Cardiovascular adverse effects of antipsychotic drugs

Direct effects of antipsychotics on potassium channels

Schizophrenia (SCZ) and bipolar disorder (BD) and are severe psychiatric conditions that contribute to disability and increased healthcare costs globally. Although first-, second-, and third-generation antipsychotics are available for treating BD and SCZ, most have various side effects unrelated to their unique functions. Many antipsychotics affect K+ channels (Kv, KCa, Kir, K2P, and other channels), which change the functions of various organs. This review summarizes the biological actions of antipsychotics, including off-target side effects involving K+ channels.

Postural tachycardia in psychiatric inpatient eating disorders treatment

Background: Postural tachycardia has been observed as a sign of malnutrition in eating disorders, including anorexia nervosa. However, there is limited information regarding other contributors to postural tachycardia in this population. Aim: This study aimed to determine the following among patients admitted to the Eating Disorders Unit (EDU) at a metropolitan tertiary hospital in Victoria, Australia: (a) the prevalence of postural tachycardia among eating disorder inpatients, and (b) the associated demographic and clinical features. Methods: Retrospective review of patient files was undertaken for inpatients aged 18-65 years with an eating disorder who resided within the Body Image & Eating Disorders Treatment & Recovery Service catchment area and were admitted to EDU between January 01, 2021 and October 30, 2023. Logistics regression was used for statistical analysis. Results: Among 177 admissions, 48 patients had postural tachycardia and this was at least partially attributed to malnutrition in 42 patients. Antipsychotics were significantly positively associated, and for every increase in one antipsychotic medication, there was an 89% increase in postural tachycardia diagnosis likelihood (B = 0.637) (Exp('B')) = 1.890). Higher admission body mass index/weight, emergency medical reviews, ≥ 10 prior psychiatric admissions, and 1-3 prior medical admissions showed significant positive associations. Conclusions: Postural tachycardia is a multifactorial issue which contributes to medical instability and is associated with antipsychotic medications and a history of multiple medical and psychiatric admissions.

Investigating the cardiotoxicity of N-n-butyl haloperidol iodide: Inhibition mechanisms on hERG channels

The human Ether-à-go-go-Related Gene (hERG) encodes a protein responsible for forming the alpha subunit of the IKr channel, which plays a crucial role in cardiac repolarization. The proper functioning of hERG channels is paramount in maintaining a normal cardiac rhythm. Inhibition of these channels can result in the prolongation of the QT interval and potentially life-threatening arrhythmias. Cardiotoxicity is a primary concern in the field of drug development. N-n-Butyl haloperidol iodide (F2), a derivative of haloperidol, has been investigated for its therapeutic potential. However, the impact of this compound on cardiac toxicity, specifically on hERG channels, remains uncertain. This study employs computational and experimental methodologies to examine the inhibitory mechanisms of F2 on hERG channels. Molecular docking and molecular dynamics simulations commonly used techniques in computational biology to predict protein-ligand complexes' binding interactions and stability. In the context of the F2-hERG complex, these methods can provide valuable insights into the potential binding modes and strength of interaction between F2 and the hERG protein. On the other hand, electrophysiological assays are experimental techniques used to characterize the extent and nature of hERG channel inhibition caused by various compounds. By measuring the electrical activity of the hERG channel in response to different stimuli, these assays can provide important information about the functional effects of ligand binding to the channel. The study's key findings indicate that F2 interacts with the hERG channel by forming hydrogen bonding, π-cation interactions, and hydrophobic forces. This interaction leads to the inhibition of hERG currents in a concentration-dependent manner, with an IC50 of 3.75 μM. The results presented in this study demonstrate the potential cardiotoxicity of F2 and underscore the significance of considering hERG channel interactions during its clinical development. This study aims to provide comprehensive insights into the interaction between F2 and hERG, which will may guid us in the safe use of F2 and in the development of new derivatives with high efficiency while low toxicity.

Association of antipsychotic formulations with sudden cardiac death in patients with schizophrenia: A nationwide population-based case-control study

The aim of this study was to clarify the association between various antipsychotic formulations-oral-daily antipsychotics (OAPs), long-acting injectable antipsychotics (LAIs), and their combination-and the risk of sudden cardiac death (SCD). We conducted a nationwide population-based case-control study using data from 2011 to 2020 from the National Health Insurance Research Database and multiple-cause-of-death data from Taiwan. The study included patients with a new diagnosis of schizophrenia who were followed for SCD occurrence until 2020. Cases and controls were frequency-matched at a 1:4 ratio by age, sex, and year of new schizophrenia diagnosis. Compared with the use of OAP monotherapy, the use of LAI and OAP combination (OR = 1.91) and LAI monotherapy (OR = 1.45) were associated with an increased risk of SCD. Additionally, cardiovascular comorbidities (adjusted OR = 11.15) were identified as a significant risk factor for SCD. This study revealed the following hierarchy of SCD risk associated with antipsychotic formulations (listed from lowest to highest risk): nonuse of antipsychotics, OAP monotherapy, LAI monotherapy, and their combination. These findings underscore the importance of assessing cardiovascular disease history before LAIs are prescribed to patients with schizophrenia and indicate that physicians should avoid prescribing combined antipsychotics when using LAIs.

Clozapine-related tachycardia: A conundrum to identify and treat

OBJECTIVE

This study examined the rates and persistence of clozapine-induced tachycardia and heart-rate differences in patients treated with β-blockers in the largest sample of patients with a psychotic disorder to date.

METHOD

An audit of medical files for 101 patients who attended a clozapine community clinic and analysis of monthly measurements of resting heart rates.

RESULTS

51% met the clinical criteria for tachycardia. Heart rates were stable over time. β-blockers were associated with small but significant reductions in heart rates.

CONCLUSION

The cardiovascular risks of clozapine are often overlooked. β-blockers are useful in lowering heart rates but they may be insufficient to reduce cardiac risk.

Haloperidol-induced sudden cardiac arrest in a recently detected HIV and hepatitis C patient: A unique case report

We herein described a case of a 45-year-old male recently detected with HIV and Hepatitis C who presented with signs of sepsis, developed delirium, and received haloperidol. Surprisingly, 10 min after intravenous administration, the patient developed Torsades de pointes and required immediate resuscitation. The report discusses the limited instances of cardiac arrest linked to haloperidol use, despite its generally perceived safety. The patient had no apparent risk factors, emphasizing the need for increased caution when administering haloperidol, particularly in critically ill patients with HIV and Hepatitis C.

Assessment of Drug-Induced QTc Prolongation in Mental Health Practice: Validation of an Evidence-Based Algorithm

Background

Drug-induced QTc interval prolongation (QTcIP) can lead to serious consequences and is often a concern for mental health practitioners, as access to experts such as cardiologists, for consultation is time-limiting and can delay treatment decisions. This research aimed at validating the content of an algorithm for the assessment, management and monitoring of drug-induced QTcIP in mental health practice.

