Associations between venous thromboembolism and antipsychotics. A study of the WHO database of adverse drug reactions

The Overlooked Risk of Venous Thromboembolism in Psychiatric Patients: Epidemiology, Pathophysiology, and Implications for Clinical Care

Psychiatric patients face a significantly shorter life expectancy than the general population due to a complex interplay of medical, behavioral, and social factors. Venous thromboembolism (VTE), encompassing both pulmonary embolism and deep vein thrombosis, is an underrecognized yet critical contributor to morbidity and mortality in this population. Evidence suggests a two to three times higher prevalence of VTE in psychiatric patients compared to the general population, with incidence rates up to 4.5 per 1,000 person-years. This elevated risk is attributed to a hypercoagulable-hypofibrinolytic state. It is influenced by metabolic abnormalities, pro-inflammatory pathways, antipsychotic medications, and genetic factors. Health care biases and reduced treatment compliance further exacerbate the burden. This review explores the epidemiology, pathophysiology, and mechanistic underpinnings of VTE in psychiatric populations, emphasizing the role of metabolic syndrome and antipsychotic therapy. To mitigate mortality and enhance outcomes for these high-risk individuals, it is imperative to address this issue through improved risk stratification and preventive strategies.

Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses

INTRODUCTION

Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge.

AREAS COVERED

This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024.

EXPERT OPINION

Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.

Possible involvement of apoptosis in the antipsychotics side effects: A minireview

Antipsychotics are used in the treatment of schizophrenia and other psychiatric disorders. Generally they are divided into typical and atypical ones, according to the fact that atypical antipychotics induce less side effects and are more effective in terms of social and cognitive improvements. Their pharmacological effects are mediated via broad range of receptors that consequently influence different cellular signaling pathways. Antipsychotics produce udesirable side effects that range from relatively minor to life-threatening ones. In vitro and in vivo studies have pointed to neurotoxic effect exerted by some antipsychotics and have shown that apoptosis might play role in some side effects induced by antipsyschotics, including tardive dyskinesia, weight gain, agranulocytosis, osteoporosis, myocarditis, etc. Although cumulative data have suggested safety of atypical antipsychotics use during pregnancy some of them have been shown to induce apoptotic neurodegenerative and structural changes in fetal brains with long-lasting impact on cognitive impairment of offsprings. Typical antipsychotics seem to be more cytotoxic than atypical ones. Recently, epidemiological studies have shown lower incidence of cancer in schizophrenic patients what suggest ability of antipsychotics to suppress risk of cancer development. Some antipsychotics have been reported to inhibit cancer cell proliferation and induce their apoptosis. Thus, antipsychotics apoptotic effect may be used as a tool in the treatmnet of some types of cancer, especially in combinatorial therapies. In this minireview, we focused on pro- and anti-apototic or "Dr. Jekyll and Mr. Hyde" effects of antipsychotics, which can be involved in their side effects, as well as their promising therapeutical indications. This article is protected by copyright. All rights reserved.

Clozapine-induced pulmonary embolism in a patient with no pre-existing risk factors: A case report

We report the case of a 51-year-old Caucasian woman who developed a pulmonary embolism in the absence of any pre-existing risk factors for VTE, 3 weeks following clozapine initiation for treatment resistant paranoid schizophrenia. She was initially misdiagnosed and treated for suspected COVID-19 infection.

Clozapine-Related Thromboembolic Events

Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. Venous thromboembolism (VTE) is a rare side effect of clozapine which can be fatal. This article summarizes current evidence regarding the risk of VTE associated with the use of clozapine. We performed a PubMed (MeSH) and Google Scholar search for the last two decades. Studies or case reports performed in humans were included in the review, of which 42 case reports of patients taking clozapine at VTE onset were included in the analysis of this review. According to the articles reviewed, the mean age was 42.9 years, with more males (71.43%) than females (28.57%). The average clozapine dose was 285.62 mg/day. VTE onset occurred within the first six months in 71.8% of the cases. Overall, 70.37% of the patients had comorbidities, and 87.5% had risk factors for VTE. In total, 68.57% were prescribed other medications at VTE onset, and 60% were being treated with another antipsychotic concomitantly. Finally, 32.5% of the patients died, while 67.5% survived. In 60% of the cases, clozapine was discontinued after VTE. In our literature review, we observed that among clozapine users, VTE occurred at a wide dose range, and most of the events occurred within the first six months. As many patients who are prescribed clozapine have risk factors for VTE, the risk should be considered at the time of prescribing. Further research should be conducted to elucidate the risk of VTE in clozapine users and the benefits of thromboprophylaxis.

