Adverse Effects of Atypical Antipsychotics in the Elderly

Pharmacologic prophylaxis of postoperative delirium in elderly patients: A network meta-analysis of randomized controlled trials

BACKGROUND

The high incidence and mortality rates of postoperative delirium (POD) among elderly patients highlights the pressing need for tailored prophylactic strategies. Despite various pharmacologic prophylactic strategies have been reported effective, their overall benefit and safety remain unclear in the geriatric population. Our network meta-analysis (NMA) aimed to systematically evaluate and rank the effectiveness of various pharmacological interventions in preventing POD in elderly patients.

METHODS

We conducted an extensive search of PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and Google Scholar for randomized controlled trials (RCTs) published up to August 1, 2023. We included RCTs examining pharmacological prophylactic effects of POD in elderly patients. To extract data in alignment with predefined areas of interest, we employed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The primary outcome was the incidence of POD. For secondary outcomes, we evaluated tolerability through all-cause discontinuation or drop-out rates, as well as all-cause mortality.

RESULTS

Our analysis encompassed a total of 44 RCTs involving 11,178 patients. Out of these, 26 RCTs involved comparisons with placebo only. For delirium prevention, the treatment groups receiving atypical antipsychotics (odds ratio (OR) of 0.27 and 95% confidence interval (CI) of 0.12-0.58), haloperidol (OR of 0.42; 95% CI of 0.25-0.71), dexmedetomidine (OR of 0.51 and 95% CI of 0.37-0.71 and melatonergic agents (MMA) (OR of 0.57 and 95% CI of 0.33-0.98) had significantly lower rates of delirium compared to the placebo group. Notably, the atypical antipsychotics ranked as the most effective treatment. For tolerability, no statistically differences in rates of dropout discontinuation and all-cause mortality among groups allocated to the placebo or individual pharmacological treatments.

CONCLUSIONS

Based on indirect evidence, our network meta-analysis identified atypical antipsychotics, dexmedetomidine, MMA, and haloperidol as effective in preventing POD in the elderly, with atypical antipsychotics ranking highest. However, it is essential to note that these findings should be confirmed through further RCTs.

Prescribing patterns for older-age bipolar disorder patients discharged from two public mental hospitals in Taiwan, 2006-2019

BACKGROUND

Older-age bipolar disorder (OABD) is commonly defined as bipolar disorder in individuals aged 60 or more. There have been no studies to examine temporal trends in the pharmacological treatment of OABD. We aimed to investigate prescription changes among OABD patients discharged from two public mental hospitals in Taiwan from 2006 to 2019.

METHODS

OABD patients discharged from the two study hospitals, from 1 January 2006 to 31 December 2019 (n = 1072), entered the analysis. Prescribed drugs at discharge, including mood stabilisers (i.e., lithium, valproate, carbamazepine, and lamotrigine), antipsychotics (i.e., second- and first-generation antipsychotics (SGAs and FGAs)), and antidepressants, were investigated. Complex polypharmacy was defined as the use of three or more agents among the prescribed drugs. Temporal trends of each prescribing pattern were analyzed using the Cochran-Armitage Trend test.

RESULTS

The most commonly prescribed drugs were SGAs (72.0%), followed by valproate (48.4%) and antidepressants (21.7%). The prescription rates of SGAs, antidepressants, antidepressants without mood stabilisers, and complex polypharmacy significantly increased over time, whereas the prescription rates of mood stabilisers, lithium, FGAs, and antidepressants plus mood stabilisers significantly decreased.

CONCLUSIONS

Prescribing patterns changed remarkably for OABD patients over a 14-year period. The decreased use of lithium and increased use of antidepressants did not reflect bipolar treatment guidelines. Future research should examine whether such prescribing patterns are associated with adverse clinical outcomes.

The treatment of behavioural and psychological symptoms in dementia: pragmatic recommendations

Behavioural and psychological symptoms of dementia (BPSD) are a clinical challenge for the lack of a sound taxonomy, frequent presentation with comorbid BPSD, lack of specific pharmacologic interventions, poor base of methodologically sound evidence with randomized clinical trials, contamination from the treatment of behavioural disturbances of young and adult psychiatric conditions, and small efficacy window of psychotropic drugs. We present here a treatment workflow based on a concept-driven literature review based on the notions that (i) the aetiology of BPSD can be mainly neurobiological (so-called 'primary' symptoms) or mainly environmental and functional ('secondary' symptoms) and that this drives treatment; (ii) the clinical efficacy of psychotropic drugs is driven by their specific profile of receptor affinity; (iii) drug treatment should follow the rules of 'start low-go slow, prescribe and revise'. This article argues in support of the distinction between primary and secondary BPSD, as well as their characteristics, which until now have been just sketchily described in the literature. It also offers comprehensive and pragmatic clinician-oriented recommendations for the treatment of BPSD.

Distinguishing features of depression in dementia from primary psychiatric disease

Depression is a common and devastating neuropsychiatric symptom in the elderly and in patients with dementia. In particular, nearly 80% of patients with Alzheimer's Disease dementia experience depression during disease development and progression. However, it is unknown whether the depression in patients with dementia shares the same molecular mechanisms as depression presenting as primary psychiatric disease or occurs and persists through alternative mechanisms. In this review, we discuss how the clinical presentation and treatment differ between depression in dementia and as a primary psychiatric disease, with a focus on major depressive disorder. Then, we hypothesize several molecular mechanisms that may be unique to depression in dementia such as neuropathological changes, inflammation, and vascular events. Finally, we discuss existing issues and future directions for investigation and treatment of depression in dementia.

Histone deacetylase inhibitors mitigate antipsychotic risperidone-induced motor side effects in aged mice and in a mouse model of Alzheimer's disease

Antipsychotic drugs are still widely prescribed to control various severe neuropsychiatric symptoms in the elderly and dementia patients although they are off-label use in the United States. However, clinical practice shows greater side effects and lower efficacy of antipsychotics for this vulnerable population and the mechanisms surrounding this aged-related sensitivity are not well understood. Our previous studies have shown that aging-induced epigenetic alterations may be involved in the increasing severity of typical antipsychotic haloperidol induced side effects in aged mice. Still, it is unknown if similar epigenetic mechanisms extend to atypical antipsychotics, which are most often prescribed to dementia patients combined with severe neuropsychiatric symptoms. In this study, we report that atypical antipsychotic risperidone also causes increased motor side effect behaviors in aged mice and 5xFAD mice. Histone deacetylase (HDAC) inhibitor Valproic Acid and Entinostat can mitigate the risperidone induced motor side effects. We further showed besides D2R, reduced expression of 5-HT2A, one of the primary atypical antipsychotic targets in the striatum of aged mice that are also mitigated by HDAC inhibitors. Finally, we demonstrate that specific histone acetylation mark H3K27 is hypoacetylated at the 5htr2a and Drd2 promoters in aged mice and can be reversed with HDAC inhibitors. Our work here establishes evidence for a mechanism where aging reduces expression of 5-HT2A and D2R, the key atypical antipsychotic drug targets through epigenetic alteration. HDAC inhibitors can restore 5-HT2A and D2R expression in aged mice and decrease the motor side effects in aged and 5xFAD mice.

Comparative Safety Signal Assessment of Hospitalization Associated With the Use of Atypical Antipsychotics

Background

Persons with symptoms of psychosis receiving treatment with atypical antipsychotics (AAPs) can experience serious adverse events (AEs) requiring admission to the hospital. The comparative likelihood of AE-related hospitalization following the use of all AAPs has not been fully characterized. Therefore, we evaluated the safety signals of hospitalizations associated with the use of AAPs.

