Atypical Antipsychotic Medications Research Articles

Falls and fractures with atypical antipsychotic medication use: a population-based cohort study.

Falls and fractures with atypical antipsychotic medication use: a population-based cohort study.

Long-Term Treatment with Olanzapine in Hospital Conditions: Prevalence and Predictors of the Metabolic Syndrome.

The risk of metabolic abnormalities is greatly increased in schizophrenic patients started on an atypical antipsychotic medication. Patients with psychiatric disorders exceed mortality ranges resulting from, among others, increased risk of cardiovascular events. Other factors contributing to the development of metabolic syndrome include prolonged duration of illness, increasing age, female sex and lifestyle factors. OBJECTIVE This cross-sectional study was taken up to assess the prevalence of the metabolic syndrome (MetS) in schizophrenic patients receiving olanzapine monotherapy for at least six months and to determine the most important risk factors associated with metabolic syndrome presence in these patients. METHODS A total of 93 long term hospitalized schizophrenic patients (71 men, 22 women), had a screening of the following: case-history data, psychiatric scales, anthropometric measures, blood (fasting glucose, lipid status, C-reactive protein--CRP) and urine samples (microalbuminuria). Prevalence of MetS according to International Diabetes Federation criteria in our study was 34.4%. The multivariate analysis distinguished the following significant predictors of MetS presence (in order of appearance): data about diabetes mellitus in family history (p = 0.002), body mass index > 25 kg/m2 (p = 0.002), hyperlipidemia in family history (p = 0.008), and elevated CRP value (p = 0.042). High rate of MetS in patients treated with olanzapine in this study exceeds MetS prevalence in general population. Among observed parameters, our study pointed to several "high risk" predictors associated with MetS presence. Regular monitoring of cardiometabolic risk factors is highly recommended. Positive heredity distress mentioned above may direct a psychiatrist to prescribe some other drug than olanzapine in the long term treatment of schizophrenia.

Auditory mismatch negativity, P300, and disability among first-episode schizophrenia patients without auditory hallucinations

Objectives The aim of this study was to determine the functional deficits, including the inter-related domains of attention, memory, and information processing, among first-episode schizophrenia patients without auditory hallucinations. Such deficits could be evaluated objectively utilizing measurements of auditory-evoked potentials. Patients and methods The study sample consisted of two groups: group I included 58 first-episode schizophrenia patients without auditory hallucinations recruited from the psychiatric outpatient's clinics of Zagazig University Hospitals and group II included 53 participants selected randomly from Zagazig University Hospitals' visitors. Patients were subjected to a semistructured psychiatric interview using DSM-IV criteria for diagnosis, and auditory mismatch negativity (MMN) and P300 were assessed in schizophrenia patients before and after treatment. The degree of disability was assessed and its correlation with auditory processing function was determined. Results Our study showed no statistically significant difference as regards MMN measures with any observable effect of atypical antipsychotics; the P300 component showed delayed latency and smaller amplitude before treatment and markedly enhanced after treatment, and there was statistically significant correlation between the degree of disability and MMN, as well as P300 measures, before and after treatment. Conclusion The current study concluded that the attention-dependent processes reflected in P300 measures are already defective during the early stage of schizophrenia and could be improved with the use of an atypical antipsychotic medication.

Efficacy, quality of life, and acceptability outcomes of atypical antipsychotic augmentation treatment for treatment-resistant depression: protocol for a systematic review and network meta-analysis.

BackgroundMajor depressive disorder (MDD) is a debilitating and costly mental disorder. Although commercially available antidepressants have proliferated over the last 20 years, a substantial number of patients either do not respond adequately to these drugs or are unable to tolerate their adverse effects. One common approach has been to augment conventional antidepressants with an adjunctive agent, but the optimal selection of atypical antipsychotic agents for adjunctive treatment of treatment-resistant depression (TRD) remains controversial.Methods/DesignAn electronic literature search of PubMed, the Cochrane Library, Embase, Web of Science, LiLACS, CINAHL, and PsycINFO for studies will be conducted with no restrictions on language, publication year, or publication type. Several clinical trial registry agencies, pharmaceutical company websites, and FDA reports will also be reviewed. Randomized clinical trials (RCTs) with atypical antipsychotic augmentation treatment for treatment-resistant depression will be considered. Data will be independently extracted by two reviewers. Traditional pairwise meta-analyses will be performed for RCTs that directly compare different treatment arms. Then, Bayesian network meta-analyses will be performed to compare the relative efficacy and acceptability of different atypical antipsychotic agents (and doses). A sensitivity analysis will be performed by excluding studies classified as a small sample size, having a high placebo effect.DiscussionThis systematic review and network meta-analysis will comparatively analyze the efficacy, quality of life, and acceptability profiles of atypical antipsychotic medications used for the adjunctive treatment of TRD. The findings should provide clinically relevant implications for comprehensively understanding the risk–benefit profiles of these adjunctive treatments.Systematic review registrationPROSPERO CRD 42014009666.

