Polypharmacy Management of Antipsychotics in Patients with Schizophrenia

HINT1 promotes neuronal apoptosis and triggers schizophrenia-like behavior in rats

This study aims to investigate the mechanism by which Histidine triad nucleotide-binding protein 1 (HINT1) promotes hippocampal neuronal apoptosis, triggering schizophrenia (SZ)-like behavior in rats. By establishing a rat SZ-like model, we assessed learning, memory, emotional response, and cognitive function through the Morris Water Maze, auditory startle response, and open field tests. HINT1 expression in the hippocampus was analyzed via RT-PCR and Western blot. We also created a HINT1 overexpression model in hippocampal neuronal cells to analyze its effects on cell proliferation and apoptosis. This analysis was conducted using the CCK-8 assay and flow cytometry, along with the quantification of apoptosis-related proteins and neurotrophic factors. Our findings indicated that the SZ-like model rats exhibited diminished learning and memory abilities, altered emotional reactions, and impaired cognitive functions, alongside a notable increase in HINT1 mRNA and protein levels. HINT1 overexpression was observed to inhibit hippocampal neuronal cell proliferation and promote apoptosis, with an increase in the expression of pro-apoptotic proteins and a decrease in neurotrophic factors. These results suggest HINT1's role in the onset and development of SZ-like behavior through its upregulation and induction of apoptosis in hippocampal neuronal cells, underlining its potential as a therapeutic target.

A systematic review and meta-analysis of the effects of combined aripiprazole on glycolipid metabolism in schizophrenia

Background

Current research on aripiprazole adjunct therapy suggests potential benefits in improving psychiatric symptoms and metabolic disorders in patients with schizophrenia. However, the evidence remains limited due to the scarcity of research and a lack of detailed analysis on glucose and lipid metabolism indicators. This study aims to systematically review and analyze randomized controlled trials (RCTs) to evaluate the effects of aripiprazole combination therapy on both psychiatric symptoms and glycolipid metabolism.

Materials and methods

A systematic search of PubMed, EMBASE, and Web of Science databases was conducted to identify randomized controlled trials (RCTs) investigating the impact of aripiprazole combination therapy on glycolipid metabolism and clinical symptoms.

Results

Adjuvant treatment with aripiprazole reduced blood glucose, triglycerides, total cholesterol, and LDL levels in patients with schizophrenia, but had no significant effect on HDL levels. In addition, the study results showed a significant improvement in metabolic parameters at short-term (≤ 8 weeks) and dosing doses >15 mg. However, aripiprazole adjuvant therapy may lead to worsening of clinical symptoms, so caution is required when using it clinically.

Conclusions

Aripiprazole adjunct therapy shows potential benefits in improving both psychiatric symptoms and metabolic parameters, but more comprehensive research is needed to solidify these findings, particularly regarding glycolipid metabolism indicators.

Management of schizophrenia and comorbid substance use disorders: expert review and guidance

BACKGROUND

Schizophrenia and substance use disorders (SUDs) are often comorbid conditions that present clinical challenges due to their heterogeneity and the difficulties associated with poor physical health, low medication adherence, high relapse and hospitalization rates, and increased risk of mortality. This is often exacerbated by a fragmented health care system that treats addiction and mental illness separately, leading to delays in proper diagnosis and treatment.

MAIN TEXT

The aim of this narrative review, based on an extensive literature search and experts' clinical experience, is to synthesize evidence on the psychopathological and clinical characteristics of patients, the burden and management at the level of healthcare system, and possible gaps in the treatment of schizophrenia with comorbid SUD in order to understand and address the needs of patients. Treatment options, differences between antipsychotic medications, and the benefits of long-acting formulations and partial dopaminergic agonists are described. Partial dopamine agonists (aripiprazole, cariprazine, and brexpiprazole) have demonstrated good control of psychotic symptoms and SUDs with a favorable safety profile.

CONCLUSION

Pharmacological interventions should be accompanied by psychosocial support within an integrated and multidisciplinary approach that promotes shared decision-making and a good therapeutic alliance between the entire medical team and the patient.

