Anticholinergic medication for antipsychotic-induced tardive dyskinesia

BACKGROUND

Antipsychotic (neuroleptic) medication is used extensively to treat people with serious mental illnesses. However, it is associated with a wide range of adverse effects, including movement disorders. Because of this, many people treated with antipsychotic medication also receive anticholinergic drugs in order to reduce some of the associated movement side-effects. However, there is also a suggestion from animal experiments that the chronic administration of anticholinergics could cause tardive dyskinesia.

OBJECTIVES

To determine whether the use or the withdrawal of anticholinergic drugs (benzhexol, benztropine, biperiden, orphenadrine, procyclidine, scopolamine, or trihexylphenidyl) are clinically effective for the treatment of people with both antipsychotic-induced tardive dyskinesia and schizophrenia or other chronic mental illnesses.

SEARCH METHODS

We retrieved 712 references from searching the Cochrane Schizophrenia Group's Study-Based Register of Trials including the registries of clinical trials (16 July 2015 and 26 April 2017). We also inspected references of all identified studies for further trials and contacted authors of trials for additional information.

SELECTION CRITERIA

We included reports identified in the search if they were controlled trials dealing with people with antipsychotic-induced tardive dyskinesia and schizophrenia or other chronic mental illness who had been randomly allocated to (a) anticholinergic medication versus placebo (or no intervention), (b) anticholinergic medication versus any other intervention for the treatment of tardive dyskinesia, or (c) withdrawal of anticholinergic medication versus continuation of anticholinergic medication.

DATA COLLECTION AND ANALYSIS

We independently extracted data from included trials and we estimated risk ratios (RR) with 95% confidence intervals (CIs). We assumed that people who left early had no improvement. We assessed risk of bias and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

The previous version of this review included no trials. We identified two trials that could be included from the 2015 and 2017 searches. They randomised 30 in- and outpatients with schizophrenia in the USA and Germany. Overall, the risk of bias was unclear, mainly due to poor reporting: allocation concealment was not described; generation of the sequence was not explicit; studies were not clearly blinded; and outcome data were not fully reported.Findings were sparse. One study reported on the primary outcomes and found that significantly more participants allocated to procyclidine (anticholinergic) had not improved to a clinically important extent compared with those allocated to isocarboxazid (MAO-inhibitor) after 40 weeks' treatment (1 RCT, n = 20; RR 4.20, 95% CI 1.40 to 12.58; very low quality evidence); that there was no evidence of a difference in the incidence of any adverse effects (1 RCT, n = 20; RR 0.33, 95% CI 0.02 to 7.32; very low quality evidence); or acceptability of treatment (measured by participants leaving the study early) (1 RCT, n = 20; RR 0.33, 95% CI 0.02 to 7.32; very low quality evidence). The other trial compared anticholinergic withdrawal with anticholinergic continuation and found no evidence of a difference in the incidence of acceptability of treatment (measured by participants leaving the study early) (1 RCT, n = 10; RR 2.14, 95% CI 0.11 to 42.52; very low quality evidence).No trials reported on social confidence, social inclusion, social networks, or personalised quality of life - outcomes designated important to patients. No studies comparing either i. anticholinergics with placebo or no treatment, or ii. studies of anticholinergic withdrawal, were found that reported on the primary outcome 'no clinically important improvement in TD symptoms and adverse events'.

AUTHORS' CONCLUSIONS

Based on currently available evidence, no confident statement can be made about the effectiveness of anticholinergics to treat people with antipsychotic-induced tardive dyskinesia. The same applies for the withdrawal of such medications. Whether the withdrawal of anticholinergics may benefit people with antipsychotic-induced TD should be evaluated in a parallel-group, placebo-controlled randomised trial, with adequate sample size and at least 6 weeks of follow-up.