Weight Loss and Lifestyle Interventions for Patients Taking Antipsychotics

Atypical antipsychotic medications increase risks for weight gain, insulin resistance, and diabetes. A randomized, controlled trial conducted in an

Atypical antipsychotics for psychosis in adolescents.

For the current issue of the Journal, we asked Dr Derryck H Smith to comment on and put into context the recent Cochrane review on the use of various atypical antipsychotic medications for adolescents with psychosis (1).

Looking for childhood-onset schizophrenia: diagnostic algorithms for classifying children and adolescents with psychosis.

Among children <13 years of age with persistent psychosis and contemporaneous decline in functioning, it is often difficult to determine if the diagnosis of childhood onset schizophrenia (COS) is warranted. Despite decades of experience, we have up to a 44% false positive screening diagnosis rate among patients identified as having probable or possible COS; final diagnoses are made following inpatient hospitalization and medication washout. Because our lengthy medication-free observation is not feasible in clinical practice, we constructed diagnostic classifiers using screening data to assist clinicians practicing in the community or academic centers. We used cross-validation, logistic regression, receiver operating characteristic (ROC) analysis, and random forest to determine the best algorithm for classifying COS (n=85) versus histories of psychosis and impaired functioning in children and adolescents who, at screening, were considered likely to have COS, but who did not meet diagnostic criteria for schizophrenia after medication washout and inpatient observation (n=53). We used demographics, clinical history measures, intelligence quotient (IQ) and screening rating scales, and number of typical and atypical antipsychotic medications as our predictors. Logistic regression models using nine, four, and two predictors performed well with positive predictive values>90%, overall accuracy>77%, and areas under the curve (AUCs)>86%. COS can be distinguished from alternate disorders with psychosis in children and adolescents; greater levels of positive and negative symptoms and lower levels of depression combine to make COS more likely. We include a worksheet so that clinicians in the community and academic centers can predict the probability that a young patient may be schizophrenic, using only two ratings.

The role of atypical antipsychotics for treatment of Tourette's syndrome: an overview.

Tourette's syndrome (TS) is a neuropsychiatric disorder of childhood onset characterized by multiple motor and phonic tics that fluctuate over time. Tic symptoms often improve by late adolescence, but some children and adults with TS may experience significant tic-related morbidity, including social and family problems, academic difficulties, and pain. When more conservative interventions are not successful, and when certain psychiatric co-morbidities further complicate the clinical profile, treating TS with an atypical antipsychotic medication may be a reasonable second-tier approach. However, the evidence supporting efficacy and safety of the atypical antipsychotics for treatment of tics is still very limited. The objective of this paper is to provide an updated overview of the role of atypical antipsychotics for treatment of TS, with evidence-based guidance on their use. Evidence for efficacy of different typical and atypical antipsychotics for treatment of tics was examined by conducting a systematic, keyword-related search of 'atypical antipsychotics' and 'Tourette's syndrome' in PubMed (National Library of Medicine, Washington, DC, USA). Four recent treatment consensus publications were also reviewed. This review focused on literature published from 2000 to 2013 and on available randomized controlled trials in TS. Evidence supporting the use of atypical antipsychotics for treatment of TS is limited. There are few randomized medication treatment trials in TS (i.e. risperidone, aripiprazole, ziprasidone), which employed varying methodologies, thereby restricting meaningful comparisons among studies. Future collaborations among clinical sites with TS expertise employing high-quality study design may better elucidate the role of atypical antipsychotics for treatment of TS.

