment of acute agitation associated with schizophrenia or bipolar disorder: investigational drugs in early stages of their clinical development, and their clinical context and potential place in therapy. Expert Opin Investig Drugs 2020; 29:245-257. [PMID: 32031021 DOI: 10.1080/13543784.2020.1727884] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Acute agitation in patients with schizophrenia or bipolar disorder may require pharmacologic management. Ideal medication characteristics for this indication include rapid onset, minimal side effects, and noninvasive administration techniques.Areas Covered: This review summarizes investigational agents in early clinical development for the management of acute agitation in patients with psychosis or mania; it also assesses where these agents may fit with current therapies to provide a clinical perspective. The authors conducted a broad search of clinicaltrials.gov to identify investigational agents for agitation or aggression in patients with schizophrenia or bipolar disorder. Two medications met the search criteria: dexmedetomidine film (BXCL501) and intranasal olanzapine (INP105).Expert Opinion: Olanzapine is a well-known molecular entity in the psychiatric armamentarium but dexmedetomidine would be a new and unfamiliar agent for mental health providers. Nonetheless, although it is too early to make definitive statements about tolerability and efficacy, their unique administration mechanisms suggest that dexmedetomidine film and intranasal olanzapine may become valuable options for the rapid management of acute agitation in patients who are willing to cooperate with medication therapy.
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Affiliation(s)
- Kristen Ward
- Clinical Pharmacy Department, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Leslie Citrome
- Department of Psychiatry and Behavioral Science, New York Medical College, Valhalla, NY, USA
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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: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Bak M, Weltens I, Bervoets C, De Fruyt J, Samochowiec J, Fiorillo A, Sampogna G, Bienkowski P, Preuss WU, Misiak B, Frydecka D, Samochowiec A, Bak E, Drukker M, Dom G. The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis. Eur Psychiatry 2019; 57:78-100. [DOI: 10.1016/j.eurpsy.2019.01.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 01/12/2023] Open
Abstract
AbstractIntroduction:Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.Method:A search in Pubmed and Embase was done to isolate RCT’s considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.Results:Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.Conclusion:Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital.
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Schwerthöffer D, Pajonk F. RETRACTED ARTICLE: Vergleich von sublingualer und intravenöser Gabe von Lorazepam bei psychiatrischen Notfällen im Notarztdienst. Anaesthesist 2019; 68:83-9. [DOI: 10.1007/s00101-018-0513-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 11/06/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022]
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Abstract
Background Drug-induced QT prolongation is associated with higher risk of cardiac arrhythmias and cardiovascular mortality. We investigated the effects of atypical antipsychotic drugs on QT interval in children and adults with mental disorders. Methods We conducted random-effects direct frequentist meta-analyses of aggregate data from randomized controlled trials (RCT) and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our search in PubMed, EMBASE, the Cochrane Library, clinicaltrials.gov, and PharmaPendium up to October 2017 identified studies that examined aripiprazole, quetiapine, risperidone, olanzapine, ziprasidone and brexpiprazole. Results Low quality evidence suggests that aripiprazole (four meta-analyses and twelve RCTs), brexpiprazole (one systematic review and four RCTs) or olanzapine (five meta-analyses and twenty RCTs) do not increase QT interval. Low quality evidence suggests that ziprasidone (five meta-analyses and 11 RCTs) increases QT interval and the rates of QT prolongation while risperidone (four meta-analyses, 70 RCTs) and quetiapine (two meta-analyses and seven RCTs) are associated with QT prolongation and greater odds of torsades de pointes ventricular tachycardia especially in cases of drug overdose. Conclusions The main conclusion of our study is that in people with mental disorders and under treatment with atypical antipsychotic drugs, in order to avoid QT prolongation and reduce the risk of ventricular tachycardia clinicians may recommend aripiprazole, brexpiprazole or olanzapine in licensed doses. Long-term comparative safety needs to be established.