[Neutropenia in a patient treated with clozapine in combination with other psychotropic drugs]

Clozapine is an atypical antipsychotic known for its efficacy in refractory schizophrenia. However, according to different epidemiological studies clozapine can induce neutropenia in less than 3% of patients and may represent a major problem for the management of treatment-resistant patients not responding to conventional or other atypical antipsychotics. Recently, a few case of neutropenia have been reported following the addition of other medications to clozapine, notably paroxetine, risperidone, trimethoprim-sulfamethoxazole and erythromycin. In our report we present the case of Mr A., a 40-year-old Caucasian patient with a 20-year history of paranoid schizophrenia. After numerous trials with conventional antipsychotics, partial remission of psychotic symptoms was obtained with clozapine. Over the past eight years during his treatment with clozapine, the patient presented 2 episodes of neutropenia. The first episode came five years after starting clozapine and was attributed to the addition 6 weeks earlier of haloperidol (2 mg/day) to clozapine (250 mg/day) and divalproex (1,500 mg/day). Recently, one week after the addition of risperidone (2 mg/day) to clozapine (550 mg/day), leukocytes count dropped from 12 100/mm(3) to 5 700/mm(3) and neutrophils from 7 400/mm(3) to 900/mm(3). The patient was also taking haloperidol (4 mg/day), methotrimeprazine (35 mg/day), procyclidine (5 mg/day) and valproic acid (1,500 mg/day). Twelve days after discontinuation of risperidone, leukocytes and neutrophils count increased to 11,100/mm(3) and 6,300/mm(3) respectively while the treatment with clozapine was continued. The first eighteen weeks of treatment represent the period where the risk of neutropenia is the highest. In our patient neutropenia occurred 5 and 7 years after starting clozapine. It is proposed that the two neutropenic episode were precipitated by adding respectively haloperidol and risperidone to clozapine. Also, divalproex can potentially cause a decrease in white blood cell count and may have contributed to the two neutropenic episode. It is suggested that drug interactions may be responsible for neutropenia in clozapine treated patients and that clozapine should not necessarily be discontinued in the presence of neutropenia. Also we propose that hematological surveillance should be done on a weekly basis for 4 to 6 weeks following the addition of psychotropic drugs known for their potential to cause neutropenia when associated with clozapine. Therefore polypharmacy may contribute to cause neutropenia in clozapine treated patients and that discontinuation of an antipsychotic should be done before introducing another one.

Effects of 10 mg and 15 mg oral procyclidine on critical flicker fusion threshold and cardiac functioning in healthy human subjects

The critical flicker fusion threshold (CFFT) is thought to index alertness and cortical arousal. Sedative drugs reduce CFFT while psychostimulants increase it. Procyclidine is an anticholinergic that is used to control the extrapyramidal side-effects of antipsychotics in schizophrenia. This study examined the effects of clinically relevant doses of oral procyclidine administration on CFFT and heart rate in two separate experiments (Experiment 1, drug dose: 10 mg, n = 16; Experiment 2, drug dose: 15 mg, n = 12) involving healthy subjects using a double-blind, placebo-controlled, cross-over design. 10 mg procyclidine had no significant effect on CFFT, heart rate or self-ratings of mood, but the 15 mg dose significantly lowered CFFT at 1 h and 2 h after procyclidine administration, increased drowsiness ratings and produced a drop in heart rate. The effects observed in this study may have implications for treatment compliance of schizophrenic patients, choice of antipsychotics, prescribing to patients with heart disease and monitoring of cardiac function under treatment. Further investigations are required to quantify the effects of procyclidine on CFFT and cardiac function in patients with schizophrenia.

Lessons to be learned: a case study approach. 'Spontaneous' intraperitoneal bladder rupture in a psychiatric patient--with diagnostic difficulties

The case described here is that of a 34-year-old woman with a psychiatric disorder who was referred to the local surgical receiving unit with abdominal pain and vomiting. She remained well and fully mobile but refused blood investigations until the day following admission. At that time the tests showed a picture of acute renal failure. With the development of increasing abdominal tenderness and pyrexia she was persuaded to have a laparotomy which demonstrated a small tear at the dome of the bladder. Her deranged blood biochemistry returned to normal within 11 h following surgery. The important points demonstrated in this case study are the special clinical difficulties encountered in psychiatric patients, which may consequently lead to delay in diagnosis. This delay allowed significant peritoneal reabsorption of urea and creatinine, which masqueraded as 'acute renal failure' on biochemical testing. The case also highlights the use of procyclidine, commonly used in patients with psychiatric disorders; urinary retention is a recognised side effect of this drug--and it is possible that such retention together with a minor and hence easily overlooked episode of trauma, may have contributed to the patient's condition.

