Safety analysis of Oseltamivir and Baloxavir Marboxil after market approval: a pharmacovigilance study based on the FDA adverse event reporting system

BACKGROUND AND OBJECTIVES

Amidst limited influenza treatment options, evaluating the safety of Oseltamivir and Baloxavir Marboxil is crucial, particularly given their comparable efficacy. This study investigates post-market safety profiles, exploring adverse events (AEs) and their drug associations to provide essential clinical references.

METHODS

A meticulous analysis of FDA Adverse Event Reporting System (FAERS) data spanning the first quarter of 2004 to the fourth quarter of 2022 was conducted. Using data mining techniques like reporting odds ratio (ROR), proportional reporting ratio, Bayesian Confidence Propagation Neural Network, and Multiple Gamma Poisson Shrinkage, AEs related to Oseltamivir and Baloxavir Marboxil were examined. Venn analysis compared and selected specific AEs associated with each drug.

RESULTS

Incorporating 15,104 Oseltamivir cases and 1,594 Baloxavir Marboxil cases, Wain analysis unveiled 21 common AEs across neurological, psychiatric, gastrointestinal, dermatological, respiratory, and infectious domains. Oseltamivir exhibited 221 significantly specific AEs, including appendicolith [ROR (95% CI), 459.53 (340.88 ∼ 619.47)], acne infantile [ROR (95% CI, 368.65 (118.89 ∼ 1143.09)], acute macular neuroretinopathy [ROR (95% CI), 294.92 (97.88 ∼ 888.64)], proctitis [ROR (95% CI), 245.74 (101.47 ∼ 595.31)], and Purpura senile [ROR (95% CI), 154.02 (81.96 ∼ 289.43)]. designated adverse events (DMEs) associated with Oseltamivir included fulminant hepatitis [ROR (95% CI), 12.12 (8.30-17.72), n=27], ventricular fibrillation [ROR (95% CI), 7.68 (6.01-9.83), n=64], toxic epidermal necrolysis [ROR (95% CI), 7.21 (5.74-9.05), n=75]. Baloxavir Marboxil exhibited 34 specific AEs, including Melaena [ROR (95% CI), 21.34 (14.15-32.18), n = 23], cystitis haemorrhagic [ROR (95% CI), 20.22 (7.57-54.00), n = 4], ileus paralytic [ROR (95% CI), 18.57 (5.98-57.71), n = 3], and haemorrhagic diathesis [ROR (95% CI), 16.86 (5.43-52.40)), n = 3]. DMEs associated with Baloxavir Marboxil included rhabdomyolysis [ROR (95% CI), 15.50 (10.53 ∼ 22.80), n = 26].

CONCLUSION

Monitoring fulminant hepatitis during Oseltamivir treatment, especially in patients with liver-related diseases, is crucial. Oseltamivir's potential to induce abnormal behavior, especially in adolescents, necessitates special attention. Baloxavir Marboxil, with lower hepatic toxicity, emerges as a potential alternative for patients with liver diseases. During Baloxavir Marboxil treatment, focused attention on the occurrence of rhabdomyolysis is advised, necessitating timely monitoring of relevant indicators for those with clinical manifestations. The comprehensive data aims to provide valuable insights for clinicians and healthcare practitioners, facilitating an understanding of the safety profiles of these influenza treatments in real-world scenarios.

Efficacy and safety of baloxavir marboxil versus neuraminidase inhibitors in the treatment of influenza virus infection in high-risk and uncomplicated patients - a Bayesian network meta-analysis

OBJECTIVES

Previous network meta-analysis (NMA) demonstrated advantageous or similar efficacy of baloxavir marboxil (baloxavir) over neuraminidase inhibitors in otherwise healthy (OwH) influenza patients. This analysis assessed the efficacy and safety of baloxavir in the subgroup of high-risk (HR) patients and in the population of uncomplicated influenza consisting of OwH and HR patients with influenza.

METHODS

A systematic literature review (SLR) was performed in Medline, Embase, CENTRAL and ICHUSHI up to August 8th, 2018. A Bayesian NMA was conducted to compare baloxavir with oseltamivir, zanamivir, laninamivir and peramivir in HR patients and all uncomplicated patients.

RESULTS

Based on the SLR, a total of 32 studies were identified as pertinent for the analysis, including 7 studies on HR patients, 13 trials on OwH patients and 14 studies on OwH + HR population. NMA of 10 trials assessing HR patients demonstrated comparable time to alleviation of symptoms for all treatments. Mean decline in virus titer from baseline at 24 h after treatment was significantly greater for baloxavir compared with oseltamivir and peramivir. The risks of total complications and drug-related adverse events were comparable between baloxavir and zanamivir, oseltamivir and laninamivir. These findings were highly consistent with results of the NMA using pooled evidence on the uncomplicated population of OwH and HR patients.

Conclusions: Baloxavir was significantly more effective than placebo regarding all outcomes except for the risk of pneumonia. Besides, baloxavir was associated with similar clinical efficacy and safety, and superior antiviral activity compared to other antivirals in HR patients, as well as in the entire population of uncomplicated patients with influenza.

