Atypical antipsychotics for the treatment of bipolar disorder: more shadows than lights

Dental and medical management of the patient with bipolar disorder

OBJECTIVE

The objective of this literature review is to understand the appropriate medical management of patients with bipolar disorder (BD) which subsequently can translate into the effective dental management of patients suffering with this illness METHODS: This study was completed using three databases which included PubMed, Google Scholar and Cochrane library. Additionally, relevant dental and medical textbooks were also used to summarize more complex topics regarding BD. Descriptors used to find relevant articles included "Bipolar Disorder", "Adverse drug effects of bipolar medications", and "Orofacial findings with patients with bipolar disorder". A total of 49 relevant articles and textbooks were found which were included in this literature review.

RESULTS

BD is a mental illness which affects millions worldwide. It is characterized by alternating episodes of mania and depression. During the manic phase there is an abnormal elevation in mood whereas the depressive episodes consist of the opposite. The medical management of BD involves pharmacotherapy and psychotherapy. Common dental findings in patients with BD include caries, periodontal disease, xerostomia and adverse oral effects from the medications used to manage this illness.

CONCLUSION

BD has a significant burden on society and to effectively manage their medical and dental needs, the clinician must be well versed in their illness.

A Comprehensive Review on Importance and Quantitation of Atypical Antipsychotic Drugs and their Active Metabolites in Commercial Dosage Forms

Background:

Schizophrenia is a severe mental illness that affects more than twenty-one million people throughout the world. Schizophrenia also causes early death. Schizophrenia and other related psychotic ailments are controlled by the prescription of antipsychotic drugs, which act by blocking certain chemical receptors in the brain and thus relieves the symptoms of psychotic disorder. These drugs are present in the different dosage forms in the market and provided in a certain amount as per the need of the patients.

Objective:

Since such medications treat mental disorders, it is very important to have a perfect and accurate dose so that the risk factor is not affected by a higher or lower dose, which is not sufficient for the treatment. For accurate assay of these kinds of drugs, different analytical methods were developed ranging from older spectrophotometric techniques to latest hyphenated methods.

Results:

The current review highlights the role of different analytical techniques that were employed in the determination and identification of antipsychotic drugs and their metabolites. Techniques such as spectrophotometry, fluorimetry, liquid chromatography, liquid chromatography-mass spectrometry, gas chromatography, and gas chromatography-mass spectrometry employed in the method development of such antipsychotic drugs were reported in the review. Different metabolites, identified using the hyphenated techniques, were also mentioned in the review. The synthesis pathways of few of the metabolites were mentioned.

Conclusion:

The review summarizes the analyses of different antipsychotic drugs and their metabolites. A brief introduction of illnesses and their symptoms and possible medications were highlighted. Synthesis pathways of the associated metabolites were also mentioned.

Movement Disorders After Exposure to Antipsychotic Drugs in Patients With Depressive Disorders

OBJECTIVES

The aims of the study were to explore the frequency of movement disorders (MDs) in depressive patients exposed to antipsychotic drugs (APDs) and to compare it with nonexposed depressive patients and APDs-treated schizophrenic patients.

METHODS

Four hundred fifty-two depressive patients not exposed to APDs (group A), 156 depressives exposed to APDs (group B), and 75 patients with schizophrenia on APDs (group C) were recruited. Presence of MDs was explored by the Simpson-Angus and UKU scales (Registration: NCT02409823).

RESULTS

Movement disorders were observed in 5%, 9%, and 13% of patients in groups A to C, respectively (P < 0.001, χ for linear trend). A logistic multivariate analysis revealed that male sex (odds ratio = 2.26, 95% confidence interval = 1.13-4.49, P < 0.01), exposure to first-generation (vs second-generation) APDs (odds ratio = 5.71, 95% confidence interval = 2.08-15.66, P < 0.01), and exposure to lithium (odds ratio = 3.99, 95% confidence interval = 1.74-9.14, P < 0.01) were independently and significantly associated with MDs.

CONCLUSIONS

Male sex, use first-generation APDs, and exposure to lithium were associated with MDs in depression. Therefore, caution is advised with the use of these drugs in depressive patients. Prospective studies are needed to confirm these results.

A Retrospective Cohort Study of Acute Kidney Injury Risk Associated with Antipsychotics

BACKGROUND

A recent large database analysis raised concerns of potential acute kidney injury (AKI) risk associated with antipsychotics. However, whether individual atypical and typical antipsychotics are associated with differential AKI risks has not been investigated.

OBJECTIVE

The current study compared the risks of AKI and known causes of AKI associated with a broad range of atypical and typical antipsychotics.