Methods

Following an initial face validity by content experts, a cross-sectional survey of mental health care practitioners with a 4-point Likert-type scale was used to assess the validity of the decision steps on the QTcIP algorithm (QTcIPA) by estimating the content validity index (CVI) and the modified kappa statistic (κ*). Participants' open-ended comments were also thematically analyzed.

Results

Mental health practitioners found the QTcIPA to be appropriate, safe, and evidence-based, as indicated by the high individual item CVI scores ranging from 0.89 to 1 for all of the steps/decision statements in the three domains assessed: appropriateness, safety and reliability of the references used. Five themes emerged from the qualitative analysis of the open-ended comments, of which three were identified as strengths, including practical usability, reliable references and beneficial for pharmacists. Two themes were recognized as limitations, namely, the need for additional clinical content and application barriers.

Conclusion

These results suggest that the QTcIPA may be a useful tool for mental health clinicians at the time of prescribing medications with potential risk of QTcIP. Future research will explore the implementation of the QTcIPA into clinical practice using computerized decision support tools through web-based and mobile applications.

The adverse effects of long-term exposure to antipsychotics among older people with intellectual disabilities: a scoping review

Background Antipsychotics are among the medications most prescribed to older adults with intellectual disabilities despite limited evidence to support their safety and efficacy in this population. Antipsychotics are associated with a significant burden of long-term adverse effects including movement disorders, metabolic and cardiovascular adverse effects, sedation and anticholinergic effects. This scoping review aims to evaluate the current extent of the literature relating to adverse effects of long-term antipsychotic use in older adults with intellectual disabilities and identify any existing gaps.  Methods The review was conducted in line with the framework for scoping reviews proposed by Arksey and O’Malley. A systematic literature search was carried out, including searches of PubMed, Cochrane Library, ScienceDirect, Embase, PsycINFO and grey literature databases. Reference lists of studies were also reviewed as part of the search. Studies were included in the review if they related to adults over 40 years of age with an intellectual disability who had been taking antipsychotic medication for at least 3 months. Results A total of 13 studies were identified for inclusion in the review. These included retrospective reviews,observational studies, case reports, cohort studies and cross-sectional studies. Adverse effects reported include extrapyramidal symptoms, cardiovascular and metabolic effects, and case reports of rhinorrhoea, hypothermia and ischaemic colitis. Increasing age was associated with a greater burden of adverse effects in some studies. Conclusion The available evidence on the adverse effects of long-term antipsychotic use in older adults with intellectual disabilities is weak and conflicting. The studies included were generally of poor quality with numerous limitations including small sample sizes and lack of control groups. More research is needed to inform understanding of adverse effects associated with long-term antipsychotic use in this population.

Effects of Psychotropic Medication on Somatic Sterol Biosynthesis of Adult Mice

Polypharmacy is commonly used to treat psychiatric disorders. These combinations often include drugs with sterol biosynthesis inhibiting side effects, including the antipsychotic aripiprazole (ARI), and antidepressant trazodone (TRZ). As the effects of psychotropic medications are poorly understood across the various tissue types to date, we investigated the effects of ARI, TRZ, and ARI + TRZ polypharmacy on the post-lanosterol biosynthesis in three cell lines (Neuro2a, HepG2, and human dermal fibroblasts) and seven peripheral tissues of an adult mouse model. We found that both ARI and TRZ strongly interfere with the function of 7-dehydrocholesterol reductase enzyme (DHCR7) and lead to robust elevation in 7-dehydrocholesterol levels (7-DHC) and reduction in desmosterol (DES) across all cell lines and somatic tissues. ARI + TRZ co-administration resulted in summative or synergistic effects across the utilized in vitro and in vivo models. These findings suggest that at least some of the side effects of ARI and TRZ are not receptor mediated but arise from inhibiting DHCR7 enzyme activity. We propose that interference with sterol biosynthesis, particularly in the case of simultaneous utilization of medications with such side effects, can potentially interfere with functioning or development of multiple organ systems, warranting further investigation.

Influence of NOS1AP Risk Variants on the Corrected QT (QTc) Interval in the Pharmacotherapy of Schizophrenia

INTRODUCTION

The variants of the gene for nitric oxide synthase 1 adaptor protein (NOS1AP) are associated with schizophrenia and cardiovascular deficits involving corrected QT (QTc) interval prolongation. Here, we investigated a possible pharmacogenetic effect of antipsychotic treatment on QTc length in interaction with two NOS1AP variants (rs12143842 and rs10494366) whose minor alleles are associated with increased QTc interval length.

METHODS

We conducted a retrospective analysis of electrocardiographic (ECG) and genotype data of 239 patients diagnosed with schizophrenia. We converted antipsychotics dosage to chlorpromazine equivalents and defined daily doses. We analysed the effects of the minor (i. e. rs12143842-CT/TT and rs10494366-GT/GG) and major (i. e. rs12143842-CC and rs10494366-TT) allele genotypes to QTc interval for female and male participants separately.

RESULTS

As expected, rs12143842 and rs10494366 exhibit strong linkage disequilibrium. Both polymorphisms had no direct effect on antipsychotic use or QTc interval. However, there was a continuous increase in QTc interval with increasing antipsychotic dosage in males. For both variants, positive correlation of QTc length with antipsychotic dosage was found in homozygous male carriers of the major alleles (i. e. rs12143842-CC and rs10494366-TT), but not in minor allele carriers. There was no significant interaction between antipsychotic dosage and QTc interval for either genotype in female patients.

CONCLUSIONS

In this study, a significant interaction was found between both NOS1AP variants, rs12143842 and rs10494366, and antipsychotic treatment on the QTc interval in a sex-dependent manner. Our findings might be relevant for adequate antipsychotic treatment in rs12143842 and rs10494366 major allele carriers.

Hemodynamic and white blood cells parameters in patients with first-episode psychosis: a pilot longitudinal study

OBJECTIVE

Patients with schizophrenia are at higher risk of cardiovascular (CVS) related mortality. Close attention is being paid to the clinical utility of readily available CVS markers.

METHODS

A pilot one-year longitudinal study in inpatients with first-episode psychosis (FEP) was carried out to determine markers of inflammation and endothelial dysfunction (monocyte- and neutrophil-to-lymphocyte ratios) and basal blood pressure, pulse, and derived hemodynamic parameters (PP: pulse pressure; RPP: rate pressure product; and MAP: mean arterial pressure).

RESULTS

After one year, PP and RPP increased, as did systolic blood pressure and heart rate. Systolic blood pressure, PP, total white blood cells, and neutrophils correlated with weight gain. After one year, correlations between monocyte-to-lymphocyte ratio and RPP and MAP were observed.

CONCLUSION

Our study indicates worsening CVS health over the first year of treatment and emphasises the importance of early monitoring of CVS status using easily accessible parameters to prevent CVS-related mortality.Key pointsPatients with schizophrenia are at higher risk of cardiovascular mortality.The CVS risk could be evaluated using affordable, routinely available CVS markers such as monocyte- and neutrophil-to-lymphocyte ratios, blood pressure, and pulse together with the derived parameters.Our pilot study in first-episode psychosis patients indicates worsening of CVS health based on these parameters during the first year of treatment, the early monitoring of CVS status is highly relevant in clinical practice.