Adverse event signal mining and severe adverse event influencing factor analysis of Lumateperone based on FAERS database

Background

Lumateperone has been approved by the Food and Drug Administration (FDA) for the treatment of schizophrenia in adults since 2019, however, there is still a lack of data report on adverse reactions in real-world settings. Conducting data mining on adverse events (AEs) associated with Lumateperone and investigating the risk factors for serious AEs can provide valuable insights for its clinical practice.

Methods

AE reports in the FDA Adverse Event Reporting System (FAERS) from 2019 Q4 (FDA approval of Lumateperone) to 2024 Q1 were collected and analyzed. Disproportionality in Lumateperone-associated AEs was evaluated using the following parameters: Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (MGPS). Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for Lumateperone-induced severe AEs.

Results

A total of 2,644 reports defined Lumateperone as the primary suspected drug was collected, including 739 reports classified as severe AEs and 1905 reports as non-severe AEs. The analysis revealed that 130 preferred terms (PTs) with significant disproportionality were based on the four algorithms, 67 (51.53%) of which were not included in the product labeling, affecting 6 systems and organs. In addition, dizziness (81 cases) was the most reported Lumateperone-associated severe AEs, and tardive dyskinesia showed the strongest signal (ROR = 186.24). Logistic regression analysis indicated that gender, bipolar II disorder, and concomitant drug use are independent risk factors for Lumateperone-associated severe AEs. Specifically, female patients had a 1.811-fold increased risk compared with male patients (OR = 1.811 [1.302, 2.519], p = 0.000), while patients with bipolar II disorder had a 1.695-fold increased risk compared with patients diagnosed with bipolar disorder (OR = 1.695 [1.320, 2.178], p = 0.000). Conversely, concomitant use of CYP3A4 inhibitors or drugs metabolized by CYP3A4 was associated with a decreased risk of severe AEs (OR = 0.524 [0.434, 0.633], P = 0.000).

Conclusion

Collectively, this study provides critical insights into the safety profile of Lumateperone. It highlights the need for cautious use in high-risk populations, such as females and individuals with bipolar II disorder, and emphasizes the importance of monitoring for AEs, including dizziness and tardive dyskinesia. Healthcare also should remain alert to potential AEs not listed in the prescribing information to ensure medical safety.

Post Hospitalization Clinical Quality Outcomes Among US Patients with Schizophrenia Treated with a Long-Acting Injectable or Switched to a New Oral Antipsychotic: A Retrospective Cohort Study

BACKGROUND

 Adherence to antipsychotic medication and care discontinuity remain a challenge to healthcare practitioners providing care to patients with schizophrenia.

OBJECTIVE

This study used real-world data from a US hospital-based, all-payer database to examine clinical quality measures among patients with schizophrenia initiated on a long-acting injectable (LAI) or switched to a new oral antipsychotic medication (OAP) following a hospitalization.

METHODS

A retrospective cohort study using the PINC AI™ Healthcare Database compared two cohorts of patients with schizophrenia on post-index hospitalization clinical quality and care continuity endpoints. Patients initiated on an LAI (n = 7292) or switched to a new OAP (n = 31,956) during an index hospitalization between April 2017 and April 2020 were included. Propensity score weighting addressed differences in patient, hospital, and clinical characteristics between the two cohorts.

RESULTS

Patients who initiated an LAI experienced significantly greater adjusted 30-day antipsychotic medication continuation to index therapy, higher rate of 30-day outpatient follow-up care, longer mean time to discontinuation of index therapy, and lower risk of discontinuing their index treatment compared to patients who switched to a new OAP (all p values < 0.001). Probability of 30-day antipsychotic medication continuation was significantly higher for LAI initiators than for patients who switched to a new OAP, even after controlling for patient, clinical, and hospital characteristics (adjusted odds ratio = 1.2, 95% CI 1.1-1.3, p < 0.001).

CONCLUSION

Patients who initiated an LAI in a hospital setting experienced better clinical quality and care continuity outcomes compared to patients who were switched to a new OAP. These findings may be useful in identifying solutions to help improve the quality of medication management post-hospital discharge among patients with schizophrenia.