Methods

We conducted a cross-sectional analysis using the FDA Adverse Event Reporting System (FAERS) database (from January 1, 2004, to December 31, 2021) to examine disproportionality in reporting hospitalizations suspected to be associated with 12 AAPs (aripiprazole, asenapine, brexpiprazole, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, and pimavanserin, quetiapine, risperidone, and ziprasidone). Hospitalization in the FAERs database is an outcome that is recorded as a result of an AE occurring at any drug dose. We estimated reporting odds ratios (RORs) by comparing the odds of hospitalization occurring with a particular AAP to the odds of its occurrence with other drugs. In addition, we considered the presence of a significant safety signal when the lower limit of the 95% confidence interval (CI) of the ROR is >1.

Results

A total of 204,287 cases of hospitalizations were reported to the FDA for individuals treated with AAPs. There were significant safety signals of hospitalization associated with using clozapine (ROR, 2.88; 95% CI, 2.84-2.92), olanzapine (ROR, 2.61; 95% CI, 2.57-2.64), quetiapine (ROR, 1.87; 95% CI, 1.85-1.89), risperidone (ROR, 1.41; 95% CI, 1.39-1.43), aripiprazole (ROR, 1.34; 95% CI, 1.32-1.35), and ziprasidone (ROR, 1.14; 95% CI, 1.10-1.18). However, no hospitalization-related safety signals were observed with the use of paliperidone, pimavanserin, iloperidone, asenapine, lurasidone, and brexpiprazole. The ROR estimates were numerically higher among older adults than younger adults.

Conclusions

This cross-sectional assessment of data from FAERs (2004-2021) suggested that users of clozapine, olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone were more likely to report being hospitalized than users of other AAPs. Given that the FAERs database only contains spontaneous reports of AEs experienced by persons exposed to a drug but without information on exposed persons who did not have an event, a cohort study comparing hospitalizations among new users of individual AAPs against each other is needed to delineate these safety signals further.

Brain-Targeted Intranasal Delivery of Zotepine Microemulsion: Pharmacokinetics and Pharmacodynamics

The purpose of our study was to improve the solubility, bioavailability, and efficacy of zotepine (ZTP) by brain-targeted intranasal delivery of microemulsion (ME) and its physicochemical properties, the pharmacokinetic and pharmacodynamic parameters were evaluated. The optimized ME formulations contain 10% w/w of oil (Capmul MCM C8, monoglycerides, and diglycerides of caprylic acid), 50% w/w of Smix (Labrasol and Transcutol HP, and 40% w/w of water resulting in a globule size of 124.6 ±3.52 nm with low polydispersity index (PDI) (0.212 ± 0.013) and 2.8-fold higher permeation coefficient through porcine nasal mucosa compared to pure drug. In vitro cell line studies on RPMI 2650, Beas-2B, and Neuro-2A revealed ZTP-ME as safe. ZTP-ME administered intranasally showed higher AUC0-t24 (18.63 ± 1.33 h x µg/g) in the brain by approximately 4.3-fold than oral ME (4.30 ± 0.92 h × µg/g) and 7.7-fold than intravenous drug solutions (2.40 ± 0.36 h × µg/g). In vivo anti-schizophrenic activity was conducted using catalepsy test scores, the formulation showed better efficacy via the intranasal route; furthermore, there was no inflammation or hemorrhage in the nasal cavity. The results concluded that the ZTP microemulsion as a safe and effective strategy could greatly enhance brain distribution by intranasal administration.

Socio demographic, clinical, and side effect profile of patients on clozapine in Kashmir, North India

Background

Clozapine is an atypical second-generation antipsychotic belonging to the family of dibenzodiazepines. There is lack of literature on clozapine from this part of the world. So, our aim was to study the socio demographic, clinical and side effect profile of patients on clozapine in Kashmir.

Results

The mean age of the study group was 32.6 ± 8.9 years with majority being males (78.4%), unmarried (78.4%), unemployed (77.2%), and belonging to nuclear families (77.2%). Almost half of them resided in urban localities (51.1%) and studied upto middle school (55.7%). Around three- fourth (75%) of the patients had diagnosis of treatment-resistant schizophrenia. The mean dose of clozapine was 338.92 ± 158.11 mgs. Sedation (76.1%), hypersalivation (69.5%), constipation (46.6%), and weight gain (34.1%) were most common side effects noted in patients. 4.5% cases developed seizures while on clozapine. 2.3% patients developed agranulocytosis while 4.5% patients developed neutropenia on clozapine. The neutropenia was more pronounced in patients of schizophrenia with suicidal tendencies with doses of more than 400 mg.

Conclusions

We have used clozapine in a wide range of indications. Our patients seem to tolerate and respond to higher doses of clozapine and the prevalence of blood dyscrasias in our study sample was much higher than the rest of India.

Cardiac Safety of Clonidine and Quetiapine in Post-Cardiac Surgery Intensive Care Unit Patients

Background: Clonidine and quetiapine are frequently used medications in the cardiac surgery intensive care unit (ICU). Objective: The purpose of this study is to assess the impact of clonidine compared to quetiapine on cardiac safety outcomes in adult cardiac surgery ICU patients. Methods: This was a single-center, retrospective observational analysis at a tertiary care, academic medical center. Results: One hundred and sixty-one cardiac surgery patients who were administered clonidine or quetiapine during their ICU stay were included between June 2015 and May 2017. The major endpoint of this study was a cardiac safety composite of bradycardia, hypotension, and QTc prolongation. Minor endpoints included ICU and hospital length of stay, and in-hospital mortality. There were 115 patients included in the clonidine arm and 46 patients in the quetiapine arm. There was no difference between groups with regard to the major endpoint (30.43% vs 33.15%; P < .8). There was a shorter ICU and hospital length of stay in the clonidine arm compared to quetiapine P < .0001. All other endpoints were not statistically significant. Conclusion: Patients who received clonidine tended to have undergone less complex procedures, be younger, and have a lower APACHE II score than patients who received quetiapine. The incidence of composite cardiac safety outcomes was not different in clonidine compared to quetiapine in cardiac surgery ICU patients.

The risk of polypharmacy and potentially inappropriate drugs in residential care dementia patients: tips from the PharE study

AIMS

The aims of the present study, conducted in two regions of Italy, Calabria and Piedmont, were to assess the use of inappropriate drugs according to the Beers Criteria and to study the possible drug-drug interactions.

METHODS

Data were obtained retrospectively from 972 residential care patients between 2016 and 2018. Mean age was 82.4 ± 8.4 years, with a prevalence of women (64.8%). Activities of daily living, instrumental activities of daily living, Mini-Mental State Examination, Cumulative Illness Rating Scale, Neuropsychiatric Inventory Scale and number and kind of drugs were recorded. A classification of potential inappropriate drugs was made according to the Beers criteria. Data were collected through an Excel file able to gather the main information. In the case of suspected adverse event, Naranjo Scale was applied. The study of possible drug-drug interactions was made by Micromedex 2.0.

RESULTS

Functional and cognitive impairments, comorbidities and number of drugs were assessed. The bivariate relationship between number of drugs and glomerular filtration rate assessed by CKD-EPI showed that the higher was the number of drugs used, the worst was kidney function assessment (p = 0.0001). The most frequent inappropriate drugs were anticholinergic drugs, tricyclics antidepressants, long-half-life benzodiazepines, antipsychotics and proton pump inhibitors.

CONCLUSIONS

These data are very interesting and show the need for an accurate choice of drugs in elderly people and for starting a wise deprescribing procedure.

Potentially inappropriate medicines for older adults with intellectual disability: Clinical implications from a medication audit

OBJECTIVE

To investigate medications that have the potential to be inappropriately prescribed for people with intellectual disability (ID) and to explore possible issues surrounding the potential harm that can result from the use of groups of medicines for people with ID who are ageing and living longer.