A pilot study of the role of prophylactic antiparkinson treatment during neuroleptic therapy

The authors administered haloperidol 4.5 mg t.i.d. to 33 drug-free schizophrenic patients. Ten patients did not receive anything else (group HPL), while ten patients received procyclidine 5 mg t.i.d., and 13 patients were given promethazine 25 mg t.i.d. (groups HPRC and HPRM respectively) in addition. Seven patients dropped out of the HPL group and three out of the HPRM group, but none out of the HPRC group. These drop outs were due to the development of early extrapyramidal side effects, which were absent in the HPRC group. The findings suggest that antiparkinson prophylaxis is useful during commencement of therapy with high-potency neuroleptic agents.

Betel nut-induced extrapyramidal syndrome: an unusual drug interaction

Two cases are described of chronic schizophrenic patients maintained on depot neuroleptics, who developed severe extrapyramidal symptoms following a period of heavy betel nut consumption. A mechanism for this effect is proposed based on the pharmacological antagonism of the anticholinergic agent, procyclidine, by the active alkaloid ingredient of the betel, arecoline.

Muscle pathology in the neuroleptic malignant syndrome

In a fatal case of neuroleptic malignant syndrome, a muscle sample taken within 1 h of death showed acute myopathic features with absence of muscle glycogen and neutral lipid. These features suggest that hyperpyrexia in this syndrome may be caused by heat production from uncoupled phosphorylation in muscle and imply that the primary biochemical abnormality responsible for this uncontrolled heat production might be muscular rather than hypothalamic.

Neuroleptic effects on platelet aggregation: a study in normal volunteers and schizophrenics

Platelet-rich plasma from healthy controls was pre-treated with neuroleptics of the phenothiazine, butyrophenone or benzamide variety before aggregation with one of the following agonist agents: ADP, adrenaline, 5-HT, collagen, platelet activating factor or ristocetin. All compounds effective as antipsychotics, except sulpiride, depressed aggregation. Unmedicated schizophrenics showed aggregation responses indistinguishable from healthy controls. However, within days of treatment with either trifluoroperazine or haloperidol responses became abnormal in acutely psychotic patients. Increased responses to 5-HT and depressed responses to platelet activating factor were detected. After 4 weeks of treatment responses tended to return to normal. Aggregation responses were normal in those patients on long-term depot neuroleptics.

Interactions between procyclidine and neuroleptic drugs. Some pharmacological and clinical aspects

Procyclidine was administered to 25 chronic psychotic inpatients, stabilised on chlorpromazine, haloperidol or fluphenazine decanoate injection. We observed a significant reduction in mean serum levels of all three neuroleptic drugs which was reversed on stopping procyclidine and was inversely correlated with mean serum procyclidine levels. No significant alterations occurred on the BPRS scores or in serum prolactin levels throughout the study in any of the three groups. Possible mechanisms of this interaction and its clinical relevance are discussed.

An experimental evaluation of the euphoric properties of antiparkinson drugs on psychotic patients

Seven psychotic inpatients (two women and five men) aged between 18 and 74 years, treated with neuroleptic and antiparkinson drugs, participated in a double-blind study with 1/3 DDD (Defined Daily Dose) of procyclidine, orphenadrine, or trihexyphenidyl hydrochloride against placebo. Euphoric effects were scored on a self-rating scale and extrapyramidal side-effects on the Simpson-Angus rating scale at drug administration and 1, 3 and 6 h thereafter. With regard to euphoric effect, there was a significant (P less than 0.02) difference between start and end point (0 and 6 h) for placebo but not for the active antiparkinson drugs. There was no significant difference in extrapyramidal side-effects. No preference of drug was found, and it was not possible to recognize the patient's own drug among the tested drugs. Side-effects from the antiparkinson drugs were also measured prior to the administration. Five patients did not return to their earlier antiparkinson drugs after the study.