Polypharmacy in antipsychotic pharmacological treatment among patients with dual diagnosis in Denmark

INTRODUCTION

Antipsychotic polypharmacy is prevalent, however literature on antipsychotic polypharmacy during treatment among patients with dual diagnosis is largely non-existent. This study aims to investigating the extent of antipsychotic polypharmacy dual diagnosis patients during hospitalisations.

METHODS

Utilizing cohort data from an integrated dual diagnosis in-patient facility from patients hospitalized between 1 March 2012, to 31 December 2016, we compared the mean antipsychotic medication administered at admission and discharge and examined covariate associations with logistic regressions.

RESULTS

The study identified 907 hospital admissions, of which 641 were the first for each patient during the period. At admission, 74.1% received antipsychotics; polypharmacy spanned psychiatric disorders. categories. Patients with affective or personality spectrum disorders were less likely to have antipsychotic polypharmacy upon admission compared to those with psychosis spectrum disorders. 2013-2016 admissions presented less polypharmacy than 2012. Mean antipsychotic numbers remained unchanged for >30-day hospitalizations. Patients admitted without antipsychotic polypharmacy with an affective spectrum disorder or aged 41-50 or over 51 years old were less likely to be discharged with antipsychotic polypharmacy when compared to patients with psychosis spectrum disorder or aged 18-30 years old.

CONCLUSION

Approximately three-quarters of admitted patients were treated with antipsychotic medication. Antipsychotic polypharmacy was observed across all psychiatric disorder categories, indicating potential off-label use. Addressing antipsychotic polypharmacy during treatment is challenging, even for specialised facilities. Rational antipsychotic prescribing, deprescribing protocols, and further prescription pattern research are needed.

Evaluation of neuroleptic malignant syndrome induced by antipsychotic drugs using spontaneous reporting system

Adverse events (AEs) of antipsychotic drugs include neuroleptic malignant syndrome (NMS), which presents complex clinical symptoms, resulting in a fatal outcome. In this study, the association between antipsychotic drugs and NMS was comprehensively evaluated by cluster and association analyses using the Japanese Adverse Drug Event Report (JADER) database. The analyses were performed using 20 typical antipsychotics (TAPs) alongside 9 atypical antipsychotics (AAPs). The Standardised MedDRA Queries (SMQ) database was used to analyze NMS (SMQ code: 20000044). Reporting odds ratios (RORs) were used for AE signal detection. The relationship between antipsychotic drugs and AEs for NMS was investigated by performing hierarchical cluster analysis using Ward's method. Between April 2004 and September 2021, the total number of JADER reports was 705,294. RORs (95 % confidence interval) of NMS for haloperidol, chlorpromazine, risperidone, and aripiprazole were 12.1 (11.1-13.3), 6.3 (5.7-7.0), 6.2 (5.8-6.6), and 4.7 (4.4-5.1), respectively. Three clusters were formed, with characteristics as follows: Cluster 1 consisted of only TAPs, such as bromperidol and fluphenazine, whilst having a high reporting rate of hypotension, tachycardia, dyskinesia, and dystonia. Cluster 2 consisted of all AAPs alongside several TAPs, such as haloperidol and chlorpromazine, with higher reporting rates of disturbance of consciousness, extrapyramidal disorders (excluding dyskinesia and dystonia), and serotonin syndrome. Cluster 3 consisted of only perphenazine, whilst having a higher reporting rate of coma, leukocytosis, and Parkinsonism. The results of this study may therefore aid in the management of NMS using antipsychotic drugs.

QTc prolongation in patients with schizophrenia taking antipsychotics: Prevalence and risk factors

BACKGROUND

QTc prolongation is one of the possible complications in patients with schizophrenia taking antipsychotics, which leads to malignant cardiac arrhythmia. No meta-analysis has been reported assessing the prevalence and correlated risk factors for QTc prolongation.

METHODS

This meta-analysis aimed to assess the evidence for the prevalence of QTc prolongation and correlated risk factors in patients with schizophrenia taking antipsychotics. Web of Science and PubMed were searched according to preset strategy. The quality of research was assessed by the Newcastle-Ottawa Scale (NOS).