METHODS

An audit of medical case records of 350 patients under the care of an organisation in New Zealand was undertaken to examine existing medication profiles.

RESULTS

Of the 350 patients, 95% were prescribed at least five or more medicines, with 7% of patients have 10 or more medicines. Increasing prescriptions are evident for those 56 years old and above.

CONCLUSIONS

Medicines that may have been appropriate for people with intellectual disability when they were younger may have the potential to cause harm when they age. It is therefore important that monitoring and evaluation of medications for ageing individuals with intellectual disability are regularly undertaken.

The Art of Safe and Judicious Deprescribing in an Elderly Patient: A Case Report

Prescription for inappropriate drugs can be dangerous to the elderly due to the increased risk of adverse drug reactions and drug-interactions. In this manuscript, we report the complexity of polypharmacy and the possible harmful consequences in an old person. An 81-year-old man with a clinical history of diabetes, blood hypertension, non-valvular atrial fibrillation, chronic obstructive pulmonary disease, osteoarthritis, anxiety, and depression, was admitted to our attention for cognitive disorders and dementia. Brain magnetic resonance imaging showed parenchymal atrophy with lacunar state involving thalami and internal capsules. Neuropsychological tests revealed cognitive impairment and a depressed mood. History revealed that he was taking 11 different drug severy day with a potential risk of 55 drug-drug interactions. Therefore, risperidone, chlorpromazine, N-demethyl-diazepam, and L-DOPA/carbidopa were gradually discontinued and citicoline (1g/day), cholecalciferol (50,000 IU once a week), and escitalopram (5 mg/day) were started. Furthermore, he started a program of home rehabilitation. During the follow-up, three months later, we recorded an improvement in both mood and cognitive tests, as well as in walking ability. The present case report shows the need for a wise prescription and deprescribing in older people.

Design, Synthesis and Biological Investigation of Flavone Derivatives as Potential Multi-Receptor Atypical Antipsychotics

The design of a series of novel flavone derivatives was synthesized as potential broad-spectrum antipsychotics by using multi-receptor affinity strategy between dopamine receptors and serotonin receptors. Among them, 7-(4-(4-(6-fluorobenzo[d]isoxazol-3-yl) piperidin- 1-yl) butoxy)-2,2-dimethylchroman-4-one (6j) exhibited a promising preclinical profile. Compound 6j not only showed high affinity for dopamine D₂, D₃, and serotonin 5-HT_1A, 5-HT_2A receptors, but was also endowed with low to moderate activities on 5-HT_2C, α₁, and H₁ receptors, indicating a low liability to induce side effects such as weight gain, orthostatic hypotension and QT prolongation. In vivo behavioral studies suggested that 6j has favorable effects in alleviating the schizophrenia-like symptoms without causing catalepsy. Taken together, compound 6j has the potential to be further developed as a novel atypical antipsychotic.

Comparative risk of Parkinsonism associated with olanzapine, risperidone and quetiapine in older adults-a propensity score matched cohort study

PURPOSE

The purpose of this study was to examine the incidence of Parkinsonism in new users of second-generation antipsychotics (SGAs) in older adults (≥65 years). In the secondary analyses, we examined the risk of Parkinsonism by type and dose of SGA and conducted age-sex interactions.

METHOD

This population-based study included older adults who had a new-onset diagnosis of Parkinsonism and who started taking olanzapine, risperidone or quetiapine between 1 January 2005, and 30 December 2016. The Cox proportional hazard (COXPH) model with inverse probability treatment weighted (IPTW) covariates was used to evaluate the risk of new-onset Parkinsonism associated with SGAs, using quetiapine as the reference. We used the Generalized Propensity Score method to evaluate the dose-response risk of Parkinsonism associated with SGAs.

RESULTS

After IPTW adjustment for covariates, the COXPH model showed that compared to quetiapine, the use of olanzapine and risperidone were associated with an increased risk of Parkinsonism. The IPTW-hazard ratios are 1.76 (95% confidence interval 1.57-1.97) and 1.31 (95%CI 1.16-1.49), respectively. The dose-response risk of Parkinsonism was highest for olanzapine with a hazard ratio of 1.69 (95%CI 1.40-2.05) and the least for quetiapine with a hazard ratio of 1.22 (95%CI 1.14-1.31). The risk of Parkinsonism in the 65 to 74-year age group was higher for both sexes with risperidone compared to olanzapine, but the risk increased with olanzapine for both sexes in the 85+ age group.

CONCLUSION

The study found that the risk of new-onset Parkinsonism in older adults is 31% and 76% higher with risperidone and olanzapine respectively compared to quetiapine.

The effects of valbenazine on tardive dyskinesia in older and younger patients

OBJECTIVE

To evaluate the effects of once-daily valbenazine (40 or 80 mg/d) in older and younger adults with tardive dyskinesia (TD).

METHODS

Data were pooled from three 6-week, randomized, double-blind, placebo-controlled (DBPC) studies (KINECT [NCT01688037], KINECT 2 [NCT01733121], and KINECT 3 [NCT02274558]) and two long-term studies (KINECT 3 extension and KINECT 4 [NCT02405091]). Outcomes analyzed in older and younger participants (55 years or older and younger than 55 years, respectively) included Abnormal Involuntary Movement Scale (AIMS) response (threshold of greater than or equal to 50% improvement from baseline in total score [items 1 to 7]) and Clinical Global Impression of Change-Tardive Dyskinesia (CGI-TD) response (score 2 or less ["very much improved" or "much improved"]). Safety assessments included treatment-emergent adverse events (TEAEs).

RESULTS

At week 6 (end of DBPC treatment), the percentage of participants who met the AIMS response threshold was higher with valbenazine versus placebo in both subgroups: 55 years or older (80 mg/d, 39.7% [P < .001]; 40 mg/d, 28.6% [P < .01]; placebo, 9.7%); younger than 55 years (80 mg/d, 39.5% [P < .001]; 40 mg/d, 20.0% [P > .05]; placebo, 10.8%). The percentage of participants with CGI-TD response was also higher with valbenazine versus placebo: 55 years or older (80 mg/d, 41.3% [P < .01]; 40 mg/d, 30.2% [P > .05]; placebo, 19.4%); younger than 55 years (80 mg/d, 39.5% [P < .05]; 40 mg/d, 35.3% [P < .05]; placebo, 18.5%). Responses at week 48 (end of long-term treatment, combined doses) were as follows: 55 years or older (AIMS, 70.7%; CGI-TD, 82.8%); younger than 55 years (AIMS, 58.7%; CGI-TD, 72.3%). No significant differences between older and younger subgroups were found for AIMS or CGI-TD response. No new safety signals or TEAEs of clinical concern were found in older participants who received long-term treatment.

CONCLUSIONS

Valbenazine improved TD and was generally well tolerated in older and younger adults.

Intranasal Zotepine Nanosuspension: intended for improved brain distribution in rats

BACKGROUND

Zotepine (ZTP), an antipsychotic drug is well tolerated and particularly effective for treating negative symptoms of psychosis. But is limited by low oral bioavailability caused by substantial first pass metabolism and thereby less amount of drug reaches the brain due to blood brain barrier (BBB).

OBJECTIVES

Since ZTP displays dose dependent side effects, purpose of the contemporary study is to develop zotepine loaded nanosuspension (ZTP-NS) for increased brain targeting in rats at lower doses.

