Anticholinergic action is rarely a good thing

The evidence for the risks associated with anticholinergic agents has grown considerably in the last two decades. Not only are they associated with causing peripheral side effects such as dry mouth, blurred vision and constipation, but they can also cause central effects such as cognitive impairment; and more recently, they have consistently been linked with an increased risk of dementia and death in older people. This paper reviews the evidence for the associations of anticholinergic agents and the risk of dementia and increased mortality in dementia.

A tool for safer prescribing in vulnerable adults: the continuing development of the Medichec app and website

AIMS AND METHOD

Adverse effects are a common concern when prescribing and reviewing medication, particularly in vulnerable adults such as older people and those with intellectual disability. This paper describes the development of an app giving information on side-effects, called Medichec, and provides a description of the processes involved in its development and how drugs were rated for each side-effect. Medications with central anticholinergic action, dizziness, drowsiness, hyponatraemia, QTc prolongation, bleeding and constipation were identified using the British National Formulary (BNF) and frequency of occurrence of these effects was determined using the BNF, product information and electronic searches, including PubMed.

RESULTS

Medications were rated using a traffic light system according to how commonly the adverse effect was known to occur or the severity of the effect.

CLINICAL IMPLICATIONS

Medichec can facilitate access to side-effects information for multiple medications, aid clinical decision-making, optimise treatment and improve patient safety in vulnerable adults.

Managing drugs with anticholinergic activity

Over the past two decades, considerable data have emerged on an association between drugs with anticholinergic activity and serious adverse effects in older people. Well-recognised anticholinergic adverse effects include dry mouth, blurred vision, constipation and urinary retention. Of particular concern is the potential impact on cognitive function with several studies showing that long-term use of medicines with anticholinergic activity is associated with worsening of cognitive function, increased incidence of dementia and increased mortality. This article gives an overview of the evidence, discusses some of the tools used to identify high-risk drugs and highlights issues to consider when prescribing drugs with anticholinergic activity with a view to reducing potential risks in older people and those at highest risk of cognitive impairment.

Antipsychotic monitoring in dementia: quality of completion of antipsychotic monitoring forms in an older adult mental health service

AIMS AND METHOD

To support safe prescribing of antipsychotics in dementia, antipsychotic monitoring forms were embedded into our electronic health records. We present a review of the data collected on these forms to assess prescribing and identify areas for improvement in our practice and processes. Data were extracted from the structured fields of antipsychotic initiation and review forms completed between 1 January 2018 and 31 January 2020.

RESULTS

We identified gaps in practice where improvements could be made, mainly with regard to physical health monitoring (and particularly electrocardiograms, performed in only 50% of patients) and the low (less than 50%) recorded use of non-pharmacological interventions for behavioural and psychological symptoms of dementia. In addition, antipsychotic treatment was continued despite lack of benefit in almost 10% of reviews.

CLINICAL IMPLICATIONS

We advocate for recommendations on physical health monitoring of people with dementia taking antipsychotics to be added to the National Institute for Health and Care Excellence guidance on dementia and the Prescribing Observatory for Mental Health (POMH-UK) national audit.

Centrally-acting anticholinergic drugs- associations with mortality, hospitalisation and cognitive decline following dementia diagnosis in people receiving antidepressant and antipsychotic drugs

OBJECTIVES

Long-term use of anticholinergic medication in older people is associated with increased risk of cognitive decline and mortality, but this relationship could be confounded by the underlying illness the drugs are treating. To investigate associations between central anticholinergic antidepressants or antipsychotics and mortality, hospitalisation and cognitive decline in people with dementia.

METHOD

In cohorts of patients with a dementia diagnosis receiving antidepressant and/or antipsychotic medication (N = 4,380 and N = 2,335 respectively), assembled from a large healthcare database, central anticholinergic burden scores were estimated using the Anticholinergic Effect on Cognition (AEC) scale. Data were linked to national mortality and hospitalisation data sources, and Mini-Mental State Examination (MMSE) scores were used to investigate cognitive decline.