Acute Pulmonary Embolism Associated with Low-Dose Olanzapine in a Patient without Risk Factors for Venous Thromboembolism

Background

Olanzapine is a second-generation antipsychotic drug commonly prescribed for certain mental/mood conditions such as schizophrenia and bipolar disorders. This agent has been considered a precipitating factor for venous thromboembolism formation. Most of the cases previously reported were associated with high-dose olanzapine therapy or in patients with high-risk factors for the development of thromboembolism. Case Presentation. We report a patient who developed pulmonary embolism after a long course of low-dose olanzapine. A 66-year-old female patient suffering from insomnia had been prescribed olanzapine 2.5 mg and paroxetine 10 mg for two years. The patient suddenly developed a syncopal episode at home and was immediately brought to the hospital. The diagnosis of pulmonary embolism was made by chance during the computerized tomography of coronary arteries. The patient made a full recovery under conventional treatment and was discharged in stable condition. The thoracic computed tomography taken two months after discharge showed a completely normal pulmonary arterial tree.

Conclusion

Olanzapine-associated pulmonary embolism is a rare entity and might be missed if the physician in charge is not vigilant and well informed. Even low-dose olanzapine can be associated with pulmonary embolism in patients with low classic risk factors if the treatment is prolonged. Pulmonary embolism should be sought in patients taking olanzapine even though the presenting manifestations are nonspecific.

Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19

BACKGROUND

clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused.

OBJECTIVE

to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic.

DATA SOURCES

a search was performed in two databases (PubMed and Web of Science) using the specific keywords "clozapine" and "schizophrenia", "side effects", "agranulocytosis", "TRS", or "bipolar affective disorder (BAF)" for the last ten years.

STUDY ELIGIBILITY CRITERIA

clinical trials on adults with acute symptoms of schizophrenia or related disorders.

RESULTS

we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection.

LIMITATIONS

we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions' severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.

Do we need sex-oriented clinical practice guidelines for the treatment of schizophrenia?

PURPOSE OF REVIEW

Clinical practice guidelines (CPGs) do not usually offer a sex-specific approach for the management of schizophrenia. With this narrative review, we aim to give an integrated and synthesized overview of the current state of knowledge regarding sex-specific aspects in schizophrenia and how this topic may be adapted in the development of CPGs.

RECENT FINDINGS

Recent studies further suggest sex-specific differences in epidemiologic features, the course of illness, underlying pathomechanisms, response likelihood to antipsychotic medication and differences in tolerability. Beyond this, selective estrogen receptor modulators like raloxifene have shown beneficial effects on symptom severity and cognition in women with schizophrenia.

SUMMARY

Sex-specific aspects can already be integrated in clinical guideline recommendations, especially with regard to efficacy and tolerability of antipsychotic treatment. Moreover, these aspects may be used for an individual risk-stratification. Recent studies provide evidence supporting the hypothesis of sex-specific modulation in schizophrenia and build the groundwork for sex-specific novel treatment options. However, there remains a clear need for additional studies focusing on women with schizophrenia to substantiate current findings.

Second-generation antipsychotics activate platelets in antipsychotic-naive and antipsychotic-free patients with schizophrenia: A retrospective study

OBJECTIVE

Among the risk factors for cerebrovascular/cardiovascular disease or thromboembolic events caused by the administration of second-generation antipsychotics, clinicians have mainly focused on metabolic side effects, with little interest in the effects on platelet activity. Because excessive platelet activity can increase the risk for cerebrovascular/cardiovascular disease, the aim of this study was to investigate the effect of second-generation antipsychotics on platelet activity in patients with schizophrenia.

METHODS

The medical records of patients with schizophrenia who were treated with second-generation antipsychotics were retrospectively reviewed. The degree of platelet activation was assessed by measuring the mean platelet component.

RESULTS

Wilcoxon signed-rank test revealed that mean platelet component levels were significantly decreased by the administration of second-generation antipsychotics (V = 20; p < 0.05), suggesting that the administration of second-generation antipsychotics may increase platelet activation.

CONCLUSION

Because platelet activation is an additional risk factor for the occurrence of cerebrovascular/cardiovascular disease, results of this study suggest that clinicians should carefully monitor the degree of platelet activation after the administration of second-generation antipsychotics.

Clozapine associated pulmonary embolism: systematic review

Background: Clozapine is a second-generation antipsychotic used in refractory schizophrenia. Clozapine can lead to pulmonary embolism (PE) by various mechanisms including immobility, weight gain and increased platelet aggregation.

Objectives: We performed a systematic review on published cases of PE associated with clozapine.

Methods: Comprehensive search of Medline, Embase and Cochrane library was done for relevant articles from inception until June 2017

Results: Total of 34 cases from 24 articles were included in the analysis. The mean age was 43.2 years with male predominance (63.6%). The mean dosage of clozapine was 281.4 mg daily. Duration of intake ranged from few days to many years. Nearly half of patients (47.82%) had no other co-morbidities for PE other than clozapine. For those reporting treatment, anticoagulation was chosen in 80%, thrombolysis in 10% and inferior vena cava filter placement in 5%. Mortality was 36.36% with three dying on presentation and an additional 9 dying during the follow-up period. Of the 18 patients in which follow-up data of clozapine were available, the drug was discontinued in 14 patients.

Conclusion: PE can occur at doses lower than usual dose of clozapine (300 mg daily). It is important to consider this association especially in patients with no other risk factors for PE.