Inhibitory Effects of Antipsychotics on the Contractile Response to Acetylcholine in Rat Urinary Bladder Smooth Muscles

The clinical applications of antipsychotics for symptoms unrelated to schizophrenia, such as behavioral and psychological symptoms, in patients with Alzheimer's disease, and the likelihood of doctors prescribing antipsychotics for elderly people are increasing. In elderly people, drug-induced and aging-associated urinary disorders are likely to occur. The most significant factor causing drug-induced urinary disorders is a decrease in urinary bladder smooth muscle (UBSM) contraction induced by the anticholinergic action of therapeutics. However, the anticholinergic action-associated inhibitory effects of antipsychotics on UBSM contraction have not been sufficiently assessed. In this study, we examined 26 clinically available antipsychotics to determine the extent to which they inhibit acetylcholine (ACh)-induced contraction in rat UBSM to predict the drugs that should not be used by elderly people to avoid urinary disorders. Of the 26 antipsychotics, six (chlorpromazine, levomepromazine (phenothiazines), zotepine (a thiepine), olanzapine, quetiapine, clozapine (multi-acting receptor targeted antipsychotics (MARTAs))) competitively inhibited ACh-induced contractions at concentrations corresponding to clinically significant doses. Further, 11 antipsychotics (perphenazine, fluphenazine, prochlorperazine (phenothiazines), haloperidol, bromperidol, timiperone, spiperone (butyrophenones), pimozide (a diphenylbutylpiperidine), perospirone, blonanserin (serotonin-dopamine antagonists; SDAs), and asenapine (a MARTA)) significantly suppressed ACh-induced contraction; however, suppression occurred at concentrations substantially exceeding clinically achievable blood levels. The remaining nine antipsychotics (pipamperone (a butyrophenone), sulpiride, sultopride, tiapride, nemonapride (benzamides), risperidone, paliperidone (SDAs), aripiprazole, and brexpiprazole (dopamine partial agonists)) did not inhibit ACh-induced contractions at concentrations up to 10-5 M. These findings suggest that chlorpromazine, levomepromazine, zotepine, olanzapine, quetiapine, and clozapine should be avoided by elderly people with urinary disorders.

Zotepine versus other atypical antipsychotics for schizophrenia

BACKGROUND

In many parts of the world, particularly in industrialised countries, second generation (atypical) antipsychotic drugs have become first line treatment for people suffering from schizophrenia. The question as to whether the effects of various second generation antipsychotic drugs differ is a matter of debate.

OBJECTIVES

To evaluate the effects of zotepine compared with other second generation antipsychotic drugs for people suffering from schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (November 2009), inspected references of all identified studies for further trials and contacted authors of trials for additional information.

SELECTION CRITERIA

We included only randomised clinical controlled trials that compared zotepine with any forms of amisulpride, aripiprazole, clozapine, olanzapine, risperidone, sertindole or ziprasidone in people suffering from only schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

SS and KK extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated weighted mean differences (MD) again based on a random-effects model.

MAIN RESULTS

We included three studies (total n=289; 2 RCTs zotepine vs clozapine; 1 RCT zotepine vs clozapine vs risperidone (at 4 mg, 8 mg doses) vs remoxipride. All studies were of limited methodological quality. When zotepine was compared with clozapine, it was clozapine that was found to be more effective in terms of global state (n=59, 1 RCT, RR No clinically significant response 8.23 CI 1.14 to 59.17). Mental state scores also favoured clozapine (n=59, 1 RCT, MD average score (BPRS total, high = poor) 6.00 CI 2.17 to 9.83) and there was less use of antiparkinson medication in the clozapine group (n=116, 2 RCTs, RR 20.96 CI 2.89 to 151.90). In the comparison of zotepine and risperidone, mental state scoring found no significant difference between the groups (vs 4 mg: n=40, 1 RCT, MD average endpoint score (BPRS total, high=poor) 1.40 CI -9.82 to 12.62; vs 8 mg: n=40, 1 RCT, MD -1.30 CI -12.95 to 10.35) and use of antiparkinson medication was equivocal (vs 4 mg: n=40, 1 RCT, MD 1.80 CI -0.64 to 4.24; vs 8 mg: n=40, 1 RCT, MD 2.50 CI -0.05 to 5.05). Finally, when zotepine was compared with remoxipride, again no effect was found for mental state (n=58, 1 RCT, MD average endpoint score (BPRS total, high=poor) 5.70 CI -4.13 to 15.53) and there was no significant difference between the two groups in terms of use of antiparkinson medication (n=49, 1 RCT, RR 0.97 CI 0.41 to 2.29).Data on important other outcomes such as other adverse events, service use or satisfaction with care, quality of life were not available.

AUTHORS' CONCLUSIONS

The evidence base around zotepine is insufficient to provide firm conclusions on its absolute or relative effects. This is despite it being in use in Austria, France, Germany, Japan and the UK.

Zotepine versus other atypical antipsychotics for schizophrenia

BACKGROUND

In many countries of the industrialised world, second generation (atypical) antipsychotic drugs have become first line treatment for people with schizophrenia. The question as to whether the effects of various second generation antipsychotic drugs differ is a matter of debate. In this review we examined how the efficacy and tolerability of zotepine differs from that of other second generation antipsychotic drugs.

OBJECTIVES

To evaluate the effects of zotepine compared with other second generation antipsychotic drugs for people with schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (April 2007) which is based on regular searches of BIOSIS, CENTRAL CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

We included all randomised trials comparing oral zotepine with oral forms of amisulpride, aripiprazole, clozapine, olanzapine, risperidone, sertindole or ziprasidone in people with schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (MD) again based on a random effects model.