METHODS

ZTP-NS is prepared by two techniques viz., sonoprecipitation (SP) and combination technique (high pressure homogenization preceded by precipitation) by employing various stabilizers. Optimized ZTP-NS was characterized for particle size, solid state, morphology and solubility. In vitro drug release of ZTP and formulations was conducted using Franz diffusion cell. Stability study was performed at different temperature conditions. Pharmacokinetic study was performed in Wistar rats to determine the bioavailability and brain distribution of ZTP after intra-nasal (IN) and intravenous (IV) administration. Histopathology of brain was done after repeated administration of IN ZTP dispersion and NS up to 14 days.

RESULTS

The optimized ZTP-NS formulated with Pluronic F-127 (0.3%w/v), Hydroxypropyl methyl cellulose E15 (0.3%w/v) and soya lecithin (0.4%w/v) showed particle size of 519.26 ± 10.44 nm & 330.2 ± 12.90 nm and zeta potential of -21.7 ± 1.39 mV and - 18.26 ± 1.64 mV with sonoprecipitation and combination technique respectively. In vitro drug release was high (81.79 ± 3.23%) for ZTP-NS prepared by combination technique. Intranasal NS resulted in high brain concentrations of 8.6 fold (sonoprecipitation) and 10.79-fold hike in AUC_0-24h in contrast to intravenous ZTP solution. Histopathology results reveal no significant changes in brain microscopic images.

CONCLUSION

ZTP-NS was successfully developed, characterized and found that nanosuspension is a favorable approach for intranasal delivery of zotepine. Graphical abstract Graphical abstract representing zotepine drawbacks, nanosuspension preparation, characterization and pharmacokinetic study in rats.

The risk factors, frequency and diagnosis of atypical antipsychotic drug-induced hypothermia: practical advice for doctors

Hypothermia is unpredictable and life-threatening adverse effect of atypical antipsychotic drug (APD) treatment, which has been little described. The aim of this article is to increase the awareness that hypothermia induced by APD drugs is more common than the current published case reports may suggest, and risk factors increase its development. Moreover, valuable guidelines regarding how to detect the early stages of hypothermia in clinical practice are included. A literature search for reports on APD-induced hypothermia in PubMed, Academic Search Complete, Medline Complete and eHealthMe databases was conducted. The literature search apart from eHealthMe database resulted in 524 articles, which included 34 case reports. Hypothermia was mostly induced by olanzapine (14) and risperidone (10). However, the data from Food and Drug Administration reports revealed several dozen more cases of APD-induced hypothermia (591case reports) compared with the published case reports (e.g. olanzapine-262 and risperidone-161). Hypothermia, mostly mild (61% of cases), has developed mainly in men (71%) having schizophrenia, a few hours after commencement of treatment or in the presence of risk factors. Owing to the increased risk of hypothermia development during APD treatment, doctors should routinely measure body temperature of patients, especially during the first days of the therapy. Early diagnosis of hypothermia and appropriate treatment may prevent death.

Choosing wisely? Quantifying the extent of three low value psychotropic prescribing practices in Australia

BACKGROUND

The global Choosing Wisely campaign has identified the following psychotropic prescribing as low-value (harmful or wasteful): (1) benzodiazepine use in the elderly, (2) antipsychotic use in dementia and (3) prescribing two or more antipsychotics concurrently. We aimed to quantify the extent of these prescribing practices in the Australian population.

METHODS

We applied indicators to dispensing claims of a 10% random sample of Australian Pharmaceutical Benefits Scheme beneficiaries to quantify annual rates of each low-value practice from 2013 to 2016. We also assessed patient factors and direct medicine costs (extrapolated to the entire Australian population) associated with each practice in 2016.

RESULTS

We observed little change in the rates of the three practices between 2013 and 2016. In 2016, 15.3% of people aged ≥65 years were prescribed a benzodiazepine, 0.5% were prescribed antipsychotics in the context of dementia and 0.2% of people aged ≥18 years received two or more antipsychotics concurrently. The likelihood of elderly people receiving benzodiazepines or antipsychotics in the context of dementia increased with age and the likelihood of receiving all three practices increased with comorbidity burden. In 2016, direct medicine costs to the government of all three practices combined, extrapolated to national figures, were > $21 million AUD.

CONCLUSIONS

Our indicators suggest that the frequency of these three practices has not changed appreciably in recent years and that they incur significant costs. Worryingly, people with the greatest risk of harm from these prescribing practices are often the most likely to receive them.

Systematic review of case reports of oropharyngeal dysphagia following the use of antipsychotics

OBJECTIVE

The purpose of this systematic review was to examine the effect of antipsychotic medication on dysphagia based on clinical case reports.

PATIENTS AND METHODS

Literature searches were performed using the electronic databases PubMed and Embase. In PubMed, we used the MeSH terms "antipsychotic agents" OR "tranquilizing agents" combined with "deglutition disorders" OR "deglutition". In Embase, we used the Emtree terms "neuroleptic agents" combined with "swallowing" OR "dysphagia". Two reviewers assessed the eligibility of each case independently.

RESULTS

A total of 1043 abstracts were retrieved, of which 36 cases met the inclusion criteria; 14 cases were related to typical antipsychotics and 22 to atypical antipsychotics. Dysphagia occurred together with extrapyramidal symptoms in half of the cases and was the only prominent symptom in the other half. The most common strategy against dysphagia was changing to another antipsychotic (n=13, 36.1%).

CONCLUSIONS

The data from this review indicate that antipsychotics can increase the prevalence of dysphagia.

Building interpretable models for polypharmacy prediction in older chronic patients based on drug prescription records

Background

Multimorbidity presents an increasingly common problem in older population, and is tightly related to polypharmacy, i.e., concurrent use of multiple medications by one individual. Detecting polypharmacy from drug prescription records is not only related to multimorbidity, but can also point at incorrect use of medicines. In this work, we build models for predicting polypharmacy from drug prescription records for newly diagnosed chronic patients. We evaluate the models’ performance with a strong focus on interpretability of the results.

Methods

A centrally collected nationwide dataset of prescription records was used to perform electronic phenotyping of patients for the following two chronic conditions: type 2 diabetes mellitus (T2D) and cardiovascular disease (CVD). In addition, a hospital discharge dataset was linked to the prescription records. A regularized regression model was built for 11 different experimental scenarios on two datasets, and complexity of the model was controlled with a maximum number of dimensions (MND) parameter. Performance and interpretability of the model were evaluated with AUC, AUPRC, calibration plots, and interpretation by a medical doctor.

Results

For the CVD model, AUC and AUPRC values of 0.900 (95% [0.898–0.901]) and 0.640 (0.635–0.645) were reached, respectively, while for the T2D model the values were 0.808 (0.803–0.812) and 0.732 (0.725–0.739). Reducing complexity of the model by 65% and 48% for CVD and T2D, resulted in 3% and 4% lower AUC, and 4% and 5% lower AUPRC values, respectively. Calibration plots for our models showed that we can achieve moderate calibration with reducing the models’ complexity without significant loss of predictive performance.

Discussion

In this study, we found that it is possible to use drug prescription data to build a model for polypharmacy prediction in older population. In addition, the study showed that it is possible to find a balance between good performance and interpretability of the model, and achieve acceptable calibration at the same time.