Venous Thromboembolism as an Adverse Effect During Treatment With Olanzapine: A Case Series

Objective: Venous thromboembolism (VTE) is a serious multifactorial disorder. Patients with severe mental illness have a higher risk of developing the condition compared to the general population. Methods: We observed 10 cases of VTE in patients with mental illness who were treated with the antipsychotic drug olanzapine. The diagnosis of VTE was made at the University Hospital Hradec Kralove (UH HK) from 2004 to 2013. VTE was objectively determined by imaging techniques (duplex ultrasonography, CT angiography) and laboratory tests (D-dimer). The average age was 46 years. The clinical manifestation of VTE was deep vein thrombosis in nine cases, including one case of simultaneous pulmonary embolism and one case of a concurrent ischemic cerebrovascular accident (iCVA). None of our patients had a history of malignant disease, trauma, or surgery. Results: Apart from antipsychotic medication, all the patients had clinical or laboratory risk factors for VTE. The most frequent clinical risk factors were obesity (n = 7) and smoking (n = 6). The most frequent laboratory risk factors were increased levels of FVIII (n = 4), mild hyperhomocysteinemia (n = 3), and factor V Leiden mutation (n = 2). VTE developed within 3 months after antipsychotic drug initiation in three patients and within 6 months in three patients. Conclusion: Olanzapine can be considered a precipitating factor for VTE formation. When olanzapine is administered, we need to monitor for clinical signs and symptoms of VTE, especially when other risk factors are present.

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.

Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of clozapine

Clozapine, a dibenzodiazepine developed in 1961, is a multireceptorial atypical antipsychotic approved for the treatment of resistant schizophrenia. Since its introduction, it has remained the drug of choice in treatment-resistant schizophrenia, despite a wide range of adverse effects, as it is a very effective drug in everyday clinical practice. However, clozapine is not considered as a top-of-the-line treatment because it may often be difficult for some patients to tolerate as some adverse effects can be particularly bothersome (i.e. sedation, weight gain, sialorrhea etc.) and it has some other potentially dangerous and life-threatening side effects (i.e. myocarditis, seizures, agranulocytosis or granulocytopenia, gastrointestinal hypomotility etc.). As poor treatment adherence in patients with resistant schizophrenia may increase the risk of a psychotic relapse, which may further lead to impaired social and cognitive functioning, psychiatric hospitalizations and increased treatment costs, clozapine adverse effects are a common reason for discontinuing this medication. Therefore, every effort should be made to monitor and minimize these adverse effects in order to improve their early detection and management. The aim of this paper is to briefly summarize and provide an update on major clozapine adverse effects, especially focusing on those that are severe and potentially life threatening, even if most of the latter are relatively uncommon.

Venous thromboembolism prophylaxis in mental health in-patient services: a qualitative study

Background Venous thromboembolism (VTE) is an important and potentially preventable cause of morbidity and mortality in hospitalised patients. It is a significant, international patient safety issue affecting medical, surgical and mental health in-patients. There is a paucity of published evidence on the incidence of VTE, and the role of VTE risk-assessment and prophylaxis, in mental healthcare settings. Epidemiological evidence indicates that antipsychotic medications are an independent risk factor for VTE. Objective To explore healthcare practitioners' experiences and perspectives regarding VTE prophylaxis for in-patients in mental health services in Ireland. Setting This study was conducted in two national teaching hospitals in Dublin, Ireland. Method This experiential, qualitative study was conducted using face-to-face, semi-structured interviews. Purposive sampling was used to allow strategic selection of participants from the pharmacy, medical and nursing disciplines. Data was analysed using inductive thematic analysis. Consolidated criteria for reporting qualitative studies guidelines were used as a reporting framework. Main outcome measure Participants' views on VTE prophylaxis for mental health in-patients. Results Five key themes were derived: risk factors in mental health, attitudes to risk-assessment, challenges with VTE prophylaxis, lack of awareness, and lack of evidence in mental health. Conclusion The results indicate considerable diversities in perceived risk of VTE, and in experiences with VTE risk-assessment and prophylaxis. VTE risk was considered in practice specifically for immobile, older adults and eating disorder patients on bed rest. Specific research is required to address this area of clinical uncertainty in mental health.

Venous thromboembolism during treatment with antipsychotics: Results of a drug surveillance programme

OBJECTIVES

Venous thromboembolism (VTE) can be a life-threatening medical condition that may lead to leg swelling, respiratory distress and death.

METHODS

The AMSP (Arzneimittelsicherheit in der Psychiatrie) is a continuous multicentre drug surveillance programme that assesses severe adverse drug reactions during treatment of psychiatric inpatients. We report on a total of 264,422 inpatients who were treated with antipsychotics (APs) and monitored from 1993 to 2011 in 99 psychiatric hospitals.

RESULTS

During this period VTE events were reported for 89 inpatients, corresponding to an occurrence rate of 34 cases per 100,000 inpatient admissions treated with APs or 43 cases per 10,000 person-years. The occurrence of VTE was greatest in patients over the age of 65 years of age with mood disorders. The chemical class of butyrophenones (48/100,000) followed by atypical APs (36/100,000) showed the highest occurrence rate for VTE compared to thioxanthenes (23/100,000), which were less associated with VTE. If imputed alone, pipamperone (61/100,000) and risperidone (55/100,000) were most frequently associated with VTE. In general, there was no difference in occurrence rate of VTE between high- and low-potency APs.