MAIN RESULTS

The review currently includes data from two short term, ill reported trials (total n=109). Both studies compared zotepine with clozapine. 34% of people left early but there was no significant difference between groups. Zotepine was less effective than clozapine (no clinically significant response: n=59, 1 RCT, RR 8.23 CI 1.14 to 59.17, NNH 3 CI 2 to 8; average score (BPRS total) at endpoint (n=59, 1 RCT, MD 6.00 CI 2.17 to 9.83). Zotepine induced more movement disorders than clozapine (use of antiparkinson medication: n=59, 1 RCT, RR 18.75 CI 1.17 to 301.08, NNH 3 CI 2 to 5) and higher prolactin levels (n=59, 1 RCT, MD 33.40 CI 14.87 to 51.93). Data on important other outcomes such as other adverse events, service use or satisfaction with care were not available.

AUTHORS' CONCLUSIONS

Zotepine may be less effective than clozapine and associated with more movement disorders and higher prolactin levels, but the evidence base is too small and prone to bias, making any practical recommendations impossible. There is no randomised evidence on the effects of zotepine compared to second generation antipsychotic drugs other than clozapine. More studies are possible to justify.

Differences in the effect of second-generation antipsychotics on prolactinaemia: six weeks open-label trial in female in-patients

OBJECTIVES

The main objective was to evaluate the effect of five second-generation antipsychotics (amisulpride, quetiapine, olanzapine, risperidone, and zotepine) on prolactinaemia during 6 week therapy in 433 female in-patients with mainly schizophrenic disorders. Secondary objectives included identification of dynamics of change in serum prolactin levels and correlations of changes of prolactinaemia with some demographic and clinical parameters.

METHODS

The trial was a prospective, open-label, single-center one with a flexible dosing of SGAs. The therapeutic effect of SGAs was assessed by a change of scores of CGI-S and CGI-I scales from a baseline to the endpoint. Blood samples were taken in the morning under fasting condition.

RESULTS

Amisulpride and risperidone increased prolactinaemia significantly in 100% of patients, as early as after week 1 of the therapy. Quetiapine and zotepine relatively reduced prolactinaemia significantly, as early as from week 1 of the quetiapine treatment. Olanzapine led to a transient mild prolactin elevation. The much lower prevalence of hyperprolactinaemia over 2 000 mIU/l differentiates olanzapine from amisulpride and risperidone. Prolactin elevation did not correlate with age, menopausal condition, therapeutic efficacy, antipsychotic daily dose, serum levels of lipids and glucose. There was significant correlation with first vs. subsequent psychotic episodes, weight, EPS and serum levels of thyroid hormones.

CONCLUSION

Amisulpride and risperidone had marked and early prolactin elevating effects, requiring, therefore, more frequent monitoring of prolactinaemia and associated undesirable effects and risks than olanzapine, quetiapine and zotepine.

Zotepine for schizophrenia

BACKGROUND

Zotepine is a relatively new antipsychotic often used for the treatment of people with schizophrenia. It is claimed to be particularly effective for negative symptoms.

OBJECTIVES

To determine the effects of zotepine compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

For the 2006 update we searched the Cochrane Schizophrenia Group's register of trials.

SELECTION CRITERIA

We included all randomised clinical trials comparing zotepine with other treatments for people with schizophrenia or other psychoses.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and abstracts, ordered papers, re-inspected these and assessed their quality. For homogenous dichotomous data we calculated the relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat/harm (NNT/H) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). We inspected all data for heterogeneity.

MAIN RESULTS

The review currently includes 11 studies with 966 participants. Most outcomes were short term (4-12 weeks). We found no data for outcomes such as relapse, time in hospital, satisfaction with care and day-to-day functioning. Compared with placebo, mental state ratings favoured zotepine (n=106, 1 RCT, RR No 20% decrease in BPRS 0.44 CI 0.3 to 0.7, NNT 3 CI 2 to 6) using the last observation carried forward method. For the comparison with typical drugs, limited data suggest that zotepine may be as effective as these older medications. Mental state measures of 'no clinically important improvement' favour zotepine when compared with other active drugs (n=356, 4 RCTs, RR 0.77 CI 0.7 to 0.9, NNT 7 CI 4 to 22). About one third of people in both the zotepine and control groups left the studies before trial completion. Zotepine may result in less movement disorder adverse effects than typical antipsychotic drugs. Trials have not highlighted clear differences between zotepine and other atypical drugs.

AUTHORS' CONCLUSIONS

Zotepine may be a valuable addition to the class of atypical antipsychotic drugs. However, more data from existing studies is urgently needed to increase confidence in the findings of this review. In addition to this, new data from well planned, conducted and reported long term pragmatic randomised trials are needed. Otherwise clinical use of zotepine will be based upon speculation of short explanatory trials for everyday practice.

Zotepine-induced catatonia as a precursor in the progression to neuroleptic malignant syndrome

A 39-year-old man with schizophrenia developed severe catatonia, hyperthermia, muscle rigidity, tachycardia, leukocytosis, and elevated muscle enzyme levels while receiving zotepine therapy. Neuroleptic malignant syndrome (NMS) was diagnosed. After withdrawal of zotepine therapy, transfer to a neurologic intensive care unit, provision of supportive care, and administration of adjunctive bromocriptine therapy, the patient's fever and catatonia subsided. Biochemical irregularities spontaneously returned to normal with no complications. Antipsychotic therapy was restarted with risperidone 12 days after the patient's NMS resolved. After more than 1 year of follow-up, he experienced no adverse events. A recent decrease in mortality from NMS is related to increased awareness of this disorder, but not to treatment with specific agents. Clinicians need to recognize NMS early; although rare, it is a potentially fatal complication of antipsychotic treatment.