An analysis of views about supported reduction or discontinuation of antipsychotic treatment among people with schizophrenia and other psychotic disorders

BACKGROUND

Antipsychotic medication can reduce psychotic symptoms and risk of relapse in people with schizophrenia and related disorders, but it is not always effective and adverse effects can be significant. We know little of patients' views about continuing or discontinuing antipsychotic treatment.

AIMS

To explore the views of people with schizophrenia and other psychotic disorders about continuing their antipsychotic medication or attempting to reduce or discontinue this medication with clinical support.

METHODS

We collected quantitative and qualitative data by conducting semi-structured interviews in London, UK. Factors predicting a desire to discontinue medication were explored. Content analysis of qualitative data was undertaken.

RESULTS

We interviewed 269 participants. 33% (95% CI, 27 to 39%) were content with taking long-term antipsychotic medication. Others reported they took it reluctantly (19%), accepted it on a temporary basis (24%) or actively disliked it (18%). 31% (95% CI, 25 to 37%) said they would like to try to stop medication with professional support, and 45% (95% CI, 39 to 51%) wanted the opportunity to reduce medication. People who wanted to discontinue had more negative attitudes towards the medication but were otherwise similar to other participants. Wanting to stop or reduce medication was motivated mainly by adverse effects and health concerns. Professional support was identified as potentially helpful to achieve reduction.

CONCLUSIONS

This large study reveals that patients are commonly unhappy about the idea of taking antipsychotics on a continuing or life-long basis. Professional support for people who want to try to reduce or stop medication is valued.

Content Validation of an Algorithm for the Assessment, Management and Monitoring of Drug-Induced QTc Prolongation in the Psychiatric Population

BACKGROUND

QTc interval (QTcI) prolongation leads to serious complications, making it a concern for clinicians. Assessing the risk of QTcI prolongation in the psychiatric population is important because they are exposed to multiple medications known to increase the risk of life-threatening arrhythmias.

AIM

The study aims to validate the content of an algorithm for the assessment, management and monitoring of drug-induced QTc prolongation in the psychiatric population.

METHODOLOGY

Qualitative semi-structured interviews of cardiologists, to gather information regarding their approach in assessing the risk of drug-induced QTc prolongation at the time of prescribing. After the interview, an orientation to the algorithm was provided with a link to a cross-sectional, anonymous survey. The online survey included quantitative and qualitative components to gather feedback on the relevance and appropriateness of each step in the algorithm.

RESULTS

Interview responses were incorporated into 4 themes. Responses indicated a lack of a unified protocol when assessing QTcI prolongation, which supports the need of an algorithm that includes a verified risk scoring tool. Quantitative survey results showed a mean score ranging from 3.08 to 3.67 out of 4 for the appropriateness of the algorithm's steps, 3.08 to 3.58 for the safety and 3.17 to 3.75 for the reliability of references used. Additional analysis using the modified kappa and I-CVI statistical measures indicate high validity of contents and high degree of agreement between raters. As per the open-ended questions, cardiologists supported the implementation of the algorithm; however, they recommended simplification of the steps as they appear to be cumbersome.

CONCLUSION

The results demonstrate that the implementation of the algorithm after minor alterations can prove to be useful as a tool for the risk assessment of QTc prolongation. Further validation of the algorithm with mental health pharmacists and clinicians will be conducted as a separate phase of the study.

Antipsychotic Use Is Associated With Longer In-hospital Lengths of Stay and Higher Rates of Venous Thromboembolism and Costs of Care After Primary Total Knee Arthroplasty

INTRODUCTION

Studies have shown that antipsychotic medication use may lead to venous thromboembolisms (VTEs); however, this association has not been demonstrated in patients undergoing primary total knee arthroplasty (TKA). Therefore, the purpose of this study was to investigate whether patients taking antipsychotic medications at the time of their primary TKA have higher rates of in-hospital lengths of stay (LOS), VTEs, and costs of care.

METHODS

Patients taking antipsychotic medications were identified and matched to a cohort in a 1:5 ratio by age, sex, and medical comorbidities. Patients who had a history of VTEs or hypercoagulable states before their TKA were excluded. The query resulted in 439,579 patients within the study (n = 73,285) and matching cohorts (n = 366,294). Outcomes analyzed included rates of in-hospital LOS, VTEs, and costs of care. A P value less than 0.01 was considered statistically significant.

RESULTS

We found statistically significant longer in-hospital LOS for patients taking antipsychotic medications (3.27 versus 3.02 days, P < 0.0001). Study patients were also found to have a higher incidence and odds ratio of VTEs (2.37 versus 1.04%; odds ratio: 1.86, 95% confidence interval: 1.75-1.97, P < 0.0001). Ninety-day costs of care were also significantly higher in the study cohort ($17,332.70 versus $15,975.00, P < 0.0001).

CONCLUSION

After adjusting for confounders, patients taking antipsychotic medication were found to have higher rates of in-hospital LOS, VTEs, and costs of care. The study can be used by orthopaedic surgeons to counsel patients taking these medications concerning the potential complications after their procedure.

Effectiveness and harms of pharmacological interventions for the treatment of delirium in adults in intensive care units after cardiac surgery: a systematic review

OBJECTIVE

The objective of this review was to synthesize the best available evidence on the effectiveness and harms of pharmacological interventions for the treatment of delirium in adult patients in the intensive care unit (ICU) after cardiac surgery.

INTRODUCTION

Patients who undergo cardiac surgery are at high risk of delirium (incidence: 50-90%). Delirium has deleterious effects, increasing the risk of death and adversely affecting recovery. Clinical interventional trials have been conducted to prevent and treat postoperative delirium pharmacologically including antipsychotics and sedatives. These trials have provided some evidence about efficacy and influenced clinical decision making. However, much reporting is incomplete and provides biased assessments of efficacy; benefits are emphasized while harms are inadequately reported.

INCLUSION CRITERIA

Participants were ≥ 16 years, any sex or ethnicity, who were treated postoperatively in a cardiothoracic ICU following cardiac surgery and were identified as having delirium. Any pharmacological intervention for the treatment of delirium was included, regardless of drug classification, dosage, intensity or frequency of administration. Outcomes of interest of this review were: mortality, duration and severity of delirium, use of physical restraints, quality of life, family members' satisfaction with delirium management, duration/severity of the aggressive episode, associated falls, severity of accidental self-harm, pharmacological harms, harms related to over-sedation, ICU length of stay, hospital length of stay (post ICU), total hospital length of stay, need for additional intervention medication and need for rescue medication. Randomized controlled trials were considered first and in their absence, non-randomized controlled trials and quasi-experimental would have been considered, followed by analytical observational studies.