CONCLUSIONS

These results suggest that clinicians should consider AP drug exposure as a potential risk factor for VTE for patients older than 65 years. Additionally, the diagnosis of an affective disorder seems to increase the risk for VTE.

Venous Thromboembolism During Treatment with Antipsychotics: A Review of Current Evidence

This article summarises the current evidence on the risk of venous thromboembolism (VTE) with the use of antipsychotics. An increasing number of observational studies indicate an elevated risk of VTE in antipsychotic drug users. Although the use of certain antipsychotics has been associated with VTE, current data can neither conclusively verify differences in occurrence rates of VTE between first- and second-generation antipsychotics or between individual compounds, nor identify which antipsychotic drugs have the lowest risk of VTE. The biological mechanisms involved in the pathogenesis of this adverse drug reaction are still to be clarified but hypotheses such as drug-induced sedation, obesity, increased levels of antiphospholipid antibodies, enhanced platelet aggregation, hyperhomocysteinaemia and hyperprolactinaemia have been suggested. Risk factors associated with the underlying psychiatric disorder may at least partly explain the increased risk. Physicians should be aware of this potentially serious and even sometimes fatal adverse drug reaction and should consider discontinuing or switching the antipsychotic treatment in patients experiencing a VTE. Even though supporting evidence is limited, prophylactic antithrombotic treatment should be considered in risk situations for VTE.

The impact of antipsychotics as a risk factor for thromboembolism

Patients with schizophrenia are predisposed toward developing cardiovascular disease. Although neuroleptics affect the cardiovascular system, it is also important to consider the consequences of the disease itself such as lower physical activity due to living on disability pension, inadequate nutrition, and/or nicotine addiction, being more common among patients with schizophrenia versus the general population. All these factors combined lead to an increased risk of death caused by cardiovascular conditions in schizophrenic patients. Individuals receiving typical antipsychotic drugs have been reported to have elevated concentrations of antiphospholipid antibodies, including anticoagulants and anticardiolipin antibodies. The presence of both antibodies is associated with an increased risk for thromboembolism. It is also likely that mental illness is accompanied by increased procoagulant activity. Patients with acute psychosis have been shown to have a statistically significant increase in the concentrations of D-dimer, P-selectin, and in the expression of platelet glycoprotein IIb/IIIa receptors. Learning about causes and mechanisms of venous thromboembolism could help to reduce or neutralize the adverse effects of antipsychotic treatment and facilitate the identification of appropriate markers necessary to monitor changes and provide preventive care against hazardous and potentially fatal complications such as deep venous thrombosis and pulmonary embolism. Before atypical neuroleptic treatment is administered to hospitalized patients, all possible risk factors for thromboembolism should be considered to allow the application of lower risk drugs. Also, other preventive measures should be taken into account, including hydration, compression stockings, regular exercise of lower extremities, and low-molecular-weight heparin injections.

Platelet haemostatic function in psychiatric disorders: Effects of antidepressants and antipsychotic drugs

Objectives Platelets, the smallest anucleated blood cells, play an essential role in the first step of complex haemostatic process. This review presents the haemostatic function of blood platelets related to their activation in psychiatric disorders (schizophrenia, depression), the role of antipsychotic and antidepressant medication, and introduces the mechanisms by which activated platelets may be involved in the pathophysiology of these disorders. Methods Platelets are interesting and easily accessible blood cells to study biochemical pathways related to schizophrenia and other psychiatric disorders, and their complex activation process might be useful as a diagnostic peripheral marker for studying psychiatric disorders and haemostatic complications. Results The excessive activation of platelets observed in patients with depression and schizophrenia is involved in cardiovascular diseases, stroke and increased risk of thrombotic complications that may be major causes of morbidity and mortality of patients. The use of antidepressants or antipsychotic drugs in depression and schizophrenia treatment is often associated with haematological side effects such as bleeding, venous thromboembolism and impaired platelet function. Conclusions Understanding the role of platelet activation in psychiatric disorders such as schizophrenia or depression and medication may improve therapies in the future.

Cardiovascular Disease in Clozapine-Treated Patients: Evidence, Mechanisms and Management

Myocarditis occurs in about 3% of those initiated on clozapine but monitoring reduces the risk of serious outcome. Cardiomyopathy may develop after myocarditis, or from prolonged tachycardia. Monitoring using echocardiography is not deemed cost effective. Tachycardia, orthostatic hypotension and reduced heart rate variability are a group of clozapine-related adverse effects associated with autonomic dysfunction and may have serious consequences in the long term. Elevated heart rate and poor heart rate variability can be treated with a β-blocker or a non-dihydropyridine calcium channel blocker, while orthostatic hypotension can be alleviated by increased fluid intake and abdominal binding, but may require pharmacological intervention. Adequate correction for heart rate may show that clozapine does not prolong the QT interval. Other cardiovascular effects, pulmonary embolism, metabolic syndrome, sudden cardiac death and particularly the excessive mortality from cardiovascular disease events may be more strongly associated with the combination of mental illness, lifestyle factors and poor treatment of cardiovascular disease and its risk factors than with clozapine treatment. In view of the efficacy of clozapine and the evidence of reduced mortality relative to other antipsychotics, clozapine should be prescribed when indicated and recipients should be enrolled in lifestyle programmes to increase exercise and improve diet, and referred for diagnosis and treatment of cardiovascular disease and its risk factors.