Das Serotoninsyndrom

The serotonin-syndrome is a possible side-effect in the treatment with serotonergic drugs. There are diagnostic criteria for diagnosis of this syndrome. After discontinuation of administering the serotonergic drug is fully reversible.

Two case studies of hypothermia induced by an increased dosage of zotepine in a combination therapy

The purpose of the present paper was to remind physicians that hypothermia is a possible side-effect of combining zotepine, valproate,and benzodiazepine. Two cases of hypothermia occurred after combining the use of zotepine, valproate, and benzodiazepine. The valproate was under therapeutic blood level when zotepine dosage was raised to 200 mg/day, and hypothermia occurred. The dosage of zotepine might constitute a positive correlation with hypothermia. The combination of zotepine, valproate or benzodiazepine may cause hypothermia as a side-effect.

[Hyperlipidemia--side-effect of the treatment with an atypical antipsychotic (zotepine)?]

In the last few years some studies and case reports has been published that suggest a frequent occurrence of metabolic disorders like hyperglycemia and hyperlipidemia during the treatment with atypical antipsychotics. However, regarding the high prevalence rates of these disorders in the general population, a possible causative relationship should be substantiated, i.e. occurrence of elevated blood levels within a short time interval after the starting of the medication. In the presented case a hyperlipidemia (triglycerides up to 1247 mg/dl) was observed soon after the beginning of zotepine medication. After the reduction of zotepine lipid levels in serum decreased and normalised after switching to classical antipsychotics. Therefore a causative relationship between the occurrence of the hyperlipidemia and the zotepine medication is very likely.

Efficacy and safety of zotepine for the treatment of Taiwanese schizophrenic patients: a double-blind comparison with haloperidol

BACKGROUND AND PURPOSE

Zotepine is claimed to be a neuroleptic drug with atypical features. However, there have been few double-blind studies in Asian patients. The purpose of this study was to compare the efficacy and safety of zotepine and haloperidol in Taiwanese patients with schizophrenia.

PATIENTS AND METHODS

Patients with positive symptoms (n = 70) were enrolled into this double-blind, randomized study. Each patient received either zotepine 150 mg/day or haloperidol 9 mg/day. The Positive and Negative Syndrome Scale (PANSS), Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impression (CGI) were assessed on Days 0, 3, 7, 14, 28, and 42 after the start of treatment. Adverse events were recorded during the trial period. The analyses were carried out on an intent-to-treat basis with the last observation carried forward.

RESULTS

In terms of the score reduction in the PANSS, BPRS, and CGI, all analyses indicated that there were no significant differences between the groups at the end of the trial. Patients who received zotepine had no acute dystonia and less severe parkinsonism (p < 0.05 or 0.10), but significantly more dizziness, body weight gain, and pulse rate increase.

CONCLUSION

In this 6-week trial, zotepine at 150 mg/day was as efficacious as haloperidol 9 mg/day in the treatment of Taiwanese patients with schizophrenia. Zotepine treatment produced fewer extrapyramidal symptoms but had a greater frequency of sedative effects compared to haloperidol.

In vivo (123)I IBZM SPECT imaging of striatal dopamine 2 receptor occupancy in schizophrenic patients

RATIONALE

Single photon emission computed tomography (SPECT) using (123)I iodobenzamide (IBZM) as tracer substance has been shown to be a useful tool to visualize dopamine 2 (D2) receptor occupancy.

OBJECTIVES

We investigated the striatal D2 receptor occupancy of zotepine which is referred to the class of atypical antipsychotic drugs.

METHODS

(123)I IBZM and SPECT were used to visualize striatal dopamine 2 (D2) receptor occupancy in zotepine-treated schizophrenic patients. Two groups of schizophrenic patients receiving either 150 mg/day zotepine (n=6) or 300 mg/day (n=6) underwent examination. For the quantification of striatal D2 receptor occupancy, striatal IBZM binding in patients treated with antipsychotics was compared to untreated healthy controls (n=8) reported earlier.

RESULTS

Zotepine led to a mean overall striatal D2 receptor occupancy of 73%. Patients with 150 mg daily showed a significantly lower occupancy (65.8%, SD=6.2) than patients with 300 mg/day (77.8%, SD=10.7; P<0.05). No clinically relevant extrapyramidal side effects occurred during treatment with zotepine.

CONCLUSIONS

There was no correlation between the degree of striatal D2 receptor occupancy and clinical improvement.

Zotepine in the treatment of acute hospitalized schizophrenic episodes

The atypical antipsychotic zotepine was studied in an open, multicentre uncontrolled, post-marketing surveillance study in 108 schizophrenic patients hospitalized in 12 trial centres in Austria. Within the dosage range of 50-450 mg (mean at the end of the study, 207 +/- 125 mg/day), a significant reduction of positive as well as negative symptoms was noted. There was no increase in extrapyramidal side-effects during the study and a significant decrease in akathisia scores. The medication was well tolerated during the 42-day observation period. Zotepine improved both positive and negative symptoms and was not accompanied by extrapyramidal side-effects, justifying its classification as an atypical antipsychotic.