METHODS

A search was conducted in PubMed, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, Epistemonikos, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, Clinical Trials in New Zealand, and ProQuest Dissertations and Theses to locate both published and unpublished studies. There was no date limit for the search. A hand search for primary studies published between January 1, 2012 and November 17, 2018 in relevant journals was also conducted. Only studies published in English were considered for inclusion. Two reviewers independently assessed the methodological quality using standardized critical appraisal instruments from JBI and McMaster University. Quantitative data were extracted using the standardized JBI data extraction tool. A meta-analysis was not performed, as there was too much clinical and methodological heterogeneity in the included studies. Results have been presented in a narrative form. Standard GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) evidence assessment of outcomes has been reported.

RESULTS

Three RCTs investigating morphine versus haloperidol (n = 53), ondansetron versus haloperidol (n = 72), and dexmedetomidine versus midazolam (n = 80) were included. Due to heterogeneity and incomplete reporting, a meta-analysis was not feasible. Overall, the methodological quality of these studies was found to be low. Additionally, this review found reporting of harms to be inadequate and superficial for all three studies and did not meet the required standards for harms reporting, as defined by the CONSORT statement extension for harms.

CONCLUSIONS

It was not possible to draw any valid conclusions regarding the effectiveness of morphine vs haloperidol, ondansetron vs haloperidol or dexmedetomidine vs midazolam in treating delirium after cardiac surgery. This is due to the low number of studies, the poor methodological quality in conducting and reporting and the heterogeneity between the studies.

The affinity and selectivity of α-adrenoceptor antagonists, antidepressants, and antipsychotics for the human α1A, α1B, and α1D-adrenoceptors

α1-adrenoceptor antagonists are widely used for hypertension (eg, doxazosin) and benign prostatic hypertrophy (BPH, eg, tamsulosin). Some antidepressants and antipsychotics have been reported to have α1 affinity. This study examined 101 clinical drugs and laboratory compounds to build a comprehensive understanding of α1-adrenoceptor subtype affinity and selectivity. [3H]prazosin whole-cell binding was conducted in CHO cells stably expressing either the full-length human α1A, α1B, or α1D-adrenoceptor. As expected, doxazosin was a high-affinity nonselective α1-antagonist although other compounds (eg, cyclazosin, 3-MPPI, and ARC239) had higher affinities. Several highly α1A-selective antagonists were confirmed (SNAP5089 had over 1700-fold α1A selectivity). Despite all compounds demonstrating α1 affinity, only BMY7378 had α1D selectivity and no α1B-selective compounds were identified. Phenoxybenzamine (used in pheochromocytoma) and dibenamine had two-component-binding inhibition curves at all three receptors. Incubation with sodium thiosulfate abolished the high-affinity component suggesting this part is receptor mediated. Drugs used for hypertension and BPH had very similar α1A/α1B/α1D-adrenoceptor pharmacological profiles. Selective serotonin reuptake inhibitors (antidepressants) had poor α1-adrenoceptor affinity. Several tricyclic antidepressants (eg, amitriptyline) and antipsychotics (eg, chlorpromazine and risperidone) had high α1-adrenoceptor affinities, similar to, or higher than, α blockers prescribed for hypertension and BPH, whereas others had poor α1 affinity (eg, protriptyline, sulpiride, amisulpiride, and olanzapine). The addition of α blockers for the management of hypertension or BPH in people already taking tricyclic antidepressants and certain antipsychotics may not be beneficial. Awareness of the α-blocking potential of different antipsychotics may affect the choice of drug for those with delirium where additional hypotension (eg, in sepsis) may be detrimental.

Haloperidol Induced Sudden Cardiac Arrest-Report of a Very Rare Case and Review of Literature

Haloperidol is a typical antipsychotic drug. This drug is still widely used in emergency medicine, psychiatry, and general medicine departments. It is mostly used for acute confusional state, psychotic disorders, agitation, delirium, and aggressive behaviour. Overdose of haloperidol can cause sudden deaths. Cardiopulmonary arrest related to use of haloperidol had been reported in literature as case reports but are very few. No such cases have been reported in India till now. We report a case of cardiac arrest due to the use of haloperidol.

The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department

INTRODUCTION

Droperidol carries a boxed warning from the United States Food and Drug Administration for QT prolongation and torsades des pointes (TdP). After a six-year hiatus, droperidol again became widely available in the US in early 2019. With its return, clinicians must again make decisions regarding the boxed warning. Thus, the objective of this study was to report the incidence of QT prolongation or TdP in patients receiving droperidol in the ED.

METHODS

Patients receiving droperidol at an urban Level I trauma center from 1997-2001 were identified via electronic health record query. All patients were reviewed for cardiac arrest. We reviewed electrocardiogram (ECG) data for both critically-ill and noncritical patients and recorded Bazett's corrected QT intervals (QTc). ECGs from critically-ill patients undergoing resuscitation were further risk-stratified using the QT nomogram.

RESULTS

Of noncritical patients, 15,374 received 18,020 doses of droperidol; 2,431 had an ECG. In patients with ECGs before and after droperidol, the mean QTc was 424.3 milliseconds (ms) (95% confidence interval [CI], 419.7-428.9) before and 427.6 ms (95% CI, 424.3-430.9), after droperidol (n = 170). Regarding critically-ill patients, 1,172 received droperidol and 396 had an ECG. In the critically-ill group with ECGs before and after droperidol mean QTc was 435.7 ms (95% CI, 426.7-444.7) before and 435.8 ms (95% CI, 427.5-444.1) after droperidol (n = 114). Of 337 ECGs suitable for plotting on the QT nomogram, 13 (3.8%) were above the "at-risk" line; 3/136 (2.2%; 95% CI, 0.05-6.3%) in the before group, and 10/202 (4.9%; 95% CI, 2.4%-8.9%) in the after group. A single case of TdP occurred in a patient with multiple risk factors that did not reoccur after a droperidol rechallenge. Thus, the incidence of TdP was 1/16,546 (0.006%; 95% CI, 0.00015 - 0.03367%).

CONCLUSION

We found the incidence of QTc prolongation and TdP in ED patients receiving droperidol to be extremely rare. Our data suggest the FDA "black box warning" is overstated, and that close ECG monitoring is useful only in high-risk patients.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Reduced heart rate variability in adults with autism spectrum disorder

A growing body of research has suggested heart rate variability (HRV) may be reduced in autism spectrum disorder (ASD) in comparison to neurotypical cohorts. While there have been several studies investigating HRV in children diagnosed with ASD, few studies have been conducted in adults. The objective of the current study was to investigate autonomic nervous system activity as assessed by HRV in adults diagnosed with ASD. We hypothesized that adults with ASD would show a reduction in HRV compared to neurotypical participants. Participants diagnosed with ASD (n = 55) were recruited from the Autism Clinic for Translational Research at the Brain and Mind Centre (University of Sydney) between 2013 and 2017. Neurotypical participants were recruited from advertisements and online media. Resting state heart rate was measured for 5 min while participants sat in an upright position. Results showed there was an overall significant difference in resting-state HRV between adults diagnosed with ASD compared to the neurotypical control group. Logarithmically transformed high frequency (HF) and root mean square of successive differences were particularly decreased in the ASD group, suggesting lower parasympathetic activity. The use of psychotropic medications and comorbidities were associated with reductions in low frequency of HRV. Our data suggest an overall dysregulation in resting autonomic activity in adults with ASD. This may represent an important physiological mechanism leading to potential cardiovascular risk in ASD, which warrants further investigation. Autism Res 2019, 12: 922-930. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: ASD is commonly associated with a range of physical and mental health comorbidities. Autonomic disruptions underlying reductions in heart rate variability (HRV) have been linked to a range of mental and physical health conditions. We assessed resting-state HRV in adults diagnosed with ASD in comparison to healthy individuals. Our results showed reduced heart rate variability in people diagnosed with ASD compared to adults without ASD. These findings implicate a role for autonomic activity as a potentially modifiable risk factor for ASD.