Are the safety profiles of antipsychotic drugs used in dementia the same? An updated review of observational studies

With an increase in the global prevalence of dementia, there is also an increase in behavioural and psychological symptoms of dementia (BPSD) for which antipsychotic drugs are often used. Despite several safety warnings on antipsychotic use in dementia, there is little evidence to support the efficacy of antipsychotics in individual BPSD symptoms or to evaluate the drug safety profile by individual antipsychotic drug. There is emerging but scarce evidence that suggests an inter-drug variability between antipsychotic safety outcomes in BPSD. The objective of this review was to examine the existing literature on antipsychotic drug use in dementia patients; in particular to see whether inter-drug differences regarding antipsychotic safety were reported. A literature search was conducted for observational studies published in the English language from 2004 to 2014 that reported the risk of all-cause mortality, cerebrovascular events, pneumonia and other outcomes such as hip/femur fracture, deep vein thrombosis (DVT) and hyperglycaemia. Six of 16 mortality studies (38%), 7 of 28 stroke studies (25%), 1 of 6 pneumonia (17%) studies and 2 of 6 fracture studies (33%) investigated inter-drug safety outcomes in elderly patients/dementia patients, while to our knowledge, there are no studies investigating the inter-drug variation of deep-vein thrombosis and hyperglycaemia risk. The results of the observational studies provide mixed results on the safety of antipsychotics in BPSD but it is clear that there are differences between the safety profiles of antipsychotic drugs. Robust evidence of such inter-drug variability could significantly improve patient safety as antipsychotics become more targeted to clinical risk factors.

Pulmonary embolism in a patient receiving risperidone and paliperidone: A case report and review of the literature

Several cases of pulmonary embolism (PE) have been associated with antipsychotic treatment. We report a case of an otherwise healthy 27-year old male who developed a PE after receiving paliperidone long acting injection. The patient received risperidone long acting injection for over 3 months before initiating paliperidone, but was switched incorrectly. After 3 weeks on paliperidone long acting injection the patient developed a PE requiring hospitalization and a course of anticoagulation. A review of atypical antipsychotic-induced venous thromboembolism is discussed.

Antipsychotic drugs and venous thromboembolism

Since preliminary case reports suggesting a possible association between first generation of antipsychotics and venous thromboembolism (VTE), consistent epidemiological data is now available suggesting a moderate association between antipsychotics and VTE. However, despite several hypotheses, the underlying mechanisms remain unknown or uncertain. In addition, if the association between antipsychotics and VTE is plausible, the intensity of this risk and the dose effect relationship do not have yet been determined. Prospective data is therefore needed in order to confirm and to quantify this association. Because of the level of uncertainty, the clinical impact on the prevention and the treatment of VTE in patients with a psychiatric illness appears to be low.

Risk of venous thromboembolism during treatment with antipsychotic agents

The evidence to date on the relation between the risk of venous thromboembolic disease (VTE) and antipsychotic agents derives primarily from observational and case history studies. While an increased risk of VTE has been associated with first-generation low-potency antipsychotic agents, particularly clozapine, there appears to be a growing number of reports on the occurrence of this adverse reaction during the use of second-generation antipsychotics, such as risperidone and olanzapine. The highest risk of pathological blood clotting emerges during the first 3 months after initiation of treatment with the product. Potential etiopathogenetic factors leading to VTE during treatment with antipsychotic agents include sedation, obesity, elevation of antiphospholipid antibodies, increased platelet activation and aggregation, hyperhomocysteinemia, and hyperprolactinemia. Diagnoses of schizophrenia and/or bipolar affective disorder, as well as hospitalization or stress with sympathetic activation and elevation of catecholamine levels, have been reported as known prothrombogenic factors. The present article contains the new version of the guideline for the prevention of VTE in psychiatric patients with limited mobility. Further prospective studies are necessary to elucidate the biological mechanisms of the relations between antipsychotic agents and VTE.

Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature

Gallerani M, Imberti D, Mari E, Marra A, Manfredini R. Risperidone and pulmonary embolism: a harmful association? Case series and review of the literature.

Objective: Risperidone is an atypical antipsychotic drug used to treat a number of psychiatric diseases, such as schizophrenia, schizoaffective and bipolar disorders and irritability in children with autism. Moreover, it is also often administered for short-term treatment of persistent aggression in people with moderate-to-severe Alzheimer's dementia. A possible association between risperidone and venous thromboembolism (VTE) has been described. We intended to verify the dimension of the problem in our hospital setting.