Acute dystonic reaction associated with increase in trazodone dose: a case report

Serotonergic drugs have been used for the treatment of various psychiatric disorders such as anxiety disorders, impulse control disorders and especially depression. Gastrointestinal system symptoms, weight changes and sleep disturbances are commonly observed side effects of serotonergic drugs. Drug-induced movement disorders are classically associated with dopamine receptor blocking agents, most notably typical and atypical antipsychotic medications. However, extrapyramidal side effects can also be seen with serotonergic agents, antiemetics, and opioid agonists. The most common extrapyramidal system symptoms are akathisia, dystonia, parkinsonism, and tardive dyskinesia. We describe a patient who developed an acute dystonic reaction after taking 100 mg trazodone and his symptoms resolved after receiving intra muscular anticholinergic treatment.

Continuation of Clozapine During Chemotherapy: A Case Report and Review of Literature

Clozapine is an atypical antipsychotic medication that has been shown to bemore effective in the treatment of refractory schizophrenia and the reduction of suicidal behavior in individuals with schizophrenia and schizoaffective disorder than other antipsychotics. Because of the 0.38% annual risk of agranulocytosis associated with clozapine use, prescription requires enrollment in a national registry with submission of complete blood count results before the medication is dispensed. Standard protocols require clozapine discontinuation or increased monitoring or both if absolute neutrophil counts (ANC) go below certain thresholds. Concerns about prolonged clozapine-induced neutropenia arise when patients require chemotherapy for the treatment of malignancy, which frequently induces a predictable but temporary period of neutropenia. We present the case of a patient being treated with clozapine who was diagnosed with lung cancer and who, in collaboration with his psychiatrist and oncologist, decided to continue clozapine during treatment with myelosuppressive chemotherapy.

Patient outcomes within schizophrenia treatment: a look at the role of long-acting injectable antipsychotics.

Compliance is a critical issue across all chronic conditions, including schizophrenia. Compliance is not an all-or-nothing phenomenon, with a continuum from taking all medications as prescribed to partial compliance to complete noncompliance. Partial compliance is a serious problem that may result in abrupt dose changes leading to unanticipated adverse effects and can demoralize the patient. Further, there is a nearly 5-fold increase in the risk of relapse in first-episode patients when antipsychotic drug treatment is discontinued. Taken together, these data indicate that it is critical to ensure continuous delivery of antipsychotic treatment. Atypical antipsychotic medications were expected to result in better adherence, primarily because of the anticipated improved efficacy and safety profile. However, atypical agents have poor adherence, irrespective of the type of atypical medication, making it difficult to predict which patients are taking their oral medications. Long-acting injectable (LAI) agents may minimize the fluctuations in peak and overall plasma levels compared with oral agents, indicating they may allow more consistent and predictable administration. Based on clinical experience in my practice, several important observations regarding LAI use in patients with schizophrenia have been identified. First, there are potential advantages to using LAIs, including assistance in understanding reasons for poor response, the possibility of eliminating daily pill ingestion, and the elimination of the abrupt loss of medication coverage. There are also several potential obstacles to the use of LAIs, including a lack of infrastructure for the delivery and disposal of syringes and the ease of use with the oral agents. Several strategies can be used to increase patient willingness to initiate and continue LAI therapy. Strategies to improve acceptance involve presenting the option with enthusiasm, ensuring proper goal setting, educating the patient that this treatment is not equivalent to emergency injections, and repeatedly recommending LAI therapy. Adherence can be improved by ensuring samples are available in the clinical setting at all times.

Atypical Antipsychotic Use Among Medicaid-Insured Children and Adolescents: Duration, Safety, and Monitoring Implications