RESULTS

There was a reduced mortality risk in people receiving agents with high central anticholinergic burden compared to those with no or low burden which was statistically significant in the antidepressant cohort (Hazard ratio (HR): 0.88; 95% confidence interval (CI): 0.79-0.98; p = 0.023) but not the antipsychotic one (HR: 0.91; 95% CI: 0.82-1.02; p = 0.105). Patients on antidepressants with no central anticholinergic burden had accelerated cognitive decline compared with other groups, whereas no differences were found in the antipsychotic cohort. No significant associations were detected between antidepressant or antipsychotic-related central anticholinergic burden and hospitalisation.

CONCLUSION

These counter-intuitive findings may reflect factors underlying the choice of psychotropics rather than the agents themselves, although do not support a strong role for central anticholinergic drug actions on dementia outcomes. Further studies, including randomized switching of agents are needed to clarify this relationship.

Improving quantification of anticholinergic burden using the Anticholinergic Effect on Cognition Scale - a healthcare improvement study in a geriatric ward setting

OBJECTIVE

Anticholinergic burden refers to the cumulative effects of taking multiple medications with anticholinergic effects. This study was carried out in a public hospital in Singapore, aimed to improve and achieve a 100% comprehensive identification and review of measured, anticholinergic burden in a geriatric psychiatry liaison service to geriatric wards. We evaluated changes in pre-to post-assessment anticholinergic burden scores and trainee feedback.

METHOD

Plan Do Study Act methodology was employed, and Anticholinergic Effect on Cognition scale (AEC) was implemented as the study intervention. A survey instrument evaluated trainee feedback.

RESULTS

There was no measured anticholinergic burden in a baseline of 170 assessments. 75 liaison psychiatry assessments were conducted between June and November 2021 in two cycles. 94.7% of pre-assessments (at the time of assessment) and 71.1% of post-assessments (following assessment) had a record of AEC scores in clinical documentation in cycle one, improving in the second cycle to 100%, 94.6%, respectively. A high post-assessment AEC score of 3 and over reduced from 15.8% in cycle one to 5.4% in cycle two. The trainee feedback suggested an enriching educational experience.

CONCLUSIONS

Using the AEC scale, the findings support the feasibility of comprehensive identification and review of measured anticholinergic burden in older people with neurocognitive disorders.

Centrally Acting Anticholinergic Drugs Used for Urinary Conditions Associated with Worse Outcomes in Dementia

OBJECTIVES

To investigate the associations between central anticholinergic burden and mortality, hospitalization, and cognitive impairment in people with dementia prescribed anticholinergic drugs for urinary symptoms.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Patients diagnosed with dementia receiving anticholinergic medication for bladder conditions (N = 540), assembled from a large healthcare database.

METHODS

Central anticholinergic burden related to bladder drugs was estimated using the anticholinergic effect on cognition scale. Data were linked to national mortality and hospitalization data sources, and serially recorded Mini-Mental State Examination scores were used to investigate cognitive decline.

RESULTS

Patients had a median survival of 4.1 years. Urinary drugs with a high anticholinergic effect on cognition score (tolterodine, oxybutynin) were associated with a 55% increased mortality risk (hazard ratio 1.55; 95% confidence interval 1.19‒2.01; P = .001) compared with drugs with low or no central anticholinergic burden (darifenacin, fesoterodine, trospium, mirabegron, solifenacin). Cognitive decline over a 24-month period around diagnosis was only detectable in the high central anticholinergic group, but there was no significant difference in cognitive trajectories between the high and low/no anticholinergic bladder drug groups. No increase of emergency hospitalization risk was seen in relation to central anticholinergic burden.

CONCLUSIONS AND IMPLICATIONS

Urinary drugs with high central anticholinergic burden cause more harm than those acting peripherally and should be avoided in people with dementia. Further research is needed to test whether centrally acting anticholinergic agents in general cause worse outcomes in dementia.