Methods: We considered all consecutive patients hospitalised in our Internal Medicine Department from January 2004 to December 2010, who were treated with risperidone and presented pulmonary embolism (PE).

Results: Four cases of patients, apparently free from the well-known major risk factors for VTE (i.e. cancer, prolonged immobilisation, acute cardiac and respiratory failure, infections), who presented PE associated with risperidone therapy, were reported in details.

Conclusions: A review of the available literature, discussing the possible different pathogenic reasons for this increased risk of VTE, is provided.

[Specific treatments of the psychiatric community and thrombogenesis]

BACKGROUND

The causes of venous thrombosis (DVT) are multifactorial. Psychiatric patients present several etiologic features.

AIM

Our objective was to determine the role of specific treatments of the psychiatric community on thrombogenesis.

METHODS

STUDY POPULATION

retrospective, descriptive and analytical study of 20 cases of DVT in psychiatric patients.

LITERATURE REVIEW

We searched MEDLINE (PubMed) between 1959 and 2009. We reviewed article titles and abstracts and full text of selected studies of psychiatric patients with venous thromboembolism (VTE) disease. We identified 31 studies that investigated the association between psychiatric disease and venous thromboembolic events.

RESULTS

Our population was young, with an average age of 44.8 years. Lower limb VT is predominant (16 cases). The most common psychiatric disorders are: anxiety-depression (12 cases), unclassifiable psychotic disorders (seven cases) and major depressive disorder (five cases). Their average duration was of 6.4 years. Seventy percent of our patients were taking first generation neuroleptics (NLP), of short half-life (13/14 cases) and at high doses (11/14 patients). Our sample is characterized by the frequency of thrombophilia (45%) and detention in a psychiatric community (35%). Our results are relatively consistent with aggregate data from the literature, underlining a facilitating and pejorative role of the psychiatric community with regard to venous thromboembolic disease. In the psychiatric community, venous thromboembolic disease is conditioned by a combination of several thromboembolism risk factors: linked in part to the psychiatric illness itself; but above all to the specific therapeutic methods in the psychiatric community (antipsychotics, restraint…) which are easily preventable. The relationship between antipsychotic medication and VTE was first suggested about four decades ago, only a few years after the introduction of phenothiazines and reserpine. An association between atypical antipsychotic agents and VTE has been previously suggested for clozapine among young adults with psychiatric disorders. More recently, an increased risk of VTE was suspected for olanzapine or risperidone. The risk for VTE seems to be highest during the initial months of treatment with antipsychotics. Several biological mechanisms of action have been proposed to explain this relationship. One plausible mechanism derives from research suggesting that conventional antipsychotic drugs are associated with enhanced platelet aggregation. A second possible explanation stems from the presence of anticardiolipin antibodies, which increase the risk of venous or arterial thrombosis, as well as in some patients prescribed chloropromazine. A third hypothesis is that venous stasis exacerbated by sedation, commonly found in patients treated with low-potency antipsychotic drugs, may contribute to processes that increase the risk of thrombosis.

CONCLUSION

Other than the medical aspect, the psychiatric community itself is characterized by a large number of variables, providing a particularly encouraging and derogatory hypothesis on the advent and development of VTE.

Venous thromboembolism in recipients of antipsychotics: incidence, mechanisms and management

Since chlorpromazine was introduced to the market in the early 1950s, the use of antipsychotic drugs has been associated with venous thromboembolism (VTE) in a number of reports. During the last decade the evidence has been strengthened with large epidemiological studies. Whether all antipsychotics increase the risk for VTE or the risk is confined to certain drugs is still unclear. The aim of this article is to present an updated critical review focusing on the incidence, mechanisms and management of VTE in users of antipsychotics. After searching the databases PubMed and Scopus for relevant articles we identified 12 observational studies, all of which were published after the year 2000. In most of these studies an elevated risk of VTE was observed for antipsychotic drugs, with the highest risk for clozapine, olanzapine and low-potency first-generation antipsychotics. The risk seems to be correlated with dose. The elderly, who mainly use lower doses, do not show an increased risk of VTE to the same extent as younger subjects. The underlying biological mechanisms explaining the association between antipsychotic medication and VTE are to a large extent unknown. Several hypotheses have been proposed, such as body weight gain, sedation, enhanced platelet aggregation, increased levels of antiphospholipid antibodies, hyperprolactinaemia and hyperhomocysteinaemia. The risk of VTE in schizophrenia and other psychotic disorders may also be related to the underlying disease rather than the medication. Very limited evidence exists to guide how cases of VTE in subjects using antipsychotics should be handled. An attempt to compile an algorithm where the patients' individual risk of VTE is assessed and preventive clinical measures are suggested has been published recently. Strong consideration should be given to discontinuation of the offending antipsychotic drug in patients experiencing a VTE, and another antipsychotic drug with a presumably lower risk should be chosen if antipsychotic drug treatment is still indicated. It is essential that physicians and patients are aware that VTE may be an adverse drug reaction to the antipsychotic treatment so the condition is identified early and treated appropriately.