Over the last two decades, the increased use of atypical antipsychotic medications, often for unlabeled indications including attention-deficit/hyperactivity disorder (ADHD), has been profound. This study aims to characterize duration of atypical antipsychotic use by age group and Medicaid eligibility category, and among youth with noncomorbid ADHD. Administrative data on 266,590 youth 2-17 years of age, and continuously enrolled in a mid-Atlantic state Medicaid program in 2006, were assessed in terms of median days of atypical antipsychotic use using bivariate analyses and multivariable quantile regression. Also, in a subanalysis of youth diagnosed with ADHD without any reported psychiatric comorbidities (i.e., noncomorbid ADHD), age-specific adjusted odds and adjusted median days of atypical antipsychotic use by Medicaid eligibility category were assessed. Additionally, patterns of use of single atypical antipsychotic regimens and two concomitant atypical antipsychotic regimens were described. Overall, the median annual duration of atypical antipsychotic use was 180 days (interquartile range: 69-298 days). Children (2-12-year-olds) had longer durations of use than did adolescents (13-17-year-olds) (median 192 vs. 179 days), respectively. In the absence of any comorbid psychiatric diagnosis, ADHD-diagnosed foster care youth had more than threefold greater adjusted odds of atypical antipsychotic use than did youth enrolled in income-eligible Medicaid categories. Nearly one third of such ADHD-diagnosed foster care youth received atypical antipsychotics regardless of age group, with annual duration of use >250 median days in 2-12-year-olds. In concomitant atypical antipsychotic regimens, risperidone, aripiprazole, and quetiapine were the most common. Exposure to atypical antipsychotics in Medicaid-insured youth, in particular for children in foster care and those diagnosed with ADHD, was substantial, warranting outcomes research for long-term effectiveness, safety, and oversight for appropriate cardiometabolic monitoring.

Successful Rechallenge of Clozapine Therapy Following Previous Clozapine-Induced Myocarditis Confirmed on Cardiac MRI

[Author Affiliation]Vincent Chow. 1 Department of Cardiology, Concord Repatriation General Hospital and The University of Sydney, Sydney, Australia.Isabelle Feijo. 2 Walker Unit, Concord Centre for Mental Health, Sydney, Australia.Joseph Trieu. 3 Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia.Jean Starling. 2 Walker Unit, Concord Centre for Mental Health, Sydney, Australia.Leonard Kritharides. 1 Department of Cardiology, Concord Repatriation General Hospital and The University of Sydney, Sydney, Australia.Address correspondence to: Vincent Chow, MBBS, Department of Cardiology, Concord Repatriation General Hospital, Level 3 West, Hospital Road, Concord, NSW 2139, Australia, E-mail: vchow@optusnet.com.auTo The Editor:Clozapine is the most effective therapy in patients with treatment refractory schizophrenia (Meltzer et al. 2003). However, clozapine is associated with potentially fatal adverse effects, such as myocarditis and cardiomyopathy.The diagnosis of clozapine-induced myocarditis is challenging, and relies on the combination of clinical, electrocardiographic, echocardiographic, or biochemical changes indicative of myocardial damage and inflammation. In reported cases, myocardial biopsy was rarely performed to confirm the diagnosis of myocarditis. Recently, cardiovascular magnetic resonance imaging (CMRI) has become the primary tool for noninvasive assessment of myocardial inflammation in patients with suspected myocarditis (Friedrich et al. 2009).We describe the first adolescent case of CMRI-confirmed clozapine-induced myocarditis and subsequent successful clozapine rechallenge without recurrence of myocarditis, as evidenced by serial monitoring over 12 months with biochemistry and imaging modalities. The role of gradual dose escalation in permitting successful rechallenge is discussed.Case ReportWe describe a 15-year-old adolescent who was first diagnosed with schizophrenia in March 2011 after having exhibited increasingly disabling psychotic symptoms over a 3 year period prior to his formal diagnosis. From March 2011 to July 2011, he was trialed on multiple atypical antipsychotic medications with limited effect. He was commenced on clozapine in July 2011, according to a standardized protocol, and soon after starting clozapine, there was a significant improvement in his mental state.Fourteen days after the commencement of clozapine, he developed sinus tachycardia and experienced an episode of chest discomfort at rest, associated with nausea and vomiting. He was afebrile with heart rate of 110 beats per minute, and his electrocardiogram (ECG) revealed sinus rhythm with new T wave inversion in leads V4-V6. Troponin I 3.99 was elevated to nearly 40 times the upper limit of normal (reference range An urgent CMRI was performed, and revealed a focus of late gadolinium enhancement within the basal lateral wall of the left ventricle (LV) in the outer epicardial portion of the myocardium. This enhancement pattern is consistent with myocarditis. LV function remained normal with LV ejection fraction (LVEF) measured at 54% (Fig. 1A). A diagnosis of clozapine-induced myocarditis was made. Clozapine was ceased and Troponin I returned to normal within 48 hours. No further episodes of chest discomfort were noted. Viral serology and eosinophil counts were normal.FIG. 1. (A) Cardiac magnetic resonance imaging (CMRI) confirmed myocarditis with focus of late gadolinium enhancement (white) within the epicardial portion of the left ventricle (arrows). Subsequent CMRI performed prior to clozapine rechallenge (B) and 6 months following treatment rechallenge (D) revealed chronic scarring with no recurrence of myocarditis. (C) Serial biochemical, hemodynamic, electrocardiographic, and echocardiographic measurements confirmed no recurrence of myocarditis at 12 months following clozapine rechallenge. …