METHOD

This retrospective cohort analysis used January 2007-June 2013 US nationwide Humana claims data to define episodes of antipsychotic drug therapy for patients with schizophrenia and bipolar disorder. Study drugs were aripiprazole, fluphenazine, haloperidol, olanzapine, quetiapine, risperidone, and ziprasidone. Study outcomes were hospitalizations with AKI, and known causes of AKI, i.e., hypotension, acute urinary retention, neuroleptic malignant syndrome/rhabdomyolysis, and pneumonia. AKI was the primary outcome of the study. Cox regressions using haloperidol as the baseline comparator were used to estimate the impact of alternative antipsychotics on the risks of study adverse events following the initiation of treatment. The Cox models controlled for treatment history, comorbidities, and concomitant drug use in the prior 6 months. They also controlled for patient demographics and dose of current treatment.

RESULTS

The overall incidence of AKI was 25.0 per 1000 person-years. According to our multivariate regression results, the risk of AKI was significantly increased in patients taking olanzapine [hazard ratio (HR) 1.344, 95% confidence interval (CI) 1.057-1.708], quetiapine (HR 1.350, 95% CI 1.082-1.685), and ziprasidone (HR 1.338, 95% CI 1.035-1.729) relative to haloperidol. Aripiprazole (HR 1.152, 95% CI 0.908-1.462) and risperidone (HR 1.147, 95% CI 0.923-1.426) had insignificantly higher risks of AKI compared with haloperidol, whereas fluphenazine (HR 0.729, 95% CI 0.483-1.102) had an insignificantly lower risk of AKI. When compared between drug classes, atypical antipsychotics had a significantly higher risk of AKI (HR 1.313, 95% CI 1.083-1.591) than typical antipsychotics.

CONCLUSIONS

Antipsychotics are associated with differential AKI risks, with several atypical antipsychotics having higher risks than haloperidol. However, the overall incidence of AKI was moderate, and AKI risk should only raise concern for clinicians with elderly patients or patients who are vulnerable to kidney disease.

Olanzapine or chlorpromazine plus lithium in first episode psychotic mania: An 8-week randomised controlled trial

Background

Treatment strategies for mental disorders may vary according to illness stage. However no data currently exist to guide treatment in first episode psychotic mania. The aim of this study was to compare the safety and efficacy profile of chlorpromazine and olanzapine, as add-on to lithium, in patients with a first episode of psychotic mania, expecting better safety profile and adherence to olanzapine but similar efficacy for both treatments.

Methods

Data from 83 patients were collected in an 8-week randomised controlled trial on clinical variables, side effects, vital signs, and weight. Analyses of treatment differences over time were based on intent-to-treat principles. Kaplan-Meier estimated survival curves were used to analyse time-to-event data and mixed effects models repeated measures analysis of variance were used to determine treatment group differences over time on safety and efficacy measures.

Results

Ethics committee approval to delay informed consent procedure until recovery from the acute episode allowed the inclusion of 83 patients highly representative of those treated in the public sector. Contrary to our hypotheses, safety profile of both medications was similar. A signal for higher rate (P=.032) and earlier occurrence (P= .043) of mania remission was observed in the olanzapine group which did not survive correction for multiple comparisons.

Conclusions

Olanzapine and chlorpromazine have a similar safety profile in a uniquely representative cohort of patients with first episode psychotic mania. The possibility for a greater impact of olanzapine on manic symptoms leading to earlier remission of the episode needs exploration in a large sample.

Patterns of atypical antipsychotic therapy use in adults with bipolar I disorder in the USA

OBJECTIVES

This study aims to describe the utilization patterns of atypical antipsychotics (AA) among insured patients with bipolar I disorder in the USA.

METHODS

We studied patients with bipolar I disorder who newly initiated an oral AA between 2002 and 2008. Utilization measures included adherence [medication possession ratio (MPR) ≥80%], persistence (gaps ≤15 days between refills and an absence of ≥30 days of continuous concomitant non-index AA use), non-compliance (16-29 day gaps with no evidence of switch/augmentation), and discontinuation of the index AA (≥30 days without index AA, no evidence of switch/augmentation).

RESULTS

The study included 16 807 patients: mean age 43.3 years, 67.7% female. Overall, adherence to the index AA was low (8.3%; mean MPR = 0.2). Only 10.5% of the patients were persistent to index AA, another 13.6% were non-compliant, and 63.4% discontinued index AA with an average time to discontinuation of 66 days. A majority (69.5%) of the discontinued patients did not resume any antipsychotic therapy. Results were similar across insurance types and index AA.