[Atypical neuroleptics: new approaches to drug therapy of schizophrenic disorders]

The introduction of conventional antipsychotics revolutionized the management of psychotic disorders in the 1950s. The use of these agents has been marked by several shortcomings, including their association with severe motor disturbances and their limited efficacy in treating the negative and cognitive symptoms of schizophrenia. Patients noncompliance has largely been the result of subjectively distressing extrapyramidal motor side-effects (EPMS). It was therefore necessary to develop antipsychotic drugs with selective pharmacological profiles, e.g. limbic selectivity. A defining characteristic of atypical neuroleptics is a higher ratio of serotonin receptor blockade to D2 receptor blockade. Their primary advantage is their superior side-effect profile. The implications of EPMS reduction touch several domains of pathology in schizophrenia such as short- and long-term movement disorders, noncompliance, relapse rate, negative symptoms and cognitive dysfunction. Novel antipsychotics may represent the second pharmacological revolution in the treatment of psychotic disorders. There is, however, still a need for a critical evaluation of the risk-benefit-ratio of differing atypical agents.

Thyroid parameters during therapy with zotepine in delusional depression. Preliminary results

There are only few data on the effects of atpyical neuroleptics on thyroid function. In an open pilot study of 12 inpatients with delusional depression, thyroid hormone levels and TRH-TSH test were determined during neuroleptic treatment with zotepine. No significant changes in triiodothyronine (T3), thyroxine (T4) and delta-TSH levels were found in this observation period (28 days).

Atypical antipsychotics and weight gain--a systematic review

OBJECTIVE

To review systematically data relating to weight changes with atypical antipsychotics.

METHOD

We conducted a Medline search on October 29 1999 and covered the period 1980-99. All recovered papers were examined for further relevant reports. In addition, we wrote to pharmaceutical manufacturers and 10 practising clinicians to ask them to provide other relevant reports known to them.

RESULTS

Eighty reports mentioning change in body weight were retrieved. Data relating to weight changes were of variable quality. Weight changes were indicated by a variety of measures. The majority of reports related to short-term changes.

CONCLUSION

All atypical drugs, with the exception of ziprasidone, have been associated with weight increases. Clozapine seems to have the highest risk of weight gain, followed by olanzapine and quetiapine. There is probably a lower risk with risperidone, sertindole and zotepine and a still lower risk with amisulpride. Ziprasidone appears not to be associated with weight gain. In the absence of more compelling data, these rankings must be considered approximate and preliminary. Longer, more robust trials are needed.

A placebo-controlled comparison of zotepine versus chlorpromazine in patients with acute exacerbation of schizophrenia

OBJECTIVE

The aim of this study was to evaluate the efficacy of zotepine in the treatment of acute episodes of schizophrenia.

METHOD

Patients with acute exacerbation of schizophrenia (DSM-III-R criteria; n = 158) were allocated on a random, double-blind basis to receive zotepine (150 or 300 mg/day), chlorpromazine (300 or 600 mg/day) or placebo for 8 weeks. Symptoms were assessed on the BPRS, SANS and CGI scales at baseline and weeks 1, 2, 4, 6 and 8 and patients were assessed at these times for adverse effects. Analysis was by analysis of variance on the intent-to-treat population, with last observation carried forward.

RESULTS

Mean BPRS scores improved statistically significantly more with zotepine than chlorpromazine (point estimate of difference -12.4, 95% CI -18.3 to -6.5) or placebo (point estimate of difference -12.7, 95% CI -18.6 to -6.8). Zotepine produced significantly fewer extrapyramidal symptoms (EPS) than chlorpromazine.

CONCLUSION

Zotepine is an effective antipsychotic with low propensity for EPS.

Weight gain: side effect of atypical neuroleptics?

During clinical experience with the "atypical" neuroleptic drugs clozapine, risperidone, and zotepine, some patients have shown a marked weight gain. To prove whether weight gain is a relevant side effect of atypical neuroleptics, the charts of all patients admitted with DSM-III-R diagnoses of schizophrenia, schizoaffective disorder, or delusional disorder in the years 1991 to 1995 were evaluated. A retrospective chart review was performed, which included all patients who were treated longer than 2 weeks with a single neuroleptic. The data analysis showed that weight gain must be considered as a common side effect of atypical neuroleptics (clozapine, risperidone, sulpiride, or zotepine). The mean weight gain (3.1, 1.5, 1.9, or 4.3 kg, respectively) was significantly higher than that of patients treated with "classic" neuroleptics (mean, 0.0-0.5 kg) (Kruskal-Wallis, p = 0.01). Young and not obese patients show the highest weight increase. Because weight gain occurs in the first weeks of treatment, particularly in previously untreated subjects, this side effect has to be considered in view of compliance with long-term neuroleptic medication.

Single oral dose kinetics of zotepine and its relationship to prolactin response and side effects

The authors investigated the single oral dose kinetics of zotepine and its relationship with prolactin response and side effects in 14 healthy male volunteers. Each subject took a single oral 25-mg dose of zotepine, and plasma concentrations of zotepine, prolactin, and their side effects were monitored up to 36 hours after dosing. The means +/- SD of the time of maximal plasma concentration (tmax), the apparent oral clearance, the apparent volume of distribution, and the elimination half-life (t1/2) were 3.8 +/- 1.2 hours, 4.6 +/- 4.2 1/h.kg, 109.0 +/- 59.0 1/kg, and 21.0 +/- 8.9 hours, respectively. The change in prolactin concentrations and side effect scores were parallel with that of drug concentrations, although no significant correlation was found between these three parameters at any time-point. The current results clearly indicate that the tmax and t1/2 of zotepine are much longer than those previously reported, which are reflected in the changes in prolactin concentrations and side effect scores.