Aspirin in people with dementia, long-term benefits, and harms: a systematic review

PURPOSE

People with dementia may have indications for aspirin prescription and clinicians are asked to balance the potential risks against benefits. This review examines the evidence for the risk and benefit of long-term aspirin use in people with dementia aged over 65 years, including randomised controlled trials and observational studies.

METHODS

We searched three databases for research published between 2007 and 2020. Each eligible article was assessed for risk of bias, and confidence in findings was rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Four papers met inclusion criteria: one randomised controlled trial, two cohort studies, and one with pooled data. All looked only at dementia of Alzheimer's type, and none addressed myocardial or cerebral infarction as outcomes. Dementia progression was reported by two studies, with conflicting results. The trial found no significant effect of aspirin on mortality (odds ratio aspirin vs. no aspirin 1.07, 95% confidence interval 0.58-1.97) but found more events of severe bleeding with aspirin (OR aspirin vs. no aspirin 6.9, 1.5-31.2). An excess in intracranial haemorrhage in the aspirin group was judged plausible based on two non-randomised studies.

CONCLUSIONS

The review findings are limited because studies include only people with Alzheimer's-type dementia and lack confirmatory studies, although an increased risk of bleeding events is recognised. Further research that addresses the benefits and risks of aspirin in more representative groups of people with dementia is needed to guide prescribing decisions.

Anticholinergic drugs and risk of dementia: Time for action?

Evidence suggests that the prescription of bladder anticholinergics is increasing. Recent studies have accentuated concerns about whether certain prescribed medications could increase risk of dementia, including anticholinergic drugs, and specifically anticholinergics used for bladder symptoms. Nevertheless, it can be difficult to draw together the evidence to review the case for possible causation. Recognising this issue in 1965, Bradford-Hill set out nine criteria to help assess whether evidence of a causal relationship could be inferred between a presumed cause and an observed effect. In this commentary, we explore the extent to which associations between anticholinergics and dementia satisfy the Bradford-Hill criteria and examine the potential implications. First, we look at studies that have examined the relationship between anticholinergic drugs with urological properties (bladder drugs) and the onset of dementia, and then present those studies which specifically focus on the cognitive effects of bladder drugs that affect muscarinic receptors in the brain versus the bladder on older people along with suggestions for future research. We also discuss the risks and benefits of these drugs for treating overactive bladder. If it can be shown that certain medications carry a specific risk of dementia, it is possible that initiatives to change prescribing could become a key tool in reducing the risk of dementia and may be easier to implement than some lifestyle changes.

The anticholinergic effect on cognition (AEC) scale-Associations with mortality, hospitalisation and cognitive decline following dementia diagnosis

OBJECTIVES

To investigate associations between central anticholinergic burden (determined through the anticholinergic effect on cognition [AEC] scale) and mortality, hospitalisation and cognitive decline in patients with dementia.

METHODS

The South London and Maudsley NHS Foundation Trust (SLaM) Clinical Records Interactive Search (CRIS) application was used to identify patients with a first diagnosis of dementia. Medication exposure was extracted through a natural language processing algorithm, allowing for calculations and comparisons of AEC scores. Data were linked to national mortality and hospitalisation data sources, and serially recorded Mini-Mental State Examination (MMSE) scores were used to investigate cognitive decline.

RESULTS

We identified 14 093 patients with dementia, 60.7% were female and the mean age at diagnosis was 79.8 years. Patients for whom a review of their medication was indicated (AEC score ≥ 2 for any individual drug or total AEC score ≥ 3) had an increased risk of mortality (hazard ratio 1.07; 95% confidence interval [CI]: 1.01-1.15) and emergency hospitalisation (1.10; 95% CI: 1.04-1.17), but there were no associations with duration of hospitalisation. Cognitive trajectory analyses showed that this exposure group had lower MMSE scores at diagnosis and a sharper increase in MMSE scores over the subsequent 6 months, but similar slopes for the 6 to 36 months period compared to the remainder of the sample.

CONCLUSIONS

Patients with dementia receiving medication with high central anticholinergic activity appear to have worse prognosis in terms of mortality and hospitalisation risk, but have, primarily, acutely impaired cognitive function, rather than longer-term differences in cognitive decline. J Am Geriatr Soc 68:-, 2020.