CONCLUSION

Adherence to and persistence with AA treatment were low in new users with bipolar I disorder. Most patients discontinued the index AA and did not restart any antipsychotic treatment. Future study should distinguish physician-directed discontinuation versus patient non-adherence.

Commentary on a recent review of lithium toxicity: what are its implications for clinical practice?

A recent paper by McKnight et al. in The Lancet has provided the first formal meta-analysis of the more common adverse reactions to lithium. The authors analyzed 385 studies and focused mainly on the harmful effects of lithium on the kidney, the thyroid and parathyroid glands, body weight, skin and congenital malformations. Their contribution is important and welcome, but as a guide for practice, it needs to be complemented by other relevant observations and individual patient-focused perspectives.The findings from that meta-analysis somewhat underestimate the renal side-effects, and distort to some degree or exclude other adverse effects. The glomerular filtration rate is reduced but not more than 0 to 5 ml/min/year of observation; this may not fully reflect the present state of knowledge. A quarter of patients in the study had abnormalities of the thyroid and/or parathyroid gland, and lithium was found to increase body weight significantly less than did olanzapine. Unfortunately, the authors did not consider the observations from spontaneous reporting systems, which may have changed the picture.We feel that some specific limitations of the study were related to the inclusion of patients regardless of adequacy of treatment, quality of monitoring, drug combinations, age and sex, and stabilization response.

Aripiprazole: a review of its use in the management of mania in adults with bipolar I disorder

Aripiprazole (Abilify®) is an atypical antipsychotic indicated for the treatment of mania associated with bipolar I disorder. It is unique in its class, as it is a partial agonist of dopamine D(2) and D(3), and serotonin 5-HT(1A) receptors and a modest antagonist of 5-HT(2A) receptors. This article reviews the pharmacological properties, clinical efficacy and tolerability of oral aripiprazole in the management of mania associated with bipolar I disorder in adults. In well designed clinical trials in patients with recent manic or mixed episodes associated with bipolar I disorder, oral aripiprazole monotherapy or adjunctive therapy to lithium or valproate improved symptoms of mania following short-term (≤12 weeks) or maintenance (≤100 weeks) treatment. In addition, maintenance treatment with aripiprazole (as monotherapy or adjunctive therapy) prevented the recurrence of any mood episodes or manic episodes (but not depressive episodes) in patients who had previously been stabilized and maintained on aripiprazole. Aripiprazole was generally well tolerated in these studies and was associated with a low risk of prolactin elevation, corrected QT interval prolongation and metabolic disturbances. Extrapyramidal symptoms occurred in up to 28% of aripiprazole recipients, but after longer-term treatment (≤100 weeks), symptom severity did not differ significantly from that in placebo recipients. Aripiprazole treatment generally did not increase bodyweight to a clinically relevant extent; however, more patients receiving aripiprazole monotherapy than placebo had clinically significant bodyweight gain during 100 weeks' treatment. Additionally, in a comparative trial, aripiprazole monotherapy was at least as effective as haloperidol monotherapy in terms of improving symptoms of mania, but had the advantage of a lower incidence of some adverse events, such as extrapyramidal symptom-related adverse events. Further trials comparing aripiprazole with other agents, including atypical antipsychotics, would help to definitively position aripiprazole relative to these agents. Current guidelines recommend aripiprazole as a first-line option (as monotherapy or adjunctive therapy) for the short-term treatment of mania associated with bipolar I disorder, and as a first-line (as monotherapy) or second-line (as adjunctive therapy) option for preventing the recurrence of mood episodes during longer-term therapy.

Lithium in pregnancy: the need to treat, the duty to ensure safety

INTRODUCTION

Untreated bipolar disorder during pregnancy leads to detrimental repercussions on the mother-infant pair's health. Despite different drugs having been proposed as mood stabilizers, lithium remains the first-choice agent for preventing mood changes.

AREAS COVERED

Analyzing up-to-date information on the reproductive safety of lithium and providing practice guidelines to optimize its use during pregnancy.