Effects of mianserin in neuroleptic-induced parkinsonism

It has been proposed that serotonin (5-HT) antagonists counteract neuroleptic-induced extrapyramidal symptoms by disinhibition of dopamine activity. The effects of the 5-HT antagonist mianserin, the anticholinergic drug procyclidine and placebo were evaluated in 16 psychiatric patients with chronic neuroleptic-induced parkinsonism in a double-blind cross-over trial. The patients received each drug in random order in 3-week periods separated by washout periods of 2 weeks. The effect of mianserin did not significantly differ from that of placebo, while parkinsonian symptoms were significantly reduced during treatment with procyclidine (P less than 0.05). Although mianserin was ineffective in chronic neuroleptic-induced parkinsonism, it cannot be excluded that 5-HT antagonists may be effective in the treatment of acute extrapyramidal side effects.

Pharmacokinetics and Pharmacodynamics of procyclidine in man

The pharmacokinetics and pharmacodynamics of procyclidine (10 mg) after oral and intravenous administration were studied in six healthy volunteers. Treatment order was randomised and the study was placebo-controlled and conducted blind. After oral dosing the mean peak plasma concentration was 116 ng/ml and mean bioavailability was 75%. After both oral and intravenous dosing the mean values for the volume of distribution, total body clearance and plasma elimination half-life of procyclidine were in the order of 1 l/kg, 68 ml/min and 12 h respectively. Autonomic effects were maximal within 0.5 h of intravenous administration and at about 1-2 h after oral dosing. Significant effects on pupil diameter, visual near point, salivary secretion and heart rate occurred after intravenous treatment and similar but less marked effects occurred after the oral dose. Significant autonomic effects were still detectable 12 h after both forms of treatment.

[Anti-epileptic and side effects of Didepil]

The action of the new antiepileptic preparation Didepil which is a combination of the anticholinergic agent procyclidine (dl-1-cyclohexyl-1-phenyl-3-pyrolidinopropane-1-ol hydrochloride) with phenobarbitone was evaluated in a group of 20 patients of either sex, mean age 28.5 years. These patients had mostly (14 cases) two types of seizures occurring up to several times daily. The mean duration of epilepsy was 12.5 years, the aetiology of the disease was different, and the patients were usually refractory to previously used drugs. Didepil was administered during 3 months, on the average, in doses of 3--4 tablets daily as the only antiepileptic drug or in combination with other anticonvulsants. The duration of follow-up of the patients before, during and after treatment was from 6 to 15 months. In each repeated EEG investigations, biochemical investigation of the blood, liver function tests, and urine analysis were performed.

RESULTS

improvement was observed in cases of grand mal as well as temporal lobe seizures in 70% of patients, EEG improvement was found in 50% of patients. Side effects including oral dryness, accomodation disturbances developed in 17 patients but were usually slight and transient, in only 4 cases they were sufficiently severe as to justify reduction of dosage. Improvement of mood and contact with surroundings was noted in 60% of cases.

CONCLUSIONS

Didepil seems to be an effective antiepileptic agent in maximal generalized seizures as well as in temporal lobe seizures.

Brom-ergocryptine in the treatment of phenothiazine-induced galactorrhoea

An ergot alkaloid, 2-br-alpha-ergocryptine (CB 154), referred to hereafter as brom-ergocryptine, has been reported to inhibit puerperal lactation (Varga, Lutterbeck et al., 1972), and to terminate breast secretion in patients with inappropriate lactation (Lutterbeck, Pryor et al., 1971). Besser, Park et al. (1972) found that the drug suppressed elevated levels of plasma prolactin in five patients whose inappropriate lactation was due to a variety of causes. This hormonal effect was accompanied by clinical changes such as the disappearance of galactorrhoea, return of menstruation, and an increase in sexual potency.

Toxic psychosis due to antiparkinsonian drugs

Nine cases of transient toxic-delirious reactions during combined antipsychotic-antiparkinsonism treatment have been described. A few days prior to the onset of the reaction, all patients had been placed on an antiparkinsonian drug.

Three clinical phases were observed: an autonomic stage (sympathicotonic signs: mydriasis, dry mouth, anorexia, excitement, disorientation, insomnia, severe constipation); a strio-thalamic phase (dyskinesias, visual and tactile hallucinations) and a post-delirious state (increased sleep and integration).

The pathogenic factors which play a role in this atropine-like toxic condition, such as age, individual susceptibility, drug response per se and the influence of rapid dose changes were briefly discussed.