Markers of thrombogenesis are activated in unmedicated patients with acute psychosis: a matched case control study

BACKGROUND

Antipsychotic treatment has been repeatedly found to be associated with an increased risk for venous thromboembolism in schizophrenia. The extent to which the propensity for venous thromboembolism is linked to antipsychotic medication alone or psychosis itself is unclear. The objective of this study was to determine whether markers of thrombogenesis are increased in psychotic patients who have not yet been treated with antipsychotic medication.

METHODS

We investigated the plasma levels of markers indicating activation of coagulation (D-dimers and Factor VIII) and platelets (soluble P-selectin, sP-selectin) in an antipsychotic-naive group of fourteen men and eleven women with acute psychosis (age 29.1 ± 8.3 years, body mass index 23.6 ± 4.7), and twenty-five healthy volunteers were matched for age, gender and body mass index.

RESULTS

D-dimers (median 0.38 versus 0.19 mg/l, mean 1.12 ± 2.38 versus 0.28 ± 0.3 mg/l; P = 0.003) and sP-selectin (median 204.1 versus 112.4 ng/ml, mean 209.9 ± 124 versus 124.1 ± 32; P = 0.0005) plasma levels were significantly increased in the group of patients with acute psychosis as compared with healthy volunteers. We found a trend (median 148% versus 110%, mean 160 ± 72.5 versus 123 ± 62.5; P = 0.062) of increased plasma levels of factor VIII in psychotic patients as compared with healthy volunteers.

CONCLUSIONS

The results suggest that at least a part of venous thromboembolic events in patients with acute psychosis may be induced by pathogenic mechanisms related to psychosis rather than by antipsychotic treatment. Finding an exact cause for venous thromboembolism in psychotic patients is necessary for its effective treatment and prevention.

Cardiovascular aspects of antipsychotics

PURPOSE OF REVIEW

Schizophrenia is associated with increased mortality and reduced life expectancy, with cardiovascular disease being the most frequent cause of death. Antipsychotics have detrimental effects on different risk factors for cardiovascular disease. This review will focus on the relationship between antipsychotic treatment and cardiovascular disease.

RECENT FINDINGS

The increased overall mortality and mortality from cardiovascular disease in schizophrenia are now well documented. Patients with schizophrenia are at risk of receiving less optimal treatment for cardiovascular disease. Patients with schizophrenia are at high risk of metabolic syndrome, a cluster of risk factors for cardiovascular disease. Some antipsychotics, in particular, clozapine and olanzapine, frequently cause weight gain, dyslipidemia and diabetes mellitus. Antipsychotics differ in their effects on body weight, lipids and glucose regulation. However, the long-term effects of these differences between individual antipsychotics on overall mortality and cardiovascular mortality are not well established.

SUMMARY

More research is needed to better understand the relationship between schizophrenia, antipsychotic treatment and cardiovascular disease. More effective treatment strategies need to be developed to reduce the burden of cardiovascular disease in schizophrenia.

Antipsychotic drug use and the risk of venous thromboembolism in elderly patients

OBJECTIVE

Our aim was to investigate the relationship between exposure to antipsychotic drugs and the risk of venous thromboembolism (VTE) in elderly patients.

METHODS

A time-matched case-control analysis nested within a cohort of 111,818 patients with at least 1 antipsychotic drug prescription during 1998 to 2008. Data were used from the PHARMO institute's database, which contains drug dispensing data from community pharmacies and hospital admission data. The index date was for the cases defined as the date of hospital admission for VTE (deep venous thrombosis [DVT] or pulmonary embolism) or, for outpatient cases, the start of therapeutic dose low-molecular weight heparin therapy. For each case, 4 controls matched by age and sex were randomly sampled from the cohort.

MEASUREMENTS

Two measures were used to evaluate the temporal relationship between antipsychotic drug use and the occurrence of VTE: being a current, recent, or past user and the duration of use up to the index date. The strength of the association was expressed as odds ratios with 95% confidence intervals, taking into account potential confounders.

RESULTS

We identified 367 cases of hospital admission for DVT, 342 cases of hospital admission for PE, and 323 cases of outpatient treatment of DVT. Current exposure to antipsychotic drugs was not associated with an increased risk of VTE, compared with nonusers (odds ratio, 0.9; 95% confidence interval, 0.7-1.1). We found no association between dosage, the duration of use, or the type of antipsychotic drug and the risk of VTE.

CONCLUSIONS

We found no evidence of an increased risk of VTE in elderly patients using antipsychotic drugs.

Olanzapine and pulmonary embolism, a rare association: a case report

Venous thromboembolism is a very common pathological process for which there are many well known (and less well-known) predisposing factors. Likewise, olanzapine is a commonly used anti-psychotic medication.

We present the case of a young Somali gentleman who developed venous thromboembolic disease after an overdose of olanzapine. The diagnosis was only made 48 hours after admission, due to the non-specific presentation of the pulmonary embolus and the fact that the link between olanzapine and pulmonary embolus was not previously widely described and therefore it did not immediately figure in the differential diagnosis. The patient made a full recovery.