'Real time' monitoring of antipsychotic prescribing in patients with dementia: a study using the Clinical Record Interactive Search (CRIS) platform to enhance safer prescribing

BACKGROUND

The use of antipsychotic drugs in dementia has been reported to be associated with increased risk of cerebrovascular events and mortality. There is an international drive to reduce the use of these agents in patients with dementia and to improve the safety of prescribing and monitoring in this area.

OBJECTIVES

The aim of this project was to use enhanced automated regular feedback of information from electronic health records to improve the quality of antipsychotic prescribing and monitoring in people with dementia.

METHODS

The South London and Maudsley NHS Foundation Trust (SLaM) incorporated antipsychotic monitoring forms into its electronic health records. The SLaM Clinical Record Interactive Search (CRIS) platform provides researcher access to de-identified health records, and natural language processing is used in CRIS to derive structured data from unstructured free text, including recorded diagnoses and medication. Algorithms were thus developed to ascertain patients with dementia receiving antipsychotic treatment and to determine whether monitoring forms had been completed. We used two improvement plan-do-study-act cycles to improve the accuracy of the algorithm for automated evaluation and provided monthly feedback on team performance.

RESULTS

A steady increase in antipsychotic monitoring form completion was observed across the study period. The percentage of our sample with a completed antipsychotic monitoring form more than doubled from October 2017 (22%) to January 2019 (58%).

CONCLUSION

'Real time' monitoring and regular feedback to teams offer a time-effective approach, complementary to standard audit methods, to enhance the safer prescribing of high risk drugs.

Benefits and Harms of Statins in People with Dementia: A Systematic Review and Meta-Analysis

OBJECTIVES

More people with dementia also fall into the category of high vascular risk, for which a statin is usually prescribed. However, these recommendations are based on studies in people without dementia. We aimed to evaluate the evidence for the long-term effectiveness and harm of statin therapy in patients with dementia.

DESIGN

Systematic review of randomized controlled trials and observational research.

SETTING

Publications from developed countries indexed in the PubMed, Web of Science, and Cochrane trial database between 2007 and 2019.

PARTICIPANTS

Trials including people with all types of dementia with a mean age older than 65 years.

INTERVENTION

Treatment with a statin for 6 months or longer.

MEASUREMENTS

Major adverse cardiovascular events, dementia progression, and general health at 2 years, or medication adverse events (AEs) at any time. Each article was assessed for bias using the Newcastle-Ottawa or Cochrane Collaboration tools. A narrative synthesis and pooled analyses are reported.

RESULTS

Five articles met the inclusion criteria. They reported only on dementia of the Alzheimer's type. There was no evidence regarding cardiovascular events or general health. We made a very low confidence finding that statins reduce dementia progression based on three cohort studies of heterogeneous design. We made a very low confidence finding of no significant difference in AEs based on two randomized controlled trials of 18 months: odds ratios of any AE = 1.21 (95% confidence interval [CI] = .83-1.77), serious AE = 1.03 (95% CI = .76-1.87), and death = 1.69 (95% CI = .79-3.62).

CONCLUSION

Evidence was insufficient to fully evaluate the efficacy of statins in people with dementia. We found that statins may have a small benefit delaying progression in Alzheimer's dementia, although this conflicted with previous findings from shorter randomized trials. For safety, the trial data lacked power to show clinically important differences between the groups. We recommend that clinical data be leveraged for further observational studies to inform prescribing decisions. J Am Geriatr Soc 68:650-658, 2020.