Two cases of deep vein thrombosis associated with a combined paroxetine and zotepine therapy

Thromboembolic events arising as a side-effect of neuroleptic and thymoleptic therapy, although rare, represent serious complications. We report on two patients suffering from an acute deep vein thrombosis after administration of a combined therapy with paroxetine and zotepine. The absence of common risk factors for the development of venous thrombosis in both patients led us to reconsider the potential impact that the drugs administered may have on thrombogenesis. Possible influences of the neuroleptic and thymoleptic therapy on the coagulation system are discussed. Although the clinical observations do not necessarily imply a strict causal relationship between drug administration and thrombosis, there are features of these two cases that should enhance our awareness of the possibility of thrombotic events occurring as a consequence of neuroleptic and thymoleptic therapy.

Conventional versus atypical neuroleptics: subjective quality of life in schizophrenic patients

BACKGROUND

The effectiveness of antipsychotic drugs against positive psychotic symptoms has been demonstrated in many studies, but their effects on quality of life have yet to be clarified. The impact of different neuroleptic therapies on the subjective quality of life of schizophrenic patients is evaluated in a cross-sectional open study.

METHOD

During a four-month period a standardised quality of life interview for schizophrenic patients was applied on day 10 after admission; 33 patients on atypical neuroleptics (AAP) were compared with 31 matched patients on conventional neuroleptics (CAP).

RESULTS

The AAP group had significantly higher scores in general quality of life as well as in different life domains: physical well-being, social life and everyday life. In separate comparisons of the AAP group, patients on clozapine and risperidone were found to have a higher quality of life score than patients on CAP or zotepine.

CONCLUSIONS

The pharmacological profile of clozapine and risperidone may provide a basis for explaining the higher subjective quality of life found in this study. The lower quality of life of the CAP group may possibly be related to intrinsic effects of the conventional antipsychotics.

[Body weight increase: a side effect of zotepin (Nipolept)?]

During our clinical experience with the new neuroleptic drug zotepine we saw some cases of marked weight gain. This retrospective chart review of 110 cases consecutively admitted with the ICD-10 diagnosis of schizophrenia, schizoaffective or delusional disorder (F20-F25) in 1991 and 1992 was aimed at showing whether the weight gain is due to accidental observations or must be considered a side effect of this new drug. The data analysis of all cases treated longer than 2 weeks with a neuroleptic revealed that cases treated with zotepine showed a significant weight gain (3.6 kg) compared to those receiving the "classic" neuroleptics (1.3 kg). A possible link to the pharmacological profile of zotepine (high D2/HT2 affinity with antagonistic effect) is discussed.

Adverse effects of zotepine and their relationship to serum concentrations of the drug and prolactin

Adverse effects of zotepine, an antipsychotic drug, and their relationship to serum concentrations of the drug and prolactin were investigated in 28 schizophrenic in-patients. The daily dose was 100 mg during the first week and 200 mg during the next 3 weeks. Adverse effects were evaluated by the UKU Side Effect Rating Scale (21 items). The mean (+/- SD) total UKU score at the end of the study was 3.1 +/- 2.5, indicating mild adverse effects. The scores of psychic adverse effects at 2 weeks and total adverse effects at 3 and 4 weeks were significantly higher in nonresponders than in responders (p < 0.05). Furthermore, there was a significant inverse correlation between percent improvement in total Brief Psychiatric Rating Scale (BPRS) scores and total UKU scores at 4 weeks (p < 0.05). These results suggest a relationship between poor clinical response and increased adverse effects during zotepine treatment. Only the scores of akathisia at 2 weeks showed a significantly positive correlation with serum zotepine concentrations (p < 0.05). No correlation was found between prolactin response and neurological adverse effects.

Pharmacotherapy of delusional depression: experience with combinations of antidepressants with the neuroleptics zotepine and haloperidol

The combination of an antidepressant with a neuroleptic is standard pharmacotherapy for delusional depression today. The neuroleptics used are rarely specified: occasionally haloperidol or perphenazine are mentioned. In two different open-treatment studies, consecutively admitted delusional depressed inpatients received a butyrophenone [haloperidol, bromperidol, approximately 10 mg/day (n = 16)] or zotepine [150-200 mg/day (n = 15)] as a neuroleptic in combination with a tri- or tetracyclic antidepressant (amitriptyline, maprotiline, 150 mg/day). There was a significant improvement in both groups in the sum score of the Hamilton depression scale (24-item version), in a subscore of so-called delusional items (items 2, 17, 19, 20, 23, and 24 together), in the subscore of remaining items and also in most single items such as mood, inhibition, agitation, feelings of guilt or hopelessness.

Three cases of alopecia areata induced by zotepine

One schizophrenic and two manic-depressive patients who after the administration of zotepine, a new antipsychotic and antimanic drug, developed alopecia areata, a kind of autoimmune disease, are reported. They recovered following the discontinuation or decrease in the dose of zotepine. These three cases of alopecia areata suggest that the antipsychotic drugs may induce autoimmune disease through their neuropsychological effect.