[Antipsychotics: features of undesirable adverse reactions in elderly and senile age]

This review summarizes and systematizes currently available literature on antipsychotics as one of the most frequently prescribed group of psychotropic drugs. Based on published data from clinical studies and meta-analyzes, the authors consider unwanted adverse reactions in patients taking antipsychotic medications. Mechanisms of development of undesirable drug reactions are discussed. Special attention is paid to those adverse reactions of antipsychotics that most often occur in old and very old age (increased risk of adverse cardiovascular and cerebrovascular events, sudden death, prolonged QTc interval, falls, fractures, orthostatic hypotension, extrapyramidal disorders, pneumonia, urinary tract infections, etc.).

A literature-based algorithm for the assessment, management, and monitoring of drug-induced QTc prolongation in the psychiatric population

BACKGROUND

Certain psychotropics and a number of other medications used to treat medical conditions in psychiatric patients can increase the risk of prolonging the corrected QT (QTc) interval on the electrocardiogram, which puts patients at risk of life-threatening ventricular arrhythmias such as torsades de pointes. Pharmacists are often consulted about medications which are known to prolong the QTc interval. Although this information is often accessible, advising how to identify, assess, manage, and refer psychiatric patients at risk for drug-induced QTc prolongation is more challenging.

OBJECTIVES

The objective of this project was first to review the literature, which describes guidelines and recommendations for the assessment and management of drug-induced QTc prolongation, and then to design an algorithm to be used by pharmacists working closely with mental health professionals or who provide care to psychiatric patients.

METHODS

A review of the literature was undertaken. Predefined keywords were used to perform the database search in MEDLINE, EMBASE, and International Pharmaceutical Abstracts to identify reviews, reports and guidelines on the assessment, prevention and monitoring of drug-induced QTc prolongation with an emphasis on psychotropic medications and management in the psychiatric population.

RESULTS

The electronic database search retrieved 637 relevant citations. These were initially screened by title and all duplicates were removed. The abstracts were then reviewed for relevancy based on the inclusion/exclusion criteria. Additional citations were retrieved from the bibliography of the articles identified in the initial search. A total of 79 articles describing QTc prolongation in the psychiatric population were thoroughly examined, but only 31 articles were selected to guide the development of the algorithm.

CONCLUSION

The literature-based algorithm developed provides a stepped-based approach for the assessment, monitoring, and management of drug-induced QTc prolongation in the psychiatric population. The algorithm may assist mental health clinicians in the decision-making process when psychiatric patients are prescribed medications known to increase the QTc interval.

Potentially fatal outcomes associated with clozapine

Clozapine has been shown to be the most efficacious therapy for treatment resistant schizophrenia, estimated at one third of all schizophrenia cases. There is significant morbidity and mortality associated with clozapine including risk of agranulocytosis, aspiration pneumonia, bowel ischemia, myocarditis, seizures, and weight gain. Here we present a case of a 62-year-old man with chronic paranoid schizophrenia refractory to numerous antipsychotics who was started on clozapine therapy during an acute inpatient psychiatric admission. Within three weeks of starting clozapine, the patient developed flu-like symptoms, pleuritic chest pain, and was sent to a medical hospital for evaluation. After transfer, the patient had a rapidly deteriorating course with newly developed congestive heart failure, acute respiratory failure requiring intubation, and cardiovascular collapse requiring vasopressors. The patient expired within two days of transfer and four days after initial symptoms developed. The underlying etiology in this case is likely clozapine induced myocarditis leading to rapid cardiovascular collapse and death. Mortality with clozapine induced myocarditis has been estimated up to 24%. Given that 90% of clozapine cardiotoxic sequelae are seen in the first month post-initiation, more rigorous post-initiation surveillance is recommended for the first four weeks of clozapine with weekly cardiac enzymes (troponins, creatinine kinase-MB), EKG, and acute inflammatory markers (C-reactive protein, and erythrocyte sedimentation rate).

Clozapine-induced cardiomyopathy and myocarditis monitoring: A systematic review

The use of clozapine requires monitoring the absolute neutrophil count because of the risk of agranulocytosis, but other potentially fatal adverse events associated with clozapine (specifically, myocarditis and cardiomyopathy) do not have mandatory procedures. We performed a systematic review of English-language articles to synthesize an evidence-based approach for myocarditis and cardiomyopathy monitoring. Articles published from January 1988 through February 2017 were identified through a search of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Google Scholar. Selected articles were required to relate to myocarditis or cardiomyopathy in humans from exposure to clozapine. A total of 144 articles were included. Recommendations varied widely. Some authors recommended baseline laboratory monitoring, with or without follow-up testing, for C-reactive protein, creatine kinase MB, and troponin. Electrocardiography was commonly recommended, and echocardiography was less commonly recommended. The expense of monitoring was a consideration. A unanimous recommendation was to stop the use of clozapine and seek a cardiovascular consultation if myocarditis or cardiomyopathy is suspected. Although there is general agreement on which tests to perform for confirming myocarditis and cardiomyopathy, preemptive screening for these clozapine-induced conditions is controversial, and cost and barriers for the use of clozapine are concerns. For asymptomatic patients receiving clozapine, testing could include baseline electrocardiography, echocardiography as part of a cardiac consultation if patients have cardiac disease or risk factors, and monitoring of C-reactive protein and troponin as indicated.