There is an increasing body of circumstantial evidence linking olanzapine to pulmonary embolus. Clinicians should bear this possible association in mind when prescribing the drug and when faced with clinical situations where venous thromboembolism (VTE) is a possible diagnosis. VTE has occasionally been described in therapeutic dose olanzapine therapy, but never in the context of an acute overdose. Khat, a recreational drug, has been linked to arterial, but not venous thrombosis.

It is hoped that this case report will further encourage research into these associations, which remain to be proven and quantified.

In the context of changing population demographics and increasing global migration, a greater awareness of the potential effects of endemic practices and their potential consequences is essential to the modern-day doctor working in a multi-cultural society.

Risk of venous thromboembolism due to antipsychotic drug therapy

An increasing number of reports suggest a link between venous thromboembolism (VTE) and the use of antipsychotics. To better understand this association the available body of evidence has been critically scrutinised. Relevant articles were identified in the databases Scopus and PubMed. Several observational studies using different methodologies show an increased risk of VTE in psychiatric patients. This elevated risk seems to be related to the use of antipsychotic medication and in particular to the use of clozapine and low-potency first-generation drugs. Many studies investigating the association have, however, methodological limitations. The biological mechanisms involved in the pathogenesis of this possible adverse reaction are largely unknown but several hypotheses have been suggested such as drug-induced sedation, obesity, increased levels of antiphospholipid antibodies, enhanced platelet aggregation, hyperhomocysteinemia and hyperprolactinemia. The association may also be related to underlying risk factors present in psychotic patients. Physicians need to be aware of this possible adverse drug reaction. Although supporting evidence has not been published they should consider discontinuing or switching the antipsychotic treatment in patients experiencing VTE. In addition, although data is lacking, the threshold for considering prophylactic antithrombotic treatment should be low when risk situations for VTE arise, such as immobilisation, surgery and so on.

Antipsychotics and risk of venous thromboembolism: A population-based case-control study

During the last decade, the risk of venous thromboembolism (VTE) has been reported in users of antipsychotic drugs. However, the reports have been inconclusive. This study aimed to determine the relative risk of VTE in antipsychotic drug users. Using data from medical databases in North Jutland and Aarhus Counties, Denmark, and the Danish Civil Registration System, we identified 5,999 cases with a first-time diagnosis of VTE and, based on risk set sampling, 59,990 sex- and age-matched population controls during 1997–2005. Users of antipsychotic drugs were identified from population-based prescription databases and categorized based on filled prescriptions prior to admission date for VTE or index date for controls as current (at least one prescription within 90 days), recent (at least one prescription within 91–180 days), former (at least one prescription within 181–365 days) or nonusers (no recorded prescription within 365 days). Compared with nonusers, current users of any antipsychotic drugs had an increased risk of VTE (adjusted relative risk [ARR]: 1.99, 95% confidence interval [CI]: 1.69–2.34). Former users of any antipsychotic drugs had a nonsignificant elevated risk of VTE compared with nonusers (ARR: 1.54, 95% CI: 0.99–2.40, p-value: 0.056). In conclusion, users of antipsychotic drugs have an increased risk of VTE, compared with nonusers, which might be due to the treatment itself, to lifestyle factors, to the underlying disease, or to residual confounding.

Risiken von Antipsychotika im Alter, speziell bei Demenzen 1Prof. Dr. Hans Gutzmann zum 60. Geburtstag gewidmet

Antipsychotika werden häufig zur Behandlung von herausforderndem Verhalten bei Demenz eingesetzt. Antipsychotika der zweiten Generation («atypische Neuroleptika») spielen dabei mittlerweile eine größere Rolle als die älteren Substanzen. Der nur mäßigen Wirksamkeit stehen schwerwiegende Risiken gegenüber: so ist unter allen Antipsychotika die Mortalität insgesamt erhöht, aber auch das Risiko für plötzlichen Herztod, Schlaganfallereignisse oder venöse Thrombosen. Die Unterschiede zwischen Antipsychotika der ersten und der zweiten Generation sind dabei gering: hochpotente Antipsychotika der ersten Generation führen häufiger zu extrapyramidalmotorischen Symptomen, unter Antipsychotika der zweiten Generation ist das allgemeine Mortalitätsrisiko wahrscheinlich etwas geringer, andererseits wahrscheinlich venöse Thrombosen und metabolische Nebenwirkungen häufiger. Für die übrigen Nebenwirkungen bestehen keine gesicherten Unterschiede. Angesichts der großen Heterogenität der Antipsychotika erscheint der Nutzen einer pauschalen Aufteilung in Antipsychotika der ersten und zweiten Generation fragwürdig. Für die Auswahl einer Substanz sind substanzspezifische Nebenwirkungen, Dosierung, Aufdosierungsgeschwindigkeit sowie Beachtung von Komorbidität, Kontraindikationen und Arzneimittelinteraktionen in Relation zum individuellen Patienten erheblich wichtiger als die Wahl nach bloßer pauschaler Zuordnung zu einer dieser beiden Gruppen. Am wichtigsten ist aber, dass Antipsychotika nur bei klarer Indikation zur Anwendung kommen!