Emerging and experimental treatments for COVID-19 and drug interactions with psychotropic agents

As yet, no agents have been approved for the treatment of COVID-19, although several experimental drugs are being used off licence. These may have serious adverse effects and potential drug interactions with psychotropic agents. We reviewed the common agents being used across the world for the treatment of COVID-19 and investigated their drug interaction potential with psychotropic agents using several drug interaction databases and resources. A preliminary search identified the following drugs as being used to treat COVID-19 symptoms: atazanavir (ATV), azithromycin (AZI), chloroquine (CLQ)/hydroxychloroquine (HCLQ), dipyridamole, famotidine (FAM), favipiravir, lopinavir/ritonavir (LPV/r), nitazoxanide, remdesivir, ribavirin and tocilizumab. Many serious adverse effects and potential drug interactions with psychotropic agents were identified. The most problematic agents were found to be ATV, AZI, CLQ, HCLQ, FAM and LPV/r in terms of both pharmacokinetic as well as serious pharmacodynamic drug interactions, including QTc prolongation and neutropenia. Significant caution should be exercised if using any of the medications being trialled for the treatment of COVID-19 until robust clinical trial data are available. An even higher threshold of vigilance should be maintained for patients with pre-existing conditions and older adults due to added toxicity and drug interactions, especially with psychotropic agents.

Safe prescribing in cognitively vulnerable patients: the use of the anticholinergic effect on cognition (AEC) tool in older adult mental health services

Aims and methodMedication with anticholinergic action is associated with potentially serious adverse effects in older people. We present an evaluation of a novel anticholinergic burden scale introduced into routine practice in older adult services in the South London and Maudsley (SLaM) NHS Foundation Trust. Our aim was to assess whether this tool improved the accurate identification of anticholinergic medication and guided safer prescribing in cognitively vulnerable older people. RESULTS: The introduction of the anticholinergic effect on cognition (AEC) tool into clinical practice led to an increase in the identification and reporting to general practitioners of anticholinergic medication from 11 to 85% of cases (P = 0.0015).Clinical implicationsApplication of the AEC tool led to improved detection of anticholinergic medication and advice to primary care on when a medication review is necessary. This is an important step towards improving the safety of prescribing in this patient group.Declaration of interestSLaM NHS Foundation Trust owns both the app and IP for Medichec.

Anticholinergic effect on cognition (AEC) of drugs commonly used in older people

OBJECTIVE

Use of anticholinergic drugs in older people is associated with increased risk of cognitive decline and of dementia and death.

METHOD

We identified drugs widely used in older people and attempted to classify their anticholinergic effect on cognition (AEC) according to our three-point scale which scored AEC according to in vitro anticholinergic potency, capacity to cross the blood-brain barrier and statements made in standard texts.

RESULTS

In total, 165 drugs were examined. We identified 21 drugs with an AEC score of 3, 18 with a score of 2, 21 with a score of 1 and 62 with a score of 0. Owing to insufficient information, we were unable to classify 43 drugs.

CONCLUSIONS

A large number of drugs commonly used in older people are likely to be associated with cognitive impairment. Copyright © 2016 John Wiley & Sons, Ltd.

Safe prescribing of physical health medication in patients with dementia

OBJECTIVE

The prescription of multiple medications for older people is common, despite concerns over the dangers associated with this. Older adults are particularly vulnerable to adverse effects of medication, and this is an even greater risk in patients with dementia. Many drugs used for physical health conditions can negatively affect cognition. Our aim was to identify areas of concern and which drugs to avoid in patients with dementia.

DESIGN

A review of the literature was carried out using Pubmed, Medline and Embase.

RESULTS

Many drugs used for physical health conditions may worsen the symptoms of dementia. They do this either by negating the effects of cognitive enhancers or through direct adverse effects on cognition

CONCLUSIONS

Where evidence exists, we provide guidance as to the safest drugs to prescribe in particular clinical situations. Anticholinergic drugs should be avoided in dementia wherever possible. Effective pain management is important in older patients, but caution should be used when selecting an opioid analgesic because of their adverse central effects. Cardiac drugs have overall negligible effects on cognition, although some have been reported to cause delirium.