A phase 1 trial evaluating thioridazine in combination with cytarabine in patients with acute myeloid leukemia

We completed a phase 1 dose-escalation trial to evaluate the safety of a dopamine receptor D2 (DRD2) antagonist thioridazine (TDZ), in combination with cytarabine. Thirteen patients 55 years and older with relapsed or refractory acute myeloid leukemia (AML) were enrolled. Oral TDZ was administered at 3 dose levels: 25 mg (n = 6), 50 mg (n = 4), or 100 mg (n = 3) every 6 hours for 21 days. Intermediate-dose cytarabine was administered on days 6 to 10. Dose-limiting toxicities (DLTs) included grade 3 QTc interval prolongation in 1 patient at 25 mg TDZ and neurological events in 2 patients at 100 mg TDZ (gait disturbance, depressed consciousness, and dizziness). At the 50-mg TDZ dose, the sum of circulating DRD2 antagonist levels approached a concentration of 10 μM, a level noted to be selectively active against human AML in vitro. Eleven of 13 patients completed a 5-day lead-in with TDZ, of which 6 received TDZ with hydroxyurea and 5 received TDZ alone. During this period, 8 patients demonstrated a 19% to 55% reduction in blast levels, whereas 3 patients displayed progressive disease. The extent of blast reduction during this 5-day interval was associated with the expression of the putative TDZ target receptor DRD2 on leukemic cells. These preliminary results suggest that DRD2 represents a potential therapeutic target for AML disease. Future studies are required to corroborate these observations, including the use of modified DRD2 antagonists with improved tolerability in AML patients. This trial was registered at www.clinicaltrials.gov as #NCT02096289.

Sudden death in schizophrenia

PURPOSE OF REVIEW

To examine the recent literature regarding sudden death in patients with schizophrenia and synthesize salient conclusions based on this evidence.

RECENT FINDINGS

Sudden cardiac death (SCD) is the largest subset of sudden unexpected death (SUD), with up to 40% of SUD from cardiovascular causes. SCD has been associated with exposure to both first and second-generation antipsychotics. Clozapine [odds ratio (OR) 3.67, 95% confidence interval (CI) 1.94-6.94] confers the highest risk of SCD followed by risperidone (OR 3.04, 95% CI 2.39-3.86) then olanzapine (OR 2.04, 95% CI 1.52-2.74). SCD not associated with antipsychotic use has been correlated to several modifiable and nonmodifiable risk factors - obesity, smoking, dyslipidemia, diabetes, hypertension, age, sex, and history of cardiovascular disease. Other subsets of SUD include hematological and pulmonary causes, including agranulocytosis leading to sepsis, deep vein thrombosis leading to pulmonary embolisms, and aspiration pneumonia leading to sepsis.

SUMMARY

There is a huge paucity in genetic and pharmacogenetic data focused on SUD in schizophrenia. Future studies should emphasize the genetic aspects as well as clarify the underlying molecular mechanisms of these pathways. Additionally, early detection of those patients at high risk for SUD and discovery of preventive measures should also be emphasized.

Clozapine-Induced Cardiovascular Side Effects and Autonomic Dysfunction: A Systematic Review

Background: Clozapine is the antipsychotic of choice for treatment-resistant schizophrenia and has minimal risk for extrapyramidal symptoms. Therapeutic benefits, however, are accompanied by a myriad of cardiometabolic side-effects. The specific reasons for clozapine's high propensity to cause adverse cardiometabolic events remain unknown, but it is believed that autonomic dysfunction may play a role in many of these.

Objective: This systematic review summarizes the literature on autonomic dysfunction and related cardiovascular side effects associated with clozapine treatment.

Method: A search of the EMBASE, MEDLINE, and EBM Cochrane databases was conducted using the search terms antipsychotic agents, antipsychotic drug^*, antipsychotic^*, schizophrenia, schizophren^*, psychos^*, psychotic^*, mental ill^*, mental disorder^*, neuroleptic^*, cardiovascular^*, cardiovascular diseases, clozapine^*, clozaril^*, autonomic^*, sympathetic^*, catecholamine^*, norepinephrine, noradrenaline, epinephrine, adrenaline.

Results: The search yielded 37 studies that were reviewed, of which only 16 studies have used interventions to manage cardiovascular side effects. Side effects reported in the studies include myocarditis, orthostatic hypotension and tachycardia. These were attributed to sympathetic hyperactivity, decreased vagal contribution, blockade of cholinergic and adrenergic receptors, reduced heart rate variability and elevated catecholamines with clozapine use. Autonomic neuropathy was identified by monitoring blood pressure and heart rate changes in response to stimuli and by spectral analysis of heart rate variability. Metoprolol, lorazepam, atenolol, propranolol, amlodipine, vasopressin and norepinephrine infusion were used to treat tachycardia and fluctuations in blood pressure, yet results were limited to case reports.

Conclusion: The results indicate there is a lack of clinical studies investigating autonomic dysfunction and a limited use of interventions to manage cardiovascular side effects associated with clozapine. As there is often no alternative treatment for refractory schizophrenia, the current review highlights the need for better designed studies, use of autonomic tests for prevention of cardiovascular disease and development of novel interventions for clozapine-induced side effects.

Management of serious cardiac adverse effects of antipsychotic medications

The use of antipsychotic medications has now expanded to multiple mental health conditions beyond schizophrenia. This has increased the overall population exposure to these medications, which have been associated with both metabolic changes and adverse cardiovascular effects. QTc prolongation, torsades de pointes, sudden cardiac death, myocarditis, and cardiomyopathy are all very real concerns that clinicians face on a regular basis. One must take these risks into consideration when selecting antipsychotic therapy and also when determining whether therapeutic changes and adjustments are necessary. This review examines a number of cardiac-associated concerns, the role that antipsychotics may play in contributing to these adverse events, and suggested management interventions.

Tachycardia in patients treated with clozapine versus antipsychotic long-acting injections

Tachycardia is a known adverse effect during clozapine treatment. However, prevalence reported differs widely between studies and hitherto there are no studies comparing clozapine-treated patients with a similar control group. The present study was carried out to assess the prevalence of tachycardia in patients treated with clozapine and antipsychotic long-acting injections (LAI). Data on heart rate (HR), concomitant medication, and relevant anthropometric and laboratory measurements were collected for all clozapine-treated patients (n=174) in a defined catchment area and compared with data on patients treated with LAI (n=87). In total, 33% of patients on long-term clozapine treatment had tachycardia (HR>100) compared with 16% in the LAI group (P<0.001). The mean HR was 91 in the clozapine group and 82 in the LAI group (P<0.001). Clozapine dose correlated with HR. The majority of patients with HR more than 100 received no specific treatment for tachycardia. In conclusion, the prevalence of tachycardia was twice as high in patients treated with clozapine as in a similar patient group with severe schizophrenia spectrum disorder. The tachycardia was in many cases clinically unnoticed. Tachycardia during antipsychotic treatment is a common phenomenon that must be monitored for actively and, when noticed, further investigated and treated.

Medical Complications of Psychiatric Treatment: An Update

Psychiatric medications are used commonly in hospitalized patients and are particularly indicated in patients who are critically ill to manage many conditions. Due to their many indications in the intensive care unit (ICU), psychiatric medications should be closely monitored in these medically compromised patients for adverse reactions and medical complications because they may affect essentially all organ systems. These range from life-threatening reactions to other less significant effects, such as sedation, to other detrimental complications, such as pancreatitis. Knowledge of psychopharmacology as well as the diagnosis and treatment of these complications is imperative in treating patients in the ICU.