RESULTS

In all, 15 studies covering 15,540 patients with schizophrenia taking antipsychotics were included. Meta-analysis showed that the prevalence of QTc prolongation in patients with schizophrenia taking antipsychotics was about 4.0% (95% confidence interval (CI): 3.0%-5.0%, p < 0.001). The prevalence was about 4.0% in Asia (95%CI: 3.0%-6.0%, p < 0.001), about 5.0% in Europe (95%CI: 2.0%-7.0%, p < 0.001), and about 2.0% in America (95%CI: 1.0%-3.0%, p < 0.001). Sensitivity analyses indicated the robustness of the result. Publication bias analysis reported a certain publication bias (t = 3.37, p = 0.012). Meta-regression suggested that female and elderly patients were clinically associated with a higher prevalence of QTc prolongation. According to included studies, smoking, comorbidity of cardiovascular disease, and abnormal levels of high-density lipoprotein/low-density lipoprotein might be related to QTc prolongation in patients with schizophrenia taking antipsychotics.

CONCLUSIONS

The prevalence of QTc prolongation in patients with schizophrenia taking antipsychotics was about 4.0%. Female and elderly patients were more likely to experience QTc prolongation. Close electrocardiogram monitoring was suggested in these at-risk populations.

Development and acceptability testing of a decision aid for considering whether to reduce antipsychotics in individuals with stable schizophrenia

AIM

Continued antipsychotic treatment is the key to preventing relapse. Maintenance antipsychotic monotherapy and optimal dose use are recommended for individuals with stable schizophrenia because of their undesirable effects. Decision aids (DAs) are clinical conversation tools that facilitate shared decision-making (SDM) between patients and health-care providers. This study aimed to describe the development process and results of acceptability testing of a DA for individuals with stable schizophrenia, considering (i) whether to continue high-dose antipsychotics or reduce to the standard dose and (ii) whether to continue two antipsychotics or shift to monotherapy.

METHODS

A DA was developed according to the guidelines for the appropriate use of psychotropic medications and International Patient Decision Aid Standards (IPDAS). First, a DA prototype was developed based on a previous systematic review and meta-analysis conducted for identifying the effects of continuing or reducing antipsychotic treatment. Second, mixed-method survey was performed among individuals with schizophrenia and health-care providers to modify and finalize the DA.

RESULTS

The DA consisted of an explanation of schizophrenia, options to continue high-dose antipsychotics or reduce to the standard dose, options to continue two antipsychotics or shift to monotherapy, pros and cons of each option, and a value-clarification worksheet for each option. The patients (n = 20) reported acceptable language use (75%), adequate information (75%), and well-balanced presentation (79%). Health-care providers (n = 20) also provided favorable overall feedback. The final DA covered six IPDAS qualifying criteria.

CONCLUSION

A DA was successfully developed for schizophrenia, considering whether to reduce antipsychotics, which can be used in the SDM process.

Nanosystems for Brain Targeting of Antipsychotic Drugs: An Update on the Most Promising Nanocarriers for Increased Bioavailability and Therapeutic Efficacy

Orally administered antipsychotic drugs are the first-line treatment for psychotic disorders, such as schizophrenia and bipolar disorder. Nevertheless, adverse drug reactions jeopardize clinical outcomes, resulting in patient non-compliance. The design formulation strategies for enhancing brain drug delivery has been a major challenge, mainly due to the restrictive properties of the blood-brain barrier. However, recent pharmacokinetic and pharmacodynamic in vivo assays confirmed the advantage of the intranasal route when compared to oral and intravenous administration, as it allows direct nose-to-brain drug transport via neuronal pathways, reducing systemic side effects and maximizing therapeutic outcomes. In addition, the incorporation of antipsychotic drugs into nanosystems such as polymeric nanoparticles, polymeric mixed micelles, solid lipid nanoparticles, nanostructured lipid carriers, nanoemulsions, nanoemulgels, nanosuspensions, niosomes and spanlastics, has proven to be quite promising. The developed nanosystems, having a small and homogeneous particle size (ideal for nose-to-brain delivery), high encapsulation efficiency and good stability, resulted in improved brain bioavailability and therapeutic-like effects in animal models. Hence, although it is essential to continue research in this field, the intranasal delivery of nanosystems for the treatment of schizophrenia, bipolar disorder and other related disorders has proven to be quite promising, opening a path for future therapies with higher efficacy.