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Affiliation(s)
- Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Tatyana A Shamliyan
- Quality Assurance, Evidence-Based Medicine Center, Elsevier, Philadelphia, PA, USA
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Zun LS. Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy. J Emerg Med 2018; 54:364-74. [DOI: 10.1016/j.jemermed.2017.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 11/22/2022]
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Katagiri H, Taketsuna M, Kondo S, Kajimoto K, Aoi E, Tanji Y. Safety and effectiveness of rapid-acting intra-muscular olanzapine for agitation associated with schizophrenia - Japan postmarketing surveillance study. Neuropsychiatr Dis Treat 2018; 14:265-272. [PMID: 29391799 PMCID: PMC5769586 DOI: 10.2147/ndt.s147124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the safety and effectiveness of rapid-acting intramuscular (IM) olanzapine in the treatment of acute agitation associated with schizophrenia in real-world clinical settings in Japan. METHODS In this multicenter, postmarketing surveillance (PMS) study, patients with acute agitation associated with schizophrenia were treated with IM olanzapine daily in a daily clinical setting. The observational period ranged from 1 to 7 days, including the day of initial administration. Safety was assessed by reporting treatment-emergent adverse events (TEAEs) and adverse drug reactions (ADRs). The Positive and Negative Syndrome Scale - Excited Component (PANSS-EC) score was used to evaluate effectiveness at baseline and at 2 hours (after each administration), 2 days, and 3 days (end of the observational period) from the last administration of the IM olanzapine injection. RESULTS The safety analysis set included 999 patients, and the initial dose of 10 mg was administered to 955 patients. TEAEs were reported in 28 patients (36 events), the most common of which were dyslalia (5 patients), akathisia and somno lence (4 patients each), hepatic function abnormal (3 patients), and constipation and dehydration (2 patients each). One serious adverse event of akathisia occurred during the observation period. The PANSS-EC score (mean ± standard deviation) was 23.3±6.4 (n=625) at baseline, 16.9±7.0 (n=522) at 2 hours after initial injection, and 14.9±6.5 (n=650) at the last observation carried forward. CONCLUSION The results of this Japanese PMS study demonstrated that IM olanzapine is safe and has a favorable effectiveness profile in the treatment of schizophrenia patients with acute agitation.
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Affiliation(s)
| | | | | | - Kenta Kajimoto
- Scientific Communications, Medicines Development Unit Japan
| | - Etsuko Aoi
- Global Patient Safety Japan, Quality and Patient Safety, Eli Lilly Japan K.K., Kobe, Japan
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Katagiri H, Taketsuna M, Kondo S, Kajimoto K, Aoi E, Tanji Y. Effectiveness and safety of oral olanzapine treatment transitioned from rapid-acting intramuscular olanzapine for agitation associated with schizophrenia. Neuropsychiatr Dis Treat 2018; 14:1083-1091. [PMID: 29719399 PMCID: PMC5922248 DOI: 10.2147/ndt.s158339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To assess the effectiveness and safety of oral olanzapine treatment transitioned from rapid-acting intramuscular olanzapine (RAIM) in patients with acute agitation associated with schizophrenia in a real-world clinical setting. METHODS The postmarketing surveillance study with a 3-day observational period after the last RAIM administration was conducted (original study). Following this, an extended study was added for patients who received oral olanzapine after RAIM administration during the original study period, in order to additionally observe them for 7 days after initial RAIM administration. Effectiveness and safety from initial RAIM administration were evaluated using the Positive and Negative Syndrome Scale-Excited Component score and treatment-emergent adverse events (TEAEs), respectively. RESULTS The effectiveness and safety analysis set included a total of 521 and 522 patients, respectively. A majority of patients received 10 mg of RAIM (475/522 patients, 91.0%). The mean ± SD total Positive and Negative Syndrome Scale-Excited Component score was 23.6±6.2 (n=318) at baseline (before initial RAIM administration), 17.4±6.8 (n=280) at 2 hours after initial administration, 16.2±6.8 (n=246) 2 days after final administration, 14.9±6.2 (n=248) 3 days after final administration, 13.8±5.9 (n=242) 4 days after final administration, 13.2±5.8 (n=221) 7 days after initial administration, and 13.4±6.2 (n=351) at final observation (with the last observation carried forward approach), showing that reduction in agitation seen with RAIM was sustained with oral dose of olanzapine. The most common TEAEs were dyslalia and somnolence (each event occurred in four patients), and abnormal hepatic function and constipation (occurred in three patients). One serious adverse event of sudden cardiac death occurred after transitioned to oral olanzapine with many other antipsychotic drugs. CONCLUSION In the treatment of acute agitation associated with schizophrenia, RAIM could be generally transitioned to oral olanzapine without exacerbating adverse events or losing treatment effect.