Quality of prescribing for schizophrenia: evidence from a national audit in England and Wales

The National Audit of Schizophrenia (NAS) examined the quality of care received in England and Wales. Part of the audit set out to determine whether six prescribing standards, set by the national clinical guidelines for schizophrenia, were being implemented and to prompt improvements in care. Mental Health Trusts and Health Boards provided data obtained from case-notes for adult patients living in the community with schizophrenia or schizoaffective disorder. An audit of practice tool was developed for data collection. Most of the 5055 patients reviewed were receiving pharmacological treatment according to national guidelines. However, 15.9% of the total sample (95%CI: 14.9-16.9) were prescribed two or more antipsychotics concurrently and 10.1% of patients (95%CI: 9.3-10.9) were prescribed medication in excess of recommended limits. Overall 23.7% (95%CI: 22.5-24.8) of patients were receiving clozapine. However, there were many with treatment resistance who had no clear reason documented as to why they had not had a trial of clozapine (430/1073, 40.1%). In conclusion, whilst most people were prescribed medication in accordance with nationally agreed standards, there was considerable variation between service providers. Antipsychotic polypharmacy, high dose prescribing and clozapine underutilisation in treatment resistance were all key concerns which need to be further addressed.

Clozapine-related EEG changes and seizures: dose and plasma-level relationships

Clozapine is a widely used atypical antipsychotic with a unique effectiveness in treatment-resistant schizophrenia. An important adverse effect is seizures, which have been observed at all stages of clozapine treatment. Valproate has traditionally been considered the drug of choice for the prophylaxis of clozapine seizures, however it may not be the most suitable choice for all patients. There is disagreement as to the best point to prescribe valproate or a suitable antiepileptic: as seizure prophylaxis at a certain clozapine dose or level, or only as remedial treatment. In this review, we examine the relevant literature with an aim to evaluate the following relationships: clozapine dose and electroencephalogram (EEG) abnormalities, plasma levels and EEG abnormalities, dose and occurrence of seizures and plasma levels and occurrence of seizures. Weighted linear regression models were fitted to investigate these relationships. There was a strong relationship between clozapine dose and plasma level and occurrence of clozapine-induced EEG abnormalities. However, a statistically significant relationship between dose and occurrence of seizures was not found. A relationship between clozapine plasma level and occurrence of seizures was not established because of the scarcity of useful data although our review found three case reports which suggested that there is a very substantial risk of seizures with clozapine plasma levels exceeding 1300 μg/l. Seizures are more common during the initiation phase of clozapine treatment, suggesting a slow titration to target plasma levels is desirable. An antiepileptic drug should be considered when the clozapine plasma level exceeds 500 μg/l, if the EEG shows clear epileptiform discharges, if seizures, myoclonic jerks or speech difficulties occur and when there is concurrent use of epileptogenic medication. The antiepileptics of choice for the treatment and prophylaxis of clozapine-induced seizures are valproate (particularly where there is mood disturbance) and lamotrigine (where there is resistance to clozapine).

Once-monthly paliperidone injection for the treatment of schizophrenia

Paliperidone palmitate is a new long-acting antipsychotic injection for the treatment of acute and maintenance therapy in schizophrenia. Paliperidone (9-hydroxyrisperidone) is the major active metabolite of risperidone and acts at dopamine D(2) and serotonin 5HT(2A) receptors. As with other atypical antipsychotics, it exhibits a high 5HT(2A):D(2) affinity ratio. It also has binding activity as an antagonist at α(1)-and α(2) adrenergic receptors and H(1) histaminergic receptors, but has virtually no affinity for cholinergic receptors. Paliperidone palmitate has been shown to be effective in reducing Positive and Negative Syndrome Scale total scores in four short-term trials in acute schizophrenia. It was also effective as maintenance therapy in a long-term trial in which time to recurrence of symptoms was significantly longer in paliperidone-treated patients compared with placebo. In addition, paliperidone was shown to be noninferior to risperidone long-acting injection in one study, but this noninferiority was not established in another longer study comparing the two drugs. Treatment should be initiated with 234 mg on day 1 and 156 mg on day 8, followed by a recommended monthly maintenance dose of 39-234 mg based on efficacy and tolerability. Paliperidone palmitate is generally well tolerated, although it can cause weight gain and a rise in prolactin levels, which is generally greater in women than in men. Overall, paliperidone palmitate may have advantages over other currently available long-acting injections, and therefore may be a useful alternative for the treatment of schizophrenia, although further long-term trials comparing it with active treatments are warranted.