Assessment of left ventricle systolic and diastolic functions in schizophrenia patients

The objective of the study was to scrutinize in detail the changes that occur in left ventricle (LV) systolic and diastolic functions using echocardiography in patients with at least 5 years of history and 40 healthy volunteers matching the patients in age and gender, who were enrolled in a cross-sectional study. All cases were examined with Tei Index, an index that could assess LV systolic and diastolic functions in conjuction, and with LV ejection fraction (LVEF) that assesses systolic function. In addition, Mitral E and A wave velocities, Isovolemic relaxation time (IVRT), Tissue Doppler Em (peak early motion) and Am (peak after motion) waves, which evaluate diastolic functions were measured. Tei Index was calculated as 0.61±0.19 in the patient group, and as 0.39±0.10 in the control group and the difference was statistically significant (p<0.001). LVEF was measured as 58%±5 in the patient group, and as 62%±3 in the control group and the difference was statistically significant (p<0.001). Also the IVRT values were significantly different between the tissue Doppler Em and Em/Am ratio among the groups (p<0.001). Echocardiographic myocardial performance, LV systolic and diastolic functions in schizophrenia patients was found to be worse than those of the control group.

Drug Metabolism Considerations in Patients With Chronic Kidney Disease

Chronic kidney disease (CKD) is a progressive process leading to end stage renal disease and either dialysis or transplantation. Patients with CKD often have numerous comorbid conditions such as diabetes, hypertension, and acid-base and electrolyte disorders that can lead to alterations in homeostasis. Changes in drug disposition including hepatic metabolism via phase 1 (ie, cytochrome P-450 enzymes) and phase 2 (ie, conjugation) pathways have been reported. Biotransformation of drugs and endogenous substances within the kidney itself may also be compromised in the presence of CKD. Reduced hepatic and renal clearance leads to systemic accumulation of the parent drug as well as active and toxic metabolites. Characterization of specific hepatic cytochrome (CYP) enzyme pathways in patients with CKD is an area of current research and will lead to an understanding of phenotypic and genotypic expression patterns of several key drug-metabolizing enzymes. The evolving knowledge of CYP enzymes and the alterations that can occur in CKD should allow clinicians to predict adverse consequences of drug therapy and thus prevent these events from occurring. The pharmacy practitioner can also provide important pharmacotherapy interventions in this special patient population, including dose individualization, therapeutic drug monitoring, and evaluation of therapeutic outcomes.

Absence of Change in Corrected QT Interval in Children and Adolescents Receiving Antipsychotic Treatment: A 12 Month Study

BACKGROUND

Prescriptions of antipsychotic drugs (AP) in children and adolescents have significantly increased in Europe as well as in the United States. However, there is limited evidence of the cardiac safety of second-generation antipsychotics (SGA) in the pediatric population.

OBJECTIVE

The aim of the study is to evaluate the cardiac side effects of SGA in children and adolescents, and how they are influenced by clinical, demographic, and treatment factors.

METHODS

This article presents a naturalistic, longitudinal, multicenter study conducted in 216 treatment-naïve or quasi-naïve children and adolescents receiving AP treatment. It analyzed the possible influence of AP treatment on variables such as corrected QT (QTc) intervals and heart rate for a period of 12 months (baseline, 3 months, 6 months, and 12 months). Differences among the three main prescribed drugs used in the sample (risperidone, quetiapine, and olanzapine) were assessed.

RESULTS

A total of 211 received one of the three most prescribed AP (quetiapine, risperidone or olanzapine). There were no significant QTc variations in the sample during follow-up (p = 0.54). There were no differences in QTc rates between the different SGA (risperidone-olanzapine p = 0.43; risperidone-quetiapine p = 0.42; olanzapine-quetiapine p = 0.23). When demographic, clinical, or concomitant treatment variables were considered, only baseline overweight correlated with QTc prolongation (p = 0.003). The heart rate in the whole sample tended to decrease during follow-up (p = 0.054). However, patients on quetiapine showed increased heart rate compared with those on risperidone (p = 0.04).

CONCLUSIONS

In this sample, SGA seem to have a safe heart side effect profile in the child and adolescent population. There was no observed mean increase in QTc or in heart rate.

Use of an electronic metabolic monitoring form in a mental health service - a retrospective file audit

BACKGROUND

People with severe mental illness have poorer physical health, experience disparities in physical health care, and lead significantly shorter lives, compared to the general population. Routine metabolic monitoring is proposed as a method of identifying risk factors for metabolic abnormalities. Efforts to date suggest routine metabolic monitoring is both incomplete and ad-hoc, however. This present study reports on the recent implementation of a routine metabolic monitoring form at a mental health service in regional Australia.

METHODS

A retrospective file audit was undertaken on 721 consumers with electronic health records at the mental health service. Descriptive statistics were used to report the frequency of use of the metabolic monitoring form and the range of metabolic parameters that had been recorded.

RESULTS

Consumers had an average age of 41.4 years (SD = 14.6), over half were male (58.4%), and the most common psychiatric diagnosis was schizophrenia (42.3%). The metabolic monitoring forms of 36% of consumers contained data. Measurements were most commonly recorded for weight (87.4% of forms), height (85.4%), blood pressure (83.5%), and body mass index (73.6%). Data were less frequently recorded for lipids (cholesterol, 56.3%; low density lipoprotein, 48.7%; high density lipoprotein, 51.7%; triglycerides, 55.2%), liver function (alanine aminotransferase, 66.3%; aspartate aminotransferase, 65.5%; gamma-glutamyl transpeptidase, 64.8%), renal function (urea, 66.3%; creatinine, 65.9%), fasting blood glucose (60.2%), and waist circumference (54.4%).

CONCLUSIONS

The metabolic monitoring forms in consumer electronic health records are not utilised in a manner that maximises their potential. The extent of the missing data suggests that the metabolic health of most consumers may not have been adequately monitored. Addressing the possible reasons for the low completion rate has the potential to improve the provision of physical health care for people with mental illness.

Screening for Metabolic Syndrome in Mental Health Consumers Using an Electronic Metabolic Monitoring Form

Metabolic syndrome is more prevalent in people with serious mental illness, compared to the general population. The main purpose of this study was to determine the extent electronic metabolic monitoring forms were being completed in a regional mental health service and the extent to which diagnoses of metabolic syndrome could be made using the data available. A retrospective file audit of 721 electronic mental health consumer records was undertaken. Metabolic monitoring data were recorded for 261 (36%) consumers, of which 57 (21.8%) met the clinical criteria for metabolic syndrome, 61 (23.4%) did not meet clinical criteria, and diagnoses could not be made for 143 (54.8%) consumers due to missing data. The limited use of electronic health records may inhibit the detection of risk factors for the diagnosis of metabolic syndrome.