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Affiliation(s)
- Hideaki Katagiri
- Bio-Medicines, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
| | - Masanori Taketsuna
- Statistical Sciences, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
| | - Shinpei Kondo
- Post Marketing Study Management, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
| | - Kenta Kajimoto
- Scientific Communications, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
| | - Etsuko Aoi
- Global Patient Safety Japan, Quality and Patient Safety, Eli Lilly Japan K.K., Kobe, Japan
| | - Yuka Tanji
- Bio-Medicines, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
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YU X, CORRELL CU, XIANG YT, XU Y, HUANG J, YANG F, WANG G, SI T, KANE JM, MASAND P. Efficacy of Atypical Antipsychotics in the Management of Acute Agitation and Aggression in Hospitalized Patients with Schizophrenia or Bipolar Disorder: Results from a Systematic Review. Shanghai Arch Psychiatry 2016; 28:241-252. [PMID: 28638198 PMCID: PMC5434280 DOI: 10.11919/j.issn.1002-0829.216072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Acute agitation and aggression are common symptoms in patients with bipolar disorder and schizophrenia. In this review, we discuss the prevalence, clinical assessment strategies, treatment options, and current Western and Chinese guidelines for the management of acute agitation and aggression in patients with bipolar disorder or schizophrenia. Among available approaches, we discuss in detail recent evidence supporting the use of intramuscular (IM) antipsychotics and some recently approved oral atypical antipsychotics for the management of acute aggression and agitation in hospitalized patients with bipolar disorder or schizophrenia presenting with acute agitation or aggression, highlighting some differences between individual antipsychotic agents.
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Affiliation(s)
- Xin YU
- Peking University Institute of Mental Health (the sixth hospital), Huayuanbeilu 51#, Haidian District, Beijing, 100191, China
- National Clinical Research Center for Mental Disorders & the Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Christoph U. CORRELL
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, 75-59 263rd St, Glen Oaks, NY 11004, USA
- Hofstra Northwell School of Medicine, 500 Hofstra University, Hempstead, NY 11549 USA
- The Feinstein Institute for Medical Research, 350 Community Dr, Manhasset, NY 11030, USA
| | - Yu-Tao XIANG
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, E12 Avenida da Universidade, Taipa, Macao SAR, China
| | - Yifeng XU
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 Wan Ping Nan Road, Shanghai 200030, China
| | - Jizhong HUANG
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 Wan Ping Nan Road, Shanghai 200030, China
| | - Fude YANG
- Beijing Huilongguan Hospital, Beijing, China
| | - Gang WANG
- Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Center of Depression, Beijing Institute for Brain Disorders & China Clinical Research Center for Mental Disorders, Beijing, China
| | - Tianmei SI
- Peking University Institute of Mental Health (the sixth hospital), Huayuanbeilu 51#, Haidian District, Beijing, 100191, China
- National Clinical Research Center for Mental Disorders & the Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - John M. KANE
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, 75-59 263rd St, Glen Oaks, NY 11004, USA
- Hofstra Northwell School of Medicine, 500 Hofstra University, Hempstead, NY 11549 USA
- The Feinstein Institute for Medical Research, 350 Community Dr, Manhasset, NY 11030, USA
| | - Prakash MASAND
- Duke-NUS Medical School, Academic Medicine Education Institute, Singapore
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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: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Kishi T, Matsunaga S, Iwata N. Intramuscular olanzapine for agitated patients: A systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res 2015; 68:198-209. [PMID: 26228420 DOI: 10.1016/j.jpsychires.2015.07.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/02/2015] [Accepted: 07/03/2015] [Indexed: 01/17/2023]
Abstract
We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs) of intramuscular (IM)-olanzapine (OLA-IM) versus controls in agitated patients. The risk ratio, number-needed-to-treat/harm, and standardized mean difference based on a random effects model were calculated. We identified 13 RCTs (19 comparisons) as follows: 7 comparisons with 1059 patients for OLA-IM versus placebo; 5 comparisons with 613 patients for OLA-IM versus haloperidol (HAL)-IM; 2 comparisons with 108 patients for OLA-IM versus ziprasidone (ZIP)-IM; 2 comparisons with 110 patients for OLA-IM versus HAL-IM plus midazolam; and 3 comparisons with 412 patients for OLA-IM versus HAL-IM plus promethazine, 2 comparisons with 355 patients for OLA-IM versus lorazepam-IM (LOR-IM); and 1 comparison with 67 patients for OLA-IM versus HAL-IM plus LOR-IM. OLA-IM was superior to placebo in both Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) and Agitation-Calmness Evaluation Scale (ACES) scores 2 h after first injection, and had a comparable side effect profile, including over sedation, extrapyramidal symptoms, akathisia, and anticholinergic use. While there was no significant difference in PANSS-EC scores after 2 h between OLA-IM and HAL-IM, OLA-IM outperformed HAL-IM in ACES after 2 h. Compared with HAL-IM, OLA-IM was associated with fewer side effects, including anticholinergic use, akathisia, extrapyramidal symptoms, and dystonia, and marginally less QT prolongation compared with HAL-IM. Based on our findings, OLA-IM is preferable to HAL-IM for the treatment of agitated patients. However, comparator data for ZIP-IM, LOR-IM and HAL-IM combination therapy were insufficient.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi 470-1192, Japan.