Antipsychotic medication and oropharyngeal dysphagia: systematic review

The association between antipsychotics (also known as neuroleptics) and oropharyngeal dysphagia (OD) has been suggested in several case reports. The purpose of this systematic review was to examine the effect of antipsychotic medication on OD. A systematic literature search was carried out according to PRISMA guidelines using the electronic databases Pubmed and Embase. In Pubmed, we used the MeSH terms 'antipsychotic agents' OR 'tranquilizing agents' combined with 'deglutition disorders' OR 'deglutition'. In Embase, we used the Emtree terms 'neuroleptic agents' combined with 'swallowing' OR 'dysphagia'. Two reviewers assessed the eligibility of each report independently. The level of evidence of the included studies was also assessed according to pre-established criteria. Case reports were excluded. We found 18 clinical studies of dysphagia related to antipsychotics: 12 were related both to typical and atypical antipsychotics, four to atypical antipsychotics and two to typical antipsychotics. According to the clinical studies included, prevalence of patients with swallowing problems taking antipsychotics ranged from 21.9 to 69.5% whereas prevalence of patients without swallowing problems taking antipsychotics ranged from 5 to 30.5%. The available evidence suggests considering an etiology of dysphagia in patients with swallowing problems who are taking antipsychotics, even if no other symptoms are present. Although few general conclusions can be drawn from current evidence, both typical and atypical antipsychotics can be associated with OD.

Histone deacetylase inhibitors reverse age-related increases in side effects of haloperidol in mice

BACKGROUND

Older patients can be especially susceptible to antipsychotic-induced side effects, and the pharmacodynamic mechanism underlying this phenomenon remains unclear. We hypothesized that age-related epigenetic alterations lead to decreased expression and functionality of the dopamine D2 receptor (D2R), contributing to this susceptibility.

METHODS

In this study, we treated young (2-3 months old) and aged (22-24 months old) C57BL/6 mice with the D2R antagonist haloperidol (HAL) once a day for 14 days to evaluate HAL-induced motor side effects. In addition, we pretreated separate groups of young and aged mice with histone deacetylase (HDAC) inhibitors valproic acid (VPA) or entinostat (MS-275) and then administered HAL.

RESULTS

Our results show that the motor side effects of HAL are exaggerated in aged mice as compared to young mice and that HDAC inhibitors are able to reverse the severity of these deficits. HAL-induced motor deficits in aged mice are associated with an age- and drug-dependent decrease in striatal D2R protein levels and functionality. Further, histone acetylation was reduced while histone tri-methylation was increased at specific lysine residues of H3 and H4 within the Drd2 promoter in the striatum of aged mice. HDAC inhibitors, particularly VPA, restored striatal D2R protein levels and functionality and reversed age- and drug-related histone modifications at the Drd2 promoter.

CONCLUSIONS

These results suggest that epigenetic changes at the striatal Drd2 promoter drive age-related increases in antipsychotic side effect susceptibility, and HDAC inhibitors may be an effective adjunct treatment strategy to reduce side effects in aged populations.

A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI

BACKGROUND

Medication-induced salivary gland dysfunction (MISGD), xerostomia (sensation of oral dryness), and subjective sialorrhea cause significant morbidity and impair quality of life. However, no evidence-based lists of the medications that cause these disorders exist.

OBJECTIVE

Our objective was to compile a list of medications affecting salivary gland function and inducing xerostomia or subjective sialorrhea.

DATA SOURCES

Electronic databases were searched for relevant articles published until June 2013. Of 3867 screened records, 269 had an acceptable degree of relevance, quality of methodology, and strength of evidence. We found 56 chemical substances with a higher level of evidence and 50 with a moderate level of evidence of causing the above-mentioned disorders. At the first level of the Anatomical Therapeutic Chemical (ATC) classification system, 9 of 14 anatomical groups were represented, mainly the alimentary, cardiovascular, genitourinary, nervous, and respiratory systems. Management strategies include substitution or discontinuation of medications whenever possible, oral or systemic therapy with sialogogues, administration of saliva substitutes, and use of electro-stimulating devices.

LIMITATIONS

While xerostomia was a commonly reported outcome, objectively measured salivary flow rate was rarely reported. Moreover, xerostomia was mostly assessed as an adverse effect rather than the primary outcome of medication use. This study may not include some medications that could cause xerostomia when administered in conjunction with others or for which xerostomia as an adverse reaction has not been reported in the literature or was not detected in our search.

CONCLUSIONS

We compiled a comprehensive list of medications with documented effects on salivary gland function or symptoms that may assist practitioners in assessing patients who complain of dry mouth while taking medications. The list may also prove useful in helping practitioners anticipate adverse effects and consider alternative medications.

Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study

OBJECTIVES

(1) To evaluate the prevalence of polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines) and (2) to determine associated demographic and clinical characteristics in an ageing population with intellectual disabilities (IDs).

DESIGN

Observational cross-sectional study.

SETTING

Wave One (2009/2010) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA).

PARTICIPANTS

A nationally representative sample of 753 persons with ID, aged between 41 and 90 years. Participants/proxy reported medicines (prescription and over the counter) taken on a regular basis; medication data was available for 736 participants (98%).

MAIN OUTCOME MEASURES/INTERVENTIONS

Participants were divided into those with no polypharmacy (0-4 medicines), polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines). Medication use patterns were analysed according to demographic variables and reported chronic conditions. A multinomial logistic regression model identified factors associated with polypharmacy (5-9 medicines) and excessive polypharmacy (≥10 medicines).

RESULTS

Overall, 90% of participants reported use of medicines. Polypharmacy was observed in 31.5% of participants and excessive polypharmacy in 20.1%. Living in a residential institution, and reporting a mental health or neurological condition were strongly associated with polypharmacy and excessive polypharmacy after adjusting for confounders, but age or gender had no significant effect.

CONCLUSIONS

Polypharmacy was commonplace for older adults with ID and may be partly explained by the high prevalence of multimorbidity reported. Review of appropriateness of medication use is essential, as polypharmacy places ageing people with ID at risk of adverse effects.

A literature review of clinical outcomes associated with antipsychotic medication use in North American nursing home residents

The benefits and harms of antipsychotic medication (APM) use in nursing home residents need to be examined because, although commonly used, APMs are considered an off-label use by the Food and Drug Administration for residents with dementia and behavioral problems. The objective of this study was to provide a realist literature review, summarizing original research studies on the clinical effects of conventional and atypical APM use in nursing home residents. Searches of multiple databases identified 424 potentially relevant research articles, of which 25 met the inclusion criteria. Antipsychotic medication use in nursing home residents was found to have variable efficacy when used off-label with an increased risk of many adverse events, including mortality, hip fractures, thrombotic events, cardiovascular events and hospitalizations. Findings suggested certain APM dosing regimens (e.g. fixed-dose) and shorter duration of use might have fewer adverse events. Non-pharmacological interventions should still be considered the first-line treatment option for nursing home residents with dementia related behavioral disturbances, as more studies are needed to establish safer criteria for APM use in nursing homes residents.

Antipsychotics-associated serious adverse events in children: an analysis of the FAERS database

OBJECTIVE

The reports submitted to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) from 1997 to 2011 were reviewed to assess serious adverse events induced by the administration of antipsychotics to children.

METHODS

Following pre-processing of FAERS data by elimination of duplicated records as well as adjustments to standardize drug names, reports involving haloperidol, olanzapine, quetiapine, clozapine, ziprasidone, risperidone, and aripiprazole were analyzed in children (age 0-12). Signals in the data that signified a drug-associated adverse event were detected via quantitative data mining algorithms. The algorithms applied to this study include the empirical Bayes geometric mean, the reporting odds ratio, the proportional reporting ratio, and the information component of a Bayesian confidence propagation neural network. Neuroleptic malignant syndrome (NMS), QT prolongation, leukopenia, and suicide attempt were focused on as serious adverse events.

RESULTS

In regard to NMS, the signal scores for haloperidol and aripiprazole were greater than for other antipsychotics. Significant signals of the QT prolongation adverse event were detected only for ziprasidone and risperidone. With respect to leukopenia, the association with clozapine was noteworthy. In the case of suicide attempt, signals for haloperidol, olanzapine, quetiapine, risperidone, and aripiprazole were detected.