EXPERT OPINION

Findings from prospective and case-control studies confirm an increased, specific risk of Ebstein's anomaly (4.45-7.6/1000 live births), although lower than that previously reported. A potential increase in the risk of neural tube defects should also be taken into consideration. Moreover, several perinatal complications may occur, and even in the presence of relatively low infant serum levels, in the case of drug exposure during late pregnancy. Despite such concerns, lithium should still be considered the first-choice agent for treating bipolar disorder in pregnancy. Indeed, the U.S. FDA recently issued a new warning regarding the reproductive safety of antipsychotics. Moreover, the risk of fetal valproate/carbamazepine syndrome (and the confirmed neurodevelopmental teratogenicity of valproate) contraindicates the use of both medications, whereas the use of lamotrigine is limited by efficacy concerns. However, women who need lithium treatment during pregnancy should be carefully monitored: a strict gynecologic and psychiatric surveillance and, probably, preconception folate supplementation is highly advisable. Moreover, delivery should be programmed in Neonatal Intensive Care Units to ensure optimal management of potential iatrogenic perinatal complications.

Antipsychotics in the treatment of bipolar disorder

Atypical antipsychotics have an important role in the acute and maintenance treatment of bipolar disorder. While robust evidence supports the efficacy of these agents in the treatment of mania and in the prevention of manic relapse, few atypical antipsychotics have shown efficacy in the treatment or prevention of depressive episodes. These agents pose a lower risk of extrapyramidal side effects compared to typical neuroleptics, but carry a significant liability for weight gain and other metabolic side effects such as hyperglycemia and hyperlipidemia. More comparative effectiveness studies are needed to assess the optimal treatment regimens, including the relative benefits and risks of antipsychotics versus mood stabilizers. The exploration of the molecular mechanisms of antipsychotics has helped to shed further light on the underlying neurobiology of bipolar disorder, since these compounds target systems thought to be key to the pathophysiology of bipolar disorder. In addition to modulating monoaminergic neurotransmission, atypical antipsychotics appear to share properties with mood-stabilizing agents known to alter intracellular signal transduction leading to changes in neuronal activity and gene expression. Atypical antipsychotic drugs have been shown to exhibit neuroprotective properties that are mediated by upregulation of trophic and cellular resilience factors. Building on our understanding of existing therapeutics, especially as it relates to underlying disease pathology, newer "plasticity enhancing" strategies hold promise for future treatments of bipolar disorder.

Clinical usefulness of second-generation antipsychotics in treating children and adolescents diagnosed with bipolar or schizophrenic disorders

The onset of severe, chronic or recurrent psychiatric illnesses, such as schizophrenia-spectrum and bipolar disorders, is a dramatic clinical event often detectable during adolescence and even in childhood. At any age, pharmacotherapy, along with enhancement of social skills and family support, is the mainstay for the management of such disorders. The aim of this review is to critically analyze findings from randomized controlled trials (RCTs) that have investigated the clinical utility of second-generation antipsychotics (SGAs) for the treatment of early-onset schizophrenia and bipolar disorders. Eighteen studies were considered, all of which were unfortunately impaired by methodologic limitations, such as the paucity of long-term data and lack of a three-arm comparison (SGA vs SGA vs placebo). Nevertheless, the results of this review allow us to suggest the effectiveness of three SGAs (aripiprazole, olanzapine, and risperidone) in the short-term treatment of both early-onset schizophrenia and bipolar mania, although such agents show different safety profiles. The use of clozapine should be strictly limited to patients with non-affective, psychotic symptoms who do not respond to any of these three SGAs. In contrast, the use of quetiapine and ziprasidone in young patients with either affective or non-affective psychosis is not yet supported by evidence-based information. Given our findings, further studies are urgently required to identify the best treatment option(s) for pediatric bipolar disorder (especially the depressive phase) and the long-term management of early-onset schizophrenia.

Second-generation antipsychotics in dementia: beyond safety concerns. A clinical, systematic review of efficacy data from randomised controlled trials

RATIONALE

Antipsychotic drugs are widely used as a first-line pharmacological approach to treat dementia-related psychiatric symptoms. However, in this population of patients, such drugs have been associated with severe safety concerns. Hence, the aim of this review is to asses systematically the efficacy of second-generation antipsychotics (SGAs) in treating dementia-related neuropsychiatric symptoms in order to establish if the potential clinical benefits of such treatment outweigh the hypothesised risks related to pharmacological intervention.

METHODS

The Cochrane Library, MEDLINE, EMBASE and PsycINFO were searched (from 1980 to June 22, 2010) using terms for included drugs (aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, SGAs) and indications (elderly, dementia, Alzheimer's disease). Electronic database search were supplemented with hand search of references lists of electronically identified articles. Peer-reviewed, randomised, controlled trials published in English and investigating the efficacy of SGAs in patients with different forms of dementia were included in the review process. Information was drawn from the 30 articles that met the inclusion criteria.