[Therapeutic and adverse effects of zotepine and their relationships with serum kinetics of the drug]

The spectrum of therapeutic and adverse effects of zotepine and their relationships with serum concentrations of the drug were investigated in 28 schizophrenic inpatients by a fixed-dose (100 mg/day for the first 1 wk and 200 mg/day for the following 3 wk) study. The mean % improvement in Brief Psychiatric Rating Scale (BPRS) scores were 63.4% for total, 64.4% for positive, 41.8% for negative and 74.2% for anxiety-depression symptoms, suggesting that zotepine has a broad therapeutic spectrum. There were significant differences in improvement of negative symptoms after 1 wk and total and positive symptoms after 2 wk (P < 0.05) between responders (more than 50% reduction in total BPRS scores at wk 4) and nonresponders. The mean scores of UKU Side Effect Rating Scale were low in this study. UKU scores of psychic at wk 2 and total adverse effects at wk 3 and wk 4 (P < 0.05) were higher in nonresponders than in responders. A negative correlation between % improvement in total BPRS and total UKU scores was observed (P < 0.05). These two results suggest some relationship between poor clinical response and increased adverse effects during zotepine treatment. Lack of close correlation between serum drug concentrations and clinical or adverse effects indicates that therapeutic monitoring of zotepine concentrations would be of little significance.

[Intraindividual comparison of haloperidol decanoate and oxyprothepine in maintenance therapy in schizophrenic psychoses]

In an open intraindividual comparison of haloperidol and oxyprothepine decanoates there was a tendency in favour of haloperidol decanoate. At the end of 9 months' maintenance treatment there were no statistically significant differences in the global BPRS score, CGI and individual BPRS items with exception of paranoidity. No differences in the occurrence of rehospitalizations and ambulatory relapses were found. As for side effects with haloperidol decanoate a higher occurrence of akathisia and a lower mean weigh increase (2 kg v. 4 kg) were observed and twice more pts had no side effects in comparison with oxyprothepine decanoate, but also these differences were not statistically significant. Taking into consideration the differences found (even if not statistically significant) and the individual reactivity, it seems to us advantageous to have a broader choice of depot neuroleptics.

Convulsive seizures in schizophrenic patients induced by zotepine administration

One hundred twenty-nine schizophrenic inpatients who were administered zotepine were studied to see if they had zotepine-induced convulsive seizures. Twenty-two patients had grand mal seizures during the administration periods. The incidence of the seizure was 17.1% and was higher than that in previous reports. The average duration of zotepine administration before the seizure was 48.3 days. The incidence of the seizure was closely related to the daily dosage of zotepine, but there was no significant correlation between the daily dosage of zotepine and the duration of administration before the onset of the seizure. The patients who received a combined administration with the higher dose of zotepine and other phenothiazines were revealed to be more likely to have the seizure. In addition, young patients and patients with a past history of head injuries showed a high incidence of the seizure with the administration of zotepine.

Zotepine in the treatment of schizophrenic patients with prevailingly negative symptoms. A double-blind trial vs. haloperidol

Zotepine, a neuroleptic agent with additional 5-HT2 blocking properties, was compared with haloperidol in the treatment of schizophrenic patients with predominantly negative symptoms using a double-blind design. During the investigation period zotepine treated patients showed significant improvements in all rating instruments whereas haloperidol treated patients did not. Patients in the zotepine group developed fewer clinical side effects. The results of the presented study confirm the positive impressions gained in earlier open trials with zotepine.

[Zotepine: treatment of schizophrenic patients with predominantly negative symptoms. A double-blind study vs. haloperidol]

Zotepine, a neuroleptic exercising a 5-HT2-antagonistic effect, was employed in a double-blind study in the treatment of schizophrenic patients with predominantly negative symptoms and was compared to haloperidol. In contrast to the patients treated with haloperidol, significant improvements were seen in the zotepine group during the observation period, according to all assessment scales that were employed. The patients of the zotepine group also developed fewer clinical side effects. The results of the study confirm previous positive impressions gained in earlier open studies with zotepine.

[Clinical effectiveness of zotepine in treatment of negative schizophrenic symptoms. Results of an open and a double-blind controlled trial]

The clinical action of Zotepine was examined in an open and in a randomised double-blind controlled study in in-patients displaying a productive or minus pattern of symptoms within the framework of a schizophrenic disease or schizoaffective psychosis. The present paper discusses only the results achieved in treating schizophrenic minus patterns of signs and symptoms. In Study I 20 schizophrenic patients were treated with two different Zotepine dosages. Group 2 (n = 12) showed at an average daily dose of 168 +/- 15 mg (150-190 mg) a significant improvement (p less than 0.05) of the anergy subscore in the BPRS scale as well as a significant improvement of the subscores affective flattening, anhedonia/asociality and attentional imparvement in the SANS scale, compared with Group 1 (n = 8) with an average daily dose of 270 +/- 37 mg (240-340 mg). This improvement developed already during the first two weeks of the treatment. In Study II the antipsychotic action of Zotepine compared to that of perazine was studied under double-blind conditions. The average daily dose in the Zotepine group (n = 20) was around 241 +/- 70 mg (106-396 mg), in the perazin group (n = 19) at 348 +/- 09 mg (214-575 mg). With regard to the BPRS subscore anergy and all the subscores of the SANS scale, there was a distinct improvement without significant group differences. Both substances were comparably well tolerated.

[Effectiveness and tolerance of zotepine in a double-blind comparison with perazine in schizophrenic patients]

40 inpatients suffering from a schizophrenia (ICD-9) were treated with either zotepine or perazin. The study was continued for a period of 28 days. Assessment of clinical efficacy was effected via BPRS, AMDP, CGI and SANS; tolerance was assessed by means of Simpson's scale. In addition, EEG, ECG and laboratory controls were conducted. The overall therapeutic efficacy was good, and it was not possible to distinguish one group from the other, i.e. both substances were equally effective, judged by means of the psychopathometric tools that were at our disposal. In 11 patients of the zotepine group and in 9 patients of the perazin group, slight extrapyramidal symptoms were observed. No clinically relevant changes were seen in EEG, ECG and laboratory controls in both groups.