| | - Shinji Matsunaga
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi 470-1192, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi 470-1192, Japan
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Katagiri H, Fujikoshi S, Suzuki T, Fujita K, Sugiyama N, Takahashi M, Gomez JC. Erratum: A randomized, double-blind, placebo-controlled study of rapid-acting intramuscular olanzapine in Japanese patients for schizophrenia with acute agitation. BMC Psychiatry 2014; 14:313. [PMID: 25927447 PMCID: PMC4260377 DOI: 10.1186/s12888-014-0313-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 08/27/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Hideaki Katagiri
- Lilly Research Laboratories Japan, Eli Lilly Japan K.K, Kobe, Japan.
| | - Shinji Fujikoshi
- Lilly Research Laboratories Japan, Eli Lilly Japan K.K, Kobe, Japan.
| | - Takuya Suzuki
- Ayase Hospital, 6-3-1 Ayase, Adachi-ku, Tokyo, 120-0005, Japan.
| | - Kiyoshi Fujita
- Seishinkai Okehazama Hospital Fujita Kokoro Care Center, 3-879 Sakaecho Minamiyakata, Toyoake-shi, Aichi, 470-1168, Japan.
| | - Naoya Sugiyama
- Numazu Chuo Hospital, 24-1 Nakasecho, Numazu-shi, Shizuoka, 410-0811, Japan.
| | - Michihiro Takahashi
- Lilly Research Laboratories Japan, Eli Lilly Japan K.K, Kobe, Japan. .,Takahashi Psychiatric Clinic, Ashiya, Hyogo, Japan.
| | - Juan-Carlos Gomez
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
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Chan HY, Ree SC, Su LW, Chen JJ, Chou SY, Chen CK, Chen YS. A double-blind, randomized comparison study of efficacy and safety of intramuscular olanzapine and intramuscular haloperidol in patients with schizophrenia and acute agitated behavior. J Clin Psychopharmacol 2014; 34:355-8. [PMID: 24743717 DOI: 10.1097/JCP.0000000000000120] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Studies of intramuscular (IM) olanzapine in Asian and Taiwanese populations are limited. This study examined the efficacy and safety of IM olanzapine in Taiwanese patients with schizophrenia and acute agitated behavior.This was a multicenter, double-blind, randomized, parallel study comparing the efficacy and safety of 10 mg/d IM olanzapine (n = 25) against 7.5 mg/d haloperidol (n = 24). The primary objective was to assess the change of agitation from baseline to 2 hours after the first IM injection on the Positive and Negative Symptom Scale-Excited Component Scale.The changes of Positive and Negative Symptom Scale-Excited Component Scale score from baseline to 2 hours after the first IM injection did not show statistically significant difference between study groups (olanzapine -9.0 ± 5.7, haloperidol -7.9 ± 4.0, P = 0.254). Both groups reported insomnia as the most common treatment-emergent adverse event, and no serious adverse event was reported.Intramuscular olanzapine and IM haloperidol are similarly effective antipsychotic agents in treating agitated symptoms in Taiwanese patients with schizophrenia. Both IM olanzapine and IM haloperidol were proven to be safe and well tolerated, which also provided alternative options in the treatment of patients with schizophrenia with agitation.
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