Dopamine Targeting Drugs for the Treatment of Schizophrenia: Past, Present and Future

Schizophrenia is a chronic and debilitating neuropsychiatric disorder affecting approximately 1% of the world's population. This disease is associated with considerable morbidity placing a major financial burden on society. Antipsychotics have been the mainstay of the pharmacological treatment of schizophrenia for decades. The traditional typical and atypical antipsychotics demonstrate clinical efficacy in treating positive symptoms, such as hallucinations and delusions, while are largely ineffective and may worsen negative symptoms, such as blunted affect and social withdrawal, as well as cognitive function. The inability to treat these latter symptoms may contribute to social function impairment associated with schizophrenia. The dysfunction of multiple neurotransmitter systems in schizophrenia suggests that drugs selectively targeting one neurotransmission pathway are unlikely to meet all the therapeutic needs of this heterogeneous disorder. Often, however, the unintentional engagement of multiple pharmacological targets or even the excessive engagement of intended pharmacological targets can lead to undesired consequences and poor tolerability. In this article, we will review marketed typical and atypical antipsychotics and new therapeutic agents targeting dopamine receptors and other neurotransmitters for the treatment of schizophrenia. Representative typical and atypical antipsychotic drugs and new investigational drug candidates will be systematically reviewed and compared by reviewing structure-activity relationships, pharmacokinetic properties, drug metabolism and safety, pharmacological properties, preclinical data in animal models, clinical outcomes and associated side effects.

Complications and mortality in patients with schizophrenia and diabetes: population-based cohort study

BACKGROUND

The long-term outcome of patients with both diabetes and schizophrenia remains unclear.

AIMS

To explore whether having schizophrenia increases the risk of advanced complications and mortality in people with diabetes.

METHOD

This is a population-based matched cohort study using Taiwan's National Health Insurance Research Database. A total of 11 247 participants with diabetes and schizophrenia and 11 247 participants with diabetes but not schizophrenia were enrolled. We used Cox proportional hazard models to determine the effect of schizophrenia on macrovascular and microvascular complications, and all-cause mortality.

RESULTS

The adjusted hazard ratios were 1.49 (95% CI 1.32-1.68) for macrovascular complications, 1.05 (95% CI 0.91-1.21) for microvascular complications and 3.68 (95% CI 3.21-4.22) for all-cause mortality in patients with diabetes and schizophrenia compared with those patients with diabetes but not schizophrenia.

CONCLUSIONS

Patients with both diabetes and schizophrenia had an increased risk of macrovascular complications and all-cause mortality but did not have statistically significant elevated risk of microvascular complications.

Scoping review of research in Australia on the co-occurrence of physical and serious mental illness and integrated care

The physical health of people with serious mental illness (SMI) has become a focal area of research. The aim of the present study was to ascertain the attention and distribution of research from within Australia on physical illness and SMI co-occurrence, and to identify gaps. A scoping review of peer-reviewed research literature from Australia, published between January 2000 and March 2014, was undertaken through an electronic literature search and coding of papers to chart trends. Four trends are highlighted: (i) an almost threefold increase in publications per year from 2000-2006 to 2007-2013; (ii) a steady release of literature reviews, especially from 2010; (iii) health-related behaviours, smoking, integrated-care programmes, and antipsychotic side-effects as the most common topics presented; and (iv) paucity of randomized, controlled trials on integrated-care models. Despite a marked increase in research attention to poorer physical health, there remains a large gap between research and the scale of the problem previously identified. More papers were descriptive or reviews, rather than evaluations of interventions. To foster more research, 12 research gaps are outlined. Addressing these gaps will facilitate the reduction of inequalities in physical health for people with SMI. Mental health nurses are well placed to lead multidisciplinary, consumer-informed research in this area.

Clozapine-induced myocarditis may warrant cardiac monitoring protocol

Background

Myocarditis, or inflammation of the heart muscle, is a black box warning associated with the use of clozapine. Although the incidence of clozapine-induced myocarditis is only 0.015% to 1.2%, recent retrospective studies have found that up to 66% of clozapine patients develop nonspecific symptoms consistent with myocarditis. Because of the difficulty in distinguishing these symptoms (including fever, tachycardia, and fatigue) from clozapine dose titration, myocarditis may be difficult to recognize. If left undetected, the condition could be fatal.

Patient Case

A 25-year-old Filipino male with a history of schizoaffective disorder, bipolar type, continued to endorse persistent and distressing command auditory and visual hallucinations despite therapy with olanzapine, 40 mg daily. Clozapine was initiated for refractory psychosis and titrated up to 125 mg over 17 days. On day 14, the patient reported “feeling sick,” having chills, a nonproductive cough, and fatigue; he was febrile and tachycardic. Abnormal laboratory values included elevated troponin-1, C-reactive protein (CRP), and creatinine phosphokinase (CPK). The last dose of clozapine was administered on day 17 with resolution of the above-mentioned signs and symptoms within 3 days.

Discussion

A literature search revealed several cases demonstrating a strong association between clozapine and myocarditis. Despite suggestions from case reports for cardiac monitoring at baseline, there are no universal monitoring guidelines.

Conclusion

As a result of this patient case of clozapine-induced myocarditis, the Veterans Affairs Palo Alto Health Care System Clozapine Tracking Team developed a cardiac monitoring protocol for veterans being initiated on clozapine.

Ivabradine, a novel treatment for clozapine-induced sinus tachycardia: a case series

OBJECTIVES

Clozapine is the most efficacious treatment for treatment-resistant schizophrenia; however its use can be limited by intolerability. Sinus tachycardia is a common adverse event associated with clozapine use, which may lead to the premature discontinuation of clozapine. Traditionally, β blockers are used to treat clozapine-associated tachycardia, though problems with intolerability and ineffectiveness can limit their utility.

METHODS

In this article, we present two cases of patients with treatment-resistant schizophrenia who developed symptomatic tachycardia associated with clozapine therapy.

RESULTS

We demonstrate that the novel heart rate controlling agent ivabradine can be effectively and safely used to control the heart rate and to allow for continued treatment with clozapine.

CONCLUSION

This is the first report in the literature demonstrating that ivabradine appears to be a well tolerated agent, which should be considered as a symptomatic treatment of clozapine-induced tachycardia if the use of a β blocker fails due to a lack of response or intolerability.

Minimizing cardiovascular adverse effects of atypical antipsychotic drugs in patients with schizophrenia

The use of atypical antipsychotic agents has rapidly increased in the United States and worldwide in the last decade. Nonetheless, many health care practitioners do not appreciate the significance of the cardiovascular side effects that may be associated with their use and the means to minimize them. Thus, atypical antipsychotic medications can cause cardiovascular side effects such as arrhythmias and deviations in blood pressure. In rare cases, they may also cause congestive heart failure, myocarditis, and sudden death. Patients with schizophrenia have a higher risk of cardiovascular mortality than healthy individuals, possibly because of excessive smoking, the underlying disorder itself, or a combination of both factors. Increased awareness of these potential complications can allow pharmacists and physicians to better manage and monitor high risk patients. Accurate assessments are very important to avoid medications from being given to patients inappropriately. Additionally, monitoring patients regularly via blood draws and checking blood pressure, heart rate, and electrocardiogram can help catch any clinical problems and prevent further complications. Finally, patient and family-member education, which pharmacists in particular can play key roles in, is central for the management and prevention of side effects, which is known to reflect positively on morbidity and mortality in these patients.