[Effectiveness of zotepine in therapy-refractory psychoses. An open, multicenter study in eight psychiatric clinics]

Zotepine was administered to 45 patients suffering from therapy-resistant psychoses hospitalized in eight psychiatric institutes (University Hospital Okayama and affiliated institutions). The psychoses of these patients were characterised by positive symptoms--predominantly hallucinations and delusions--and could not be influenced by a large variety of conventional antipsychotics, such as haloperidol. Previous medications were discontinued or administered together with zotepine. To assess changes in the pattern of symptoms, the Brief Psychiatric Rating Scale (BPRS) was employed over a period of up to 12 weeks at 2-week intervals. Ten patients dropped out of the study because of undesirable effects or for other reasons. 35 patients completed the 12-week study according to schedule. There was a relation between general improvement and certain patient characteristics. Zotepine proved to be effective especially in the catatonic type of schizophrenia, in chronic schizophrenias with acute exacerbation (DSM-III) and in relatively young patients in whom the disease had existed for a short time only. In the 26 patients who were markedly, moderately or slightly improved, BPRS score had dropped significantly after only two weeks of treatment. This points to a rapid onset of the therapeutic action of zotepine.

[Zotepine vs. haloperidol in paranoid schizophrenia: a double-blind study]

The efficacy and tolerance of zotepine and haloperidol were examined in 40 patients suffering from paranoid schizophrenia (DSM III). The study period was 6 weeks. Psychopathology was assessed with BPRS and CGI. Documentation of side effects was done with DOTES. The safety parameters were pulse, blood pressure, leucocyte count, liver enzymes, ECG and EEG, determined at different times. Both treatment groups improved significantly without any differences in respect to efficacy. The patients who had been treated with zotepine had significantly fewer extrapyramidal side effects. However, transient increases in liver enzyme levels were seen more frequently in the zotepine group. There were no differences between the groups in respect to other side effects.

[Double-blind comparison of 3 x 75 mg zotepine und 3 x 4 mg haloperidol in acute schizophrenic patients]

To assess the efficiency/risk ratio, fixed doses of zotepine and haloperidol were compared by means of a double-blind study in acute schizophrenics over a 4-week period. The assessment tools were BPRS, CGI, and the Simpson-Angus scale for the extrapyramidal disturbances, and a free report on side effects. No differences between the groups were found in respect of efficacy. According to the Simpson-Angus scale, the patients who had been treated with zotepine achieved better values, this being a general trend. There were significant differences according to the free report on side effects. Especially at onset of treatment, the patients treated with zotepine complained of tiredness. Partly marked extrapyramidal disturbances were seen in the patients who had been treated with haloperidol.

[Zotepine versus perazine in patients with paranoid schizophrenia: a double-blind controlled trial of its effectiveness]

The dibenzothiepine zotepine is a new potential "atypical" neuroleptic exhibiting powerful antiserotonergic and antidopaminergic properties. The efficacy of zotepine was evaluated in a double-blind controlled trial versus the tricyclic neuroleptic perazine in 41 patients suffering mainly from the paranoid-hallucinatory type of schizophrenia. The key outcome variable was the extent of mental disturbance as defined by the total score of the BPRS. Additional outcome variables were GAS and CGI. In addition, adverse reactions and extrapyramidal side effects were assessed according to the FSUCL scale and the Gerlach and AIMS rating scale, respectively. Additional variables recorded were blood pressure, heart rate and routine laboratory parameters as well as electrocardiogram and electroencephalogram. In the first two days, standard equivalent doses of both drugs were administered. Thereafter, doses were administered as required. The efficacy of both substances was compared after 7, 14 and 28 days of treatment. Both drugs showed a similar antipsychotic efficacy. Under zotepine treatment a 55% improvement of the BPRS total score was observed while perazine led to a 41% BPRS score reduction. After 7 days the zotepine group was significantly more improved than the perazine group, possibly due to a dosing effect in the perazine group. In the zotepine group, fewer adverse reactions and a better benefit/risk index were observed although the differences between the two treatment groups did not reach levels of statistical significance. There were no drug-specific abnormal laboratory findings. Thus, in the present study there was no significant difference between zotepine and perazine with respect to antipsychotic efficacy and side-effect rates. However, zotepine showed a trend to a better benefit/risk index at the end of treatment.

[Traffic safety in treatment with dosulepin]

Forty-eight healthy volunteers aged between 18 and 61 years, 24 men, 24 women, received dosulepin (Idom) or placebo in a randomized fashion over a period of 16 days. The study was designed as a double-blind, placebo controlled parallel trial. The single daily dose of 75 mg was given in the evening. In order to assess driving ability under medication, the following parameters were examined before the study and on days 3, 10 and 17: visual orientation, concentration stress toleration while performing reaction tasks, eye-hand coordination, vigilance, accuracy and speed of reaction, and sense of wellbeing. Apart from a mild loss of concentration and decrease in the sense of wellbeing, none of the other parameters showed any significant changes as compared with placebo. The results are in good agreement with those of earlier relevant trials with other antidepressants. The results of the present study form the basis for an assessment of the driving ability of the individual patient receiving dosulepin.