Expert opinion on the management of behavioural and psychological symptoms of dementia (BPSD) and investigation into prescribing practices in the UK

BACKGROUND

The management of Behavioural and Psychological Symptoms of Dementia (BPSD) has been the subject of considerable debate over the last few years in view of the poor evidence base for pharmacological agents and concerns about their safety.

OBJECTIVES

This study sought to obtain expert opinion on the management of BPSD and to investigate current prescribing practices in the UK.

METHOD

A total of 166 expert opinion surveys were emailed to UK consultants in Old Age Psychiatry asking them to rate the appropriateness of psychotropics in different aspects of BPSD. A service evaluation was also carried out in 8 UK centres to investigate prescribing patterns.

RESULTS

Overall, 59 consultants returned completed questionnaires, a response rate of 35%. Results revealed that experts rated quetiapine as the most appropriate agent for all BPSD followed by acetylcholinesterase inhibitors for psychotic symptoms, benzodiazepines for agitation or aggression and trazodone for behavioural symptoms such as disinhibition. The service evaluations showed that benzodiazepines were most frequently prescribed for BPSD.

CONCLUSIONS

Although quetiapine was judged by experts to be the most appropriate agent for BPSD, it appears that in clinical practice benzodiazepines are most often used to manage these symptoms. Evidence from both studies show wide inconsistencies in prescribing trends.

Risperidone long-acting injection: a 6-year mirror-image study of healthcare resource use

OBJECTIVE

To evaluate naturalistic use of risperidone long-acting injection (RLAI) and its effect on healthcare resource use.

METHOD

Mirror-image comparison of healthcare resource use for 3 years before RLAI initiation and 3 years after.

RESULTS

In total, 211 of 277 patients consecutively prescribed RLAI were evaluable over the full 6-year study period. Median days in hospital/patient increased significantly in the 3 years after RLAI initiation [87 days (inter-quartile range 25-236) before vs. 192 days (47-426) after; P < 0.001]. Those 34 patients who continued RLAI for 3 years showed no change in median bed days [64 days (6.5-182) before vs. 64 days (12-180) after] and median number of admissions was decreased [1.5 (1-2.25) before vs. 1.00 (0-1.25) after; P = 0.001]. Healthcare costs more than doubled for the whole cohort (P < 0.001) and discontinuers (P < 0.001) and increased significantly for continuers (P = 0.010).

CONCLUSION

RLAI did not decrease either time spent in hospital or overall healthcare costs in this patient cohort.

Risperidone long-acting injection: a prospective 3-year analysis of its use in clinical practice

OBJECTIVE

To evaluate outcomes of clinical use of risperidone long-acting injection (RLAI) and determine factors predicting continuation with treatment.

METHOD

This prospective, 3-year follow-up of consecutive patients started on treatment with RLAI in normal clinical practice between August 2002 and September 2003 obtained demographic and clinical data from case notes, prescription charts, and hospital computer records. To determine predictors of continuation, a proportional hazards regression (Cox) model was constructed.

RESULTS

The study included 211 evaluable patients. Over 3 years, 84% of subjects discontinued RLAI; 27.7% of these switched to oral risperidone. The Cox model showed that younger age (p = .001), longer duration of illness (p = .001), inpatient status at initiation (p = .002), and an RLAI dose of 25 mg/2 weeks (p < .001) predicted greater probability of discontinuation.

CONCLUSION

A small proportion of patients initiated on treatment with RLAI continued for 3 years. Outcome is likely to be improved by targeting RLAI treatment at specific patient groups and by using a dose of more than 25 mg/2 weeks.