RESULTS

Nearly all reviewed studies suffer from methodological limitations too severe to draw definitive conclusions that may inform the decision-making process. Moreover, studies conducted with similar methodological design show conflicting efficacy results.

CONCLUSIONS

Because of their undemonstrated effectiveness, SGAs should be avoided in patients with dementia complicated by psychotic and/or behavioural symptoms. Hence, further researches are urgently needed to identify useful pharmacological strategies that can be used to improve the clinical condition of such patients and to reduce burden to caregivers when behavioural interventions are ineffective.

Antipsychotic therapy during early and late pregnancy. A systematic review

OBJECTIVE

Both first- (FGAs) and second-generation antipsychotics (SGAs) are routinely used in treating severe and persistent psychiatric disorders. However, until now no articles have analyzed systematically the safety of both classes of psychotropics during pregnancy. DATA SOURCES AND SEARCH STRATEGY: Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, TOXNET, EMBASE, and The Cochrane Library. Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from companies developing drugs. Search terms were pregnancy, psychotropic drugs, (a)typical-first-second-generation antipsychotics, and neuroleptics. A separate search was also conducted to complete the safety profile of each reviewed medication. Searches were last updated on July 2008.

DATA SELECTION

All articles reporting primary data on the outcome of pregnancies exposed to antipsychotics were acquired, without methodological limitations.

CONCLUSIONS

Reviewed information was too limited to draw definite conclusions on structural teratogenicity of FGAs and SGAs. Both classes of drugs seem to be associated with an increased risk of neonatal complications. However, most SGAs appear to increase risk of gestational metabolic complications and babies large for gestational age and with mean birth weight significantly heavier as compared with those exposed to FGAs. These risks have been reported rarely with FGAs. Hence, the choice of the less harmful option in pregnancy should be limited to FGAs in drug-naive patients. When pregnancy occurs during antipsychotic treatment, the choice to continue the previous therapy should be preferred.

Contributing factors to weight gain during long-term treatment with second-generation antipsychotics. A systematic appraisal and clinical implications

The increased rates of both overweight and obesity reported in severely mentally-ill patients are prevalently due to the use of second-generation antipsychotics (SGAs). Hence, the main purpose of this article is to analyze systematically potential patient- and drug-related factors which may increase the risk of weight gain during long-term treatment with such medications. Literature information published in English since 1966 and last updated on 17 January 2009 was identified through different databases and using various combinations of search terms. Searches provided 242 articles, whereas 6 additional references were identified manually. Peer-reviewed articles focusing on the risk of weight gain during SGA-chronic treatment (at least 52 weeks, N = 81) were acquired. Data were extracted from the 39 peer-reviewed articles which investigated factors potentially associated with an increased risk of this event. Evidence-based information suggests that a number of factors, either patient- (age, baseline BMI/bodyweight, recent onset of psychotic episodes, need of concomitant psychotropic medications) or drug-specific (relative receptorial affinity, timing of weight changes plateau, daily dose, iatrogenic concomitant changes in biochemical metabolic parameters) may contribute to increase either rates and/or magnitude of this effect during long-term treatments with specific SGAs. All contributors and their relationship with specific drugs should be taken into consideration when designing a long-term therapy with SGAs. Among the best studied agents (clozapine, olanzapine, and risperidone) of this class, the latter seems to be the most susceptible drug to the amplifying effects of both patient- and drug-related factors on the risk of inducing weight changes during chronic treatments.

A systematic review of quality of life and weight gain-related issues in patients treated for severe and persistent mental disorders: focus on aripiprazole

Aripiprazole is a relatively novel second-generation antipsychotic belonging to the chemical class of benzisoxazole derivatives and is characterized by a unique pharmacological profile which suggests that the drug acts as a dopamine-serotonin system stabilizer. Whereas all previously available antipsychotics are antagonists at D(2) receptors, aripiprazole is the only available partial agonist at these receptors. Thus, it has been suggested that aripiprazole could be associated with a relatively neutral impact on bodyweight, possibly reducing risks of a detrimental impact on the quality of life that often complicates management for a large number of patients diagnosed with severe and persistent mental disorders (SPMDs) treated chronically with antipsychotic medications. However, data from short- and long-term reviewed studies indicate that the prevalence rate of clinically relevant weight gain during therapy with this drug is similar to that occurring during treatments with other antipsychotic agents, either typical or atypical. Moreover, information on the impact of aripiprazole therapy on the quality of life of patients diagnosed with SPMDs is scarce and characterized by conflicting results. Given these results, further, large, well-designed studies are needed before confirming potential advantages of aripiprazole over first-generation antipsychotics and other SGAs.