CONCLUSIONS

It was suggested that there is a level of diversity in the strength of the association between various first- and second-generation antipsychotics with associated serious adverse events, which possibly lead to fatal outcomes. We recommend that research be continued in order to gather a large variety and quantity of related information, and that both available and newly reported data be placed in the context of multiple medical viewpoints in order to lead to improved levels of care.

Comparative analysis of the treatment of chronic antipsychotic drugs on epileptic susceptibility in genetically epilepsy-prone rats

Antipsychotic drugs (APs) are of great benefit in several psychiatric disorders, but they can be associated with various adverse effects, including seizures. To investigate the effects of chronic antipsychotic treatment on seizure susceptibility in genetically epilepsy-prone rats, some APs were administered for 7 weeks, and seizure susceptibility (audiogenic seizures) was evaluated once a week during treatment and for 5 weeks after drug withdrawal. Furthermore, acute and subchronic (5-day treatment) effects were also measured. Rats received haloperidol (0.2-1.0 mg/kg), clozapine (1-5 mg/kg), risperidone (0.03-0.50 mg/kg), quetiapine (2-10 mg/kg), aripriprazole (0.2-1.0 mg/kg), and olanzapine (0.13-0.66 mg/kg), and tested according to treatment duration. Acute administration of APs had no effect on seizures, whereas, after regular treatment, aripiprazole reduced seizure severity; haloperidol had no effects and all other APs increased seizure severity. In chronically treated rats, clozapine showed the most marked proconvulsant effects, followed by risperidone and olanzapine. Quetiapine and haloperidol had only modest effects, and aripiprazole was anticonvulsant. Finally, the proconvulsant effects lasted at least 2-3 weeks after treatment suspension; for aripiprazole, a proconvulsant rebound effect was observed. Taken together, these results indicate and confirm that APs might have the potential to increase the severity of audiogenic seizures but that aripiprazole may exert anticonvulsant effects. The use of APs in patients, particularly in patients with epilepsy, should be monitored for seizure occurrence, including during the time after cessation of therapy. Further studies will determine whether aripiprazole really has a potential as an anticonvulsant drug and might also be clinically relevant for epileptic patients with psychiatric comorbidities.

Rare and very rare adverse effects of clozapine

Clozapine (CLZ) is the drug of choice for the treatment of resistant schizophrenia; however, its suitable use is limited by the complex adverse effects' profile. The best-described adverse effects in the literature are represented by agranulocytosis, myocarditis, sedation, weight gain, hypotension, and drooling; nevertheless, there are other known adverse effects that psychiatrists should readily recognize and manage. This review covers the "rare" and "very rare" known adverse effects of CLZ, which have been accurately described in literature. An extensive search on the basis of predefined criteria was made using CLZ and its combination with adverse effects as keywords in electronic databases. Data show the association between the use of CLZ and uncommon adverse effects, including ischemic colitis, paralytic ileus, hematemesis, gastroesophageal reflux disease, priapism, urinary incontinence, pityriasis rosea, intertriginous erythema, pulmonary thromboembolism, pseudo-pheochromocytoma, periorbital edema, and parotitis, which are influenced by other variables including age, early diagnosis, and previous/current pharmacological therapies. Some of these adverse effects, although unpredictable, are often manageable if promptly recognized and treated. Others are serious and potentially life-threatening. However, an adequate knowledge of the drug, clinical vigilance, and rapid intervention can drastically reduce the morbidity and mortality related to CLZ treatment.

Amisulpride for older patients with long-standing schizophrenia

A large and growing number of older people across the world experience schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. The present study was designed to evaluate the efficacy and safety of amisulpride monotherapy in a diagnostically homogeneous group of elderly patients without cognitive impairment experiencing schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for schizophrenia). Mortality and rehospitalization for a 5-year period were the predefined outcome measures. We conducted a retrospective chart review of all elderly (60 years and older) schizophrenia patients treated in a large tertiary care center. Of the 527 elderly schizophrenia patients for a 5-year period (2007-2013), 30 patients, mean (SD) age of 67.5 (5.8) years, were treated with amisulpride monotherapy. There were 19 women and 11 men in the analyzed group. Mean duration of disease was 34.4 years. All had been exposed to at least 3 first- and second-generation antipsychotics before amisulpride treatment. Amisulpride was very well tolerated by the patients, and mortality rate (10% vs 19%) was significantly lower than that of other first- and second-generation antipsychotics (P < 0.02). Rehospitalization rates with amisulpride were significantly lower than those with other second-generation antipsychotics (P < 0.001). We tentatively conclude that our preliminary results demonstrate that amisulpride is an efficacious and safe atypical antipsychotic for the treatment for elderly schizophrenia patients.

Efficacy and tolerability of benzodiazepines for the treatment of behavioral and psychological symptoms of dementia: a systematic review of randomized controlled trials

The objective of this review is to summarize the available data on the use of benzodiazepines for the treatment of behavioral and psychological symptoms of dementia (BPSD) from randomized controlled trials (RCTs). A systematic search of 5 major databases, PubMed, MEDLINE, PsychINFO, EMBASE, and Cochrane Collaboration, yielded a total of 5 RCTs. One study compared diazepam to thioridazine, 1 trial compared oxazepam to haloperidol and diphenhydramine, 1 trial compared alprazolam to lorazepam, 1 trial compared lorazepam to haloperidol, and 1 trial compared intramuscular (IM) lorazepam to IM olanzapine and placebo. The data indicates that in 4 of the 5 studies, there was no significant difference in efficacy between the active drugs to treat the symptoms of BPSD. One study indicated that thioridazine may have better efficacy than diazepam for treating symptoms of BPSD. In 1 study, the active drugs had greater efficacy in treating BPSD when compared to placebo. There was no significant difference between the active drugs in terms of tolerability. However, in 2 of the 5 studies, about a third of the patients were noted to have dropped out of the studies. Available data, although limited, do not support the routine use of benzodiazepines for the treatment of BPSD. But these drugs may be used in certain circumstances where other psychotropic medications are unsafe for use in individuals with BPSD or when there are significant medication allergies or tolerability issues with certain classes of psychotropic medications.

Use and safety of antipsychotics in behavioral disorders in elderly people with dementia

In recent years, the use of antipsychotics has been widely debated for reasons concerning their safety in elderly patients affected with dementia. To update the use of antipsychotics in elderly demented people, a MEDLINE search was conducted using the following terms: elderly, conventional and atypical antipsychotics, adverse events, dementia, and behavioral and psychotic symptoms in dementia (BPSD). Owing to the large amounts of studies on antipsychotics, we mostly restricted the field of research to the last 10 years. Conventional antipsychotics have been widely used for BPSD; some studies showed they have an efficacy superior to placebo only at high doses, but they are associated with several and severe adverse effects. Atypical antipsychotics showed an efficacy superior to placebo in randomized studies in BPSD treatment, with a better tolerability profile versus conventional drugs. However, in 2002, trials with risperidone and olanzapine in elderly patients affected with dementia-related psychoses suggested the possible increase in cerebrovascular adverse events. Drug regulatory agencies issued specific recommendations for underlining that treatment of BPSD with atypical antipsychotics is "off-label." Conventional antipsychotics showed the same likelihood to increase the risk of death in the elderly as atypical agents, and they should not replace the atypical agents discontinued by Food and Drug Administration warnings. Before prescribing an antipsychotic drug, the following are factors to be seriously considered: the presence of cardiovascular diseases, QTc interval on electrocardiogram, electrolytic imbalances, familiar history for torsades des pointes, concomitant treatments, and use of drugs able to lengthen QTc. Use of antipsychotics in dementia needs a careful case-by-case assessment, together with the possible drug-drug, drug-disease, and drug-food interactions.