Upcoming agents for the treatment of schizophrenia: mechanism of action, efficacy and tolerability

Since the introduction of a group of atypical antipsychotics in the 1990s, there has been a decline in the rate of new antipsychotics being introduced into clinical practice. However, with increasing safety and efficacy concerns over currently available drugs and a dearth of options available for atypical depot formulations, there is a considerable need for the development of new formulations and agents. This review examines the profile of seven antipsychotic drugs currently in the premarketing stage of development and summarizes their mechanism of action, clinical potential and safety.Asenapine is an antipsychotic with activity for multiple receptors and has potential to improve negative and cognitive symptoms of schizophrenia. Bifeprunox is a partial dopamine D2 and serotonin 5-HT(1A) receptor agonist showing a less than convincing efficacy profile, but which may offer safety advantages over available agents by means of a reduced risk of metabolic complications. Iloperidone is a D2 and 5-HT(2A) receptor antagonist requiring further studies to establish its effectiveness. It has a high affinity for alpha(1)-adrenoceptors, which can lead to associated haemodynamic adverse effects. Nemonapride is essentially a typical antipsychotic drug, similar in structure to sulpiride, which has been available for some time in Japan. It has efficacy against positive symptoms and has shown some antidepressant and anxiolytic properties, although efficacy data for it are somewhat limited. Norclozapine (N-desmethylclozapine) is a major metabolite of clozapine formed by its demethylation. Its partial agonist activity at D2 receptors has raised interest in it as an antipsychotic in its own right. In addition, it appears to have muscarinic agonist activity, which is believed to be responsible for the observed positive effects it has on cognition. It was envisaged to be effective as an adjunct to other agents or at high doses in the treatment of refractory schizophrenia, although a recent randomized, controlled study showed that it was no more effective than placebo in patients with schizophrenia experiencing an acute psychotic episode. Olanzapine pamoate depot injection has shown comparable efficacy to oral olanzapine in several studies. However, it has provoked considerable safety concerns by its association with inadvertent intravascular injection events in numerous patients. This accidental intravascular administration of olanzapine pamoate leads to excessive sedation, confusion, dizziness and altered speech. Post-injection observation periods and postmarketing surveillance are planned following the introduction of the depot. Paliperidone palmitate is the palmitate ester of paliperidone, the major metabolite of risperidone, and is formulated as a long-acting injection for intramuscular use. Its pharmacology is comparable to risperidone, having D2 and 5-HT(2A) receptor antagonist activity. Efficacy studies have shown positive results, and because paliperidone has no antagonistic activity at cholinergic receptors, it has low potential for anticholinergic adverse effects, including cognitive dysfunction. However, with higher doses, the frequency of extrapyramidal side effects and orthostatic hypotension have been shown to be greater than with placebo.

Asenapine monotherapy in the acute treatment of both schizophrenia and bipolar I disorder

Asenapine is a new atypical antipsychotic agent currently under development for the treatment of schizophrenia and bipolar disorder. It has high affinity for various receptors including antagonism at 5HT(2A), 5HT(2B), 5HT(2C), 5HT(6) and 5HT(7) serotonergic receptor subtypes, alpha(1A), alpha(2A), alpha(2B) and alpha(2C) adrenergic and D(3) and D(4) dopaminergic receptors. As with other atypicals, asenapine exhibits a high 5HT(2A):D(2) affinity ratio. Although similar to clozapine in its multi-target profile, it shows no appreciable affinity for muscarinic receptors. Asenapine has shown efficacy in alleviating both positive and negative symptoms of schizophrenia compared with placebo. Although promising, further studies are required in order to determine whether it has advantages over placebo and other antipsychotics in alleviating cognitive impairment associated with schizophrenia. It has also shown long-term efficacy comparable with olanzapine in bipolar I disorder. Asenapine is generally well tolerated and appears to be metabolically neutral. It has low propensity to cause weight gain and prolactin elevation. There were no concerns in the studies about its effects on the cardiovascular system and QTc prolongation. The incidence of extrapyramidal symptoms with asenapine however has been found to be higher than that with olanzapine. It may be a useful alternative to aripiprazole in schizophrenia and bipolar disorder in patients who are at high risk of metabolic abnormalities.