Inappropriate long-term use of antipsychotic drugs is common among people with dementia living in specialized care units

Background

Antipsychotic drugs are widely used for the treatment of Behavioral and Psychological Symptoms of Dementia (BPSD), despite their limited efficacy and concerns about safety. The aim of this study was to describe antipsychotic drug therapy among people with dementia living in specialized care units in northern Sweden.

Methods

This study was conducted in 40 specialized care units in northern Sweden, with a total study population of 344 people with dementia. The study population was described in regard to antipsychotic drug use, ADL function, cognitive function and BPSD, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). These data were collected at baseline and six months later. Detailed data about antipsychotic prescribing were collected from prescription records.

Results

This study showed that 132 persons (38%) in the study population used antipsychotic drugs at the start of the study. Of these, 52/132 (39%) had prescriptions that followed national guidelines with regard to dose and substance.

After six months, there were 111 of 132 persons left because of deaths and dropouts. Of these 111 people, 80 (72%) were still being treated with antipsychotics, 63/111 (57%) with the same dose. People who exhibited aggressive behavior (OR: 1.980, CI: 1.515-2.588), or passiveness (OR: 1.548, CI: 1.150-2.083), or had mild cognitive impairment (OR: 2.284 CI: 1.046-4.988), were at increased risk of being prescribed antipsychotics.

Conclusion

The prevalence of antipsychotic drug use among people with dementia living in specialized care units was high and inappropriate long-term use of antipsychotic drugs was common.

Short-term safety and pharmacokinetic profile of asenapine in older patients with psychosis

OBJECTIVES

The aim of this study was to assess the short-term tolerability of two titration schedules of sublingual asenapine in older patients with psychosis, not associated with organic brain disease, and to compare asenapine pharmacokinetics in older patients versus younger adults with schizophrenia.

METHODS

Patients ≥ 65 years with psychosis without dementia were randomized for 6 weeks to two dose-escalation regimens: 2 days at 2 mg twice daily (BID), 2 days at 5 mg BID, and 10 mg BID thereafter (slow escalation); or 4 days at 5 mg BID and 10 mg BID thereafter (rapid escalation). Clinical and pharmacokinetic assessments were performed in each group.

RESULTS

Of 122 randomized patients, 76 (62.3%) completed the trial. The incidence of treatment-emergent adverse events (AEs) was comparable (72.1%) with both regimens. The most frequently reported AEs were hypertension, headache, and somnolence; incidence of extrapyramidal symptom-related AEs was 5.7%. Mean end point weight change was 0.4 kg. For asenapine 5 and 10 mg BID, median times to maximum concentration were 1.00 and 1.06 h, respectively; maximum concentrations (C(max) ) were 4.73 and 7.93 ng/mL; areas under the concentration versus time curve (0-12 h; AUC(0-12) ) were 32.1 and 56.3 ng∙h/mL.

CONCLUSIONS

Despite 12-30% increases in asenapine C(max) and AUC(0-12) in older patients compared with previously published findings in younger schizophrenia patients, possibly as a result of slower drug clearance, asenapine was generally well tolerated during both dose-escalation schedules. No dose adjustment appears to be necessary in older patients.

Risk of falls and fractures in older adults using atypical antipsychotic agents: a propensity score-adjusted, retrospective cohort study

BACKGROUND

Atypical antipsychotic agents are extensively prescribed in the elderly to treat various behavioral and psychiatric disorders. Past literature has documented an increased risk of falls and factures with the use of risperidone and olanzapine compared with nonuse. However, none of the studies assessed the comparative safety profiles of atypical agents with respect to falls and fractures.

OBJECTIVE

The goal of this study was to evaluate the risk of falls and fractures associated with the use of risperidone, olanzapine, and quetiapine in community-dwelling adults aged ≥50 years.

METHODS

The study involved a propensity score-adjusted approach in new users of risperidone, olanzapine, or quetiapine anytime between July 1, 2000, and June 30, 2008, using data from the IMS LifeLink Health Plan Claims database. Patients were followed up until a hospitalization/emergency department visit for fall/fracture or the end of the study period, whichever occurred earlier. The Cox proportional hazards regression model was used to evaluate the comparative risk of falls/fractures. The covariates in the final model included propensity scores and their interaction terms.

RESULTS

There were 12,145 new users of atypical agents in the study population (5083 risperidone, 4377 olanzapine, and 2685 quetiapine). A total of 417 cases of falls/fractures with at least 1 hospitalization/ emergency department visit after the use of the antipsychotic agents were identified. The number of falls for risperidone, olanzapine, and quetiapine were 179 (3.56%), 123 (2.84%), and 115 (4.34%), respectively. After adjusting for propensity scores, the Cox proportional hazards model showed that there was no statistically significant difference with use of risperidone (hazard ratio = 1.10 [95% CI, 0.86-1.39]) or quetiapine (hazard ratio = 1.12 [95% CI, 0.86-1.46]) compared with olanzapine (reference group) in the risk of falls or fractures.

CONCLUSIONS

The study found no significant difference across the individual atypical agents in the risk of falls/fractures in community-dwelling older adults. Future studies are required to evaluate the overall safety profiles of the antipsychotic agents in this population.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Are atypical antipsychotics safer than typical antipsychotics for treating behavioral and psychological symptoms of dementia?

Atypical antipsychotics seem to be preferable than conventional agents in treating psychological symptoms of dementia (BPSD), because they have substantially lower risks of extrapyramidal neurological effects with lower reported rates of parkinsonism and tardive dyskinesia. However, in the course of time, with the increase in their use, more and more side effects have been reported. The benefits and risks of antipsychotic treatment should be carefully evaluated according to the co-morbidity and the severity of the psychological and behavioral symptoms and their impact on the individual elderly patient. It is recommended to keep those medications in the lower range of therapeutic doses. Due to the complexity of the individual patient, no guidelines have been yet established. Therefore, clinical judgment should be used in applying the dose and the type of those drugs.

The use of medications with anticholinergic properties and risk factors for their use in hospitalised elderly patients

PURPOSE

The aims of the present study were to evaluate the use of drugs with anticholinergic properties in elderly patients and to identify risk factors that increase the patient's chance of being given such medications.

METHODS

The study was performed on a sample of 1636 patients aged ≥65 years hospitalised during the period between 1 January 2008 and 31 December 2009 in three municipal hospitals. To evaluate the factors influencing the use of anticholinergic medications, we compared two groups-users and non-users of such drugs-in terms of sociodemographic and clinical characteristics as well as comorbid conditions. The most important risk factors were identified using the binary logistic regression model.

RESULTS

Hospitalisation led to a significant increase in the prevalence of anticholinergic medication users, when comparing their occurrence at the time of hospital admission and discharge (10.5% and 14.2%, respectively; p < 0.001). A significantly higher total number of prescribed drugs were found in the group of users compared with non-users, at both hospital admission (7.2 ± 3.5 vs 5.7 ± 3.1; p < 0.001) and discharge (8.7 ± 3.1 vs 7.5 ± 2.9; p < 0.001). Immobilisation, urinary incontinence and retention, constipation, gastroduodenal ulcer disease as well as neurologic and psychiatric comorbidities (depression, Parkinson's disease, epilepsy) appeared as the most important risk factors of using anticholinergic medications.

CONCLUSIONS

Physicians should be aware of the greater risk of adverse anticholinergic effects of drugs in certain therapeutic classes in the elderly. In patients with risk factors mentioned previously, special attention should be paid to active identification of anticholinergic effects of medications.

Pharmacokinetics and metabolism update for some recent antipsychotics

INTRODUCTION

The search for drugs that reduce psychotic symptoms, with minimal adverse effects, has led to the development of new agents that act somewhat differently from their older antipsychotic counterparts. These agents, which include aripiprazole, lurasidone and perospirone, act by targeting both D₂ and 5-HT(1A) receptors, in addition to other characteristic receptors.

AREAS COVERED

This article covers the pharmacokinetics and metabolism of aripiprazole, perospirone, lurasidone and cariprazine. The review also describes the effects of physiological and pathological variables on these drugs as well as potential drug interactions. The author provides the reader with knowledge of the fundamental pharmacokinetic characteristics and metabolic pathways of these new antipsychotics, emphasizing the clinically important common features and differences compared to other older agents.

EXPERT OPINION

Aripiprazole, perospirone, lurasidone and cariprazine share some of the pharmacokinetic characteristics of older, lipophilic antipsychotics and, like these, each has some distinct pharmacokinetic features that are clinically beneficial and some that are not. We await the results of future practical effectiveness trials of these new antipsychotics and their follow-on derivatives to learn more about their benefit/risk profile compared with established antipsychotics. It is hoped that some of these newer antipsychotics will not only increase the range of pharmacotherapeutic options, but decisively improve the expectations of psychotherapy for schizophrenia.

Exploring off-targets and off-systems for adverse drug reactions via chemical-protein interactome--clozapine-induced agranulocytosis as a case study

In the era of personalized medical practice, understanding the genetic basis of patient-specific adverse drug reaction (ADR) is a major challenge. Clozapine provides effective treatments for schizophrenia but its usage is limited because of life-threatening agranulocytosis. A recent high impact study showed the necessity of moving clozapine to a first line drug, thus identifying the biomarkers for drug-induced agranulocytosis has become important. Here we report a methodology termed as antithesis chemical-protein interactome (CPI), which utilizes the docking method to mimic the differences in the drug-protein interactions across a panel of human proteins. Using this method, we identified HSPA1A, a known susceptibility gene for CIA, to be the off-target of clozapine. Furthermore, the mRNA expression of HSPA1A-related genes (off-target associated systems) was also found to be differentially expressed in clozapine treated leukemia cell line. Apart from identifying the CIA causal genes we identified several novel candidate genes which could be responsible for agranulocytosis. Proteins related to reactive oxygen clearance system, such as oxidoreductases and glutathione metabolite enzymes, were significantly enriched in the antithesis CPI. This methodology conducted a multi-dimensional analysis of drugs' perturbation to the biological system, investigating both the off-targets and the associated off-systems to explore the molecular basis of an adverse event or the new uses for old drugs.

Idiosyncratic drug reactions (IDR) generally cannot be identified until after a drug is taken by a large population, but usually result in restricted use or withdrawal. Clozapine provides the most effective treatment for schizophrenia but its use is limited because of a life-threatening IDR, i.e., the agranulocytosis. A high impact clinical study demonstrated the necessity of moving clozapine from 3^rd line to 1^st line drug; therefore, intensive research has aimed at identifying genes responsible for clozapine-induced agranulocytosis (CIA). Olanzapine, an analog of clozapine, has much lower incidence of agranulocytosis. Based on this phenomenon, we proposed an in silico methodology termed as antithesis chemical-protein interactome (CPI), which mimics the differences in the drug-protein interactions of the two drugs across a panel of human proteins. e.g., HSPA1A was identified to be targeted by clozapine not olanzapine. Furthermore, the gene expression of the HSPA1A-related gene system was also found up-regulated after clozapine treatment. This approach can examine the system's perturbation in terms of both the off-target and the off-system's interaction with the drug, providing theoretical basis for decoding the adverse drug reactions or the new uses for old drugs.

The elderly safety imperative and antipsychotic usage

Behavioral and psychotic symptoms are common problems in older adults, and as the population ages, understanding the benefits and risks of antipsychotic usage is increasingly important. In this age group, psychotic symptoms may occur in patients with dementia or as part of schizophrenia, mood disorders, delirium, or delusional disorder. Various antipsychotics have been studied in older adults with psychotic symptoms, demonstrating mixed, but real, benefit, especially in relation to carefully selected patients. Caution is required because of the potential side effects and risks, which include increased mortality and cardiovascular and cerebrovascular events. This article reviews the use of antipsychotics in older adults, with emphasis on the risks and side effects, particularly in dementia patients with behavioral and psychotic symptoms.

An epidemiologic study of psychotropic medication and obesity-related chronic illnesses in older psychiatric patients

OBJECTIVE

Adverse effects from medication vary with age. Weight gain with several psychotropics is well known in adults but less information is available related to extent and complications of psychotropic-induced weight gain in older psychiatric patients. We determined the relative incidence of 2 obesity-related conditions (diabetes and hypertension) in older psychiatric patients receiving antipsychotics, antidepressants, and mood stabilizers.

METHOD

A population-based case-control study of all psychiatric patients aged 67 years or older in contact with either specialist services or primary care using administrative data from Nova Scotia.

RESULTS

We identified incident cases of diabetes (n = 608) and of hypertension (n = 1056), as well as an equal number of control subjects for each condition. Amitryptiline, selective serotonin reuptake inhibitors (SSRIs), and olanzapine were associated with an increased risk of presenting with hypertension 6 months after initial prescription. By contrast, conventional antipsychotics were associated with a reduced incidence of hypertension. Olanzapine was also significantly associated with diabetes after 6 months (OR adj = 2.58, 95% CI 1.12 to 5.92). The findings for SSRIs and olanzapine remained significant after adjusting for potential confounders such as sociodemographic characteristics, schizophrenia, beta blockers, thiazide diuretics, and corticosteroids.

CONCLUSIONS

Our results suggest that the association of psychotropics and 2 obesity-related conditions, hypertension and diabetes, applies to older psychiatric patients as well as younger populations. Within drug classes, there are drugs that have a greater association than others, and this may be a factor when choosing a specific agent.

Population pharmacokinetic modelling of aripiprazole and its active metabolite, dehydroaripiprazole, in psychiatric patients

AIMS

The aims of this study were to develop a combined population pharmacokinetic model for both aripiprazole and its active metabolite, dehydroaripiprazole, in psychiatric patients and to identify to what extent the genetic polymorphisms of cytochrome P450 (CYP) enzymes contribute to the variability in pharmacokinetics (PK).

METHODS

A population pharmacokinetic analysis was performed using NONMEM software based on 141 plasma concentrations at steady state from 80 patients receiving multiple oral doses of aripiprazole (10-30 mg day(-1)).

RESULTS

A one-compartment model with first-order kinetics for aripiprazole and dehydroaripiprazole each was developed to describe simultaneously the concentration data. The absorption rate constant was fixed to 1.06 h(-1). The typical value of apparent distribution volume of aripiprazole was estimated to be 192 l. Covariate analysis showed that CYP2D6 genetic polymorphisms significantly influenced the apparent clearance of aripiprazole (CL/F), reducing the interindividual variability on CL/F from 37.8% CV (coefficient of variation) to 30.5%. The CL/F in the CYP2D6 IMs was approximately 60% of that in CYP2D6 EMs having two functional alleles. Based on the CYP2D6 genotype, the metabolic ratios were calculated at 0.20-0.34. However, the plasma concentration : dose ratios of dehydroaripiprazole were not different across the CYP2D6 genotype.

CONCLUSIONS

This population pharmacokinetic model provided an adequate fit to the data for both aripiprazole and dehydroaripiprazole in psychiatric patients. The usefulness of CYP genotyping as an aid to select the starting dose should be further investigated.