Reduction of Parkinsonism and Psychosis with Mirtazapine: A Case Report

Psychosis in Parkinson disease is a therapeutic challenge. Regular strategies of treatment are aimed at reducing dopamine medication, and if necessary addition of clozapine. We describe the case of a patient with persistent psychosis. Nocturnal visual hallucinations persisted in spite of reduced dopaminergic medication and sequential treatment with atypical antipsychotic medication (quetiapine and clozapine) in combination with an acetylcholinesterase inhibitor (rivastigmine). After dispensing a dopamine enhancing antidepressant (mirtazapine), prescribed to improve sleeping, the psychotic symptoms almost immediately disappeared while Parkinson's symptoms declined. One other case about a positive effect of mirtazapine on (auditory) hallucinations in Parkinson has been published. The reason for the reduction of psychosis in Parkinson-related disease could have been the effect of antagonism of serotonin (5HT)-2 A and/or antagonism of 5HT-2C leading to dopamine release. Therapeutic effects of medication with strong antagonism for 5HT-2 A and 5HT-2C, like mirtazapine, mianserine, trazodone and nefazodone, in Parkinson-related diseases should be subject for further research. Serotonin might be associated with psychosis in Parkinson-related disease.

Challenges in Estimating Mortality Risk From Antipsychotics in People With Alzheimer’s Disease

Back to table of contents Previous article Next article Communications and UpdatesFull AccessChallenges in Estimating Mortality Risk From Antipsychotics in People With Alzheimer’s DiseaseRyan M. Carnahan, Pharm.D., M.S.Ryan M. CarnahanSearch for more papers by this author, Pharm.D., M.S.Published Online:1 Feb 2014https://doi.org/10.1176/appi.ajp.2013.13091231AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I read with interest the article by Lopez et al. (1) in the September 2013 issue on the long-term effects of antipsychotics in people with Alzheimer’s disease, which suggested that after controlling for psychiatric symptoms, neither typical nor atypical antipsychotics were associated with time to death. I would like to expand on one of the limitations noted by the authors, as I believe it is critical to interpreting the results.Previous research suggests that the excess mortality associated with antipsychotics is greatest early in treatment, with the relative risk trending toward no mortality effect of drug as the duration of antipsychotic use increases (2). The Lopez et al. study assessed medications every 6 months, without tracking interim changes. Periodic assessments such as this create challenges when interpreting results that are related to adverse events for which the greatest excess risk occurs early in treatment. This is a particularly important issue in a dementia sample, where death is not a rare occurrence. That is, if someone both started an antipsychotic and died during the time between two assessments, there would be no record that the individual received an antipsychotic before they died, and only those who survived the early treatment period would be recorded as receiving an antipsychotic. Thus, data are lost from individuals who may be particularly vulnerable to the adverse event of interest, in this case death. This is termed “depletion of susceptibles” and may lead to bias in effect estimates, as those who survive treatment through an initial high-risk period are often less susceptible to an adverse effect. This is one reason that new-user designs are generally preferred in pharmacoepidemiology studies of adverse drug effects (3).Lopez et al. have presented a compelling case that psychotic symptoms are a prognostic marker for increased mortality in people with dementia and an influential unmeasured confounder in observational studies of antipsychotics and mortality. However, the design limitations make it difficult to fully discern the role of the psychiatric symptoms relative to that of antipsychotics that were received but not recorded. I admire the authors’ efforts to address this important question but do not place higher weight on these results than on those of randomized controlled trials that identify an increased risk of mortality associated with antipsychotic use in dementia. Randomized trials have their own limitations, such as highly selected samples, shorter follow-up, and small numbers of events in any given trial. Yet Schneider et al.’s meta-analysis of these trials (4) showing greater mortality with antipsychotics compared with placebo included more than 10 times as many antipsychotic users as were in the Lopez et al. study. I hope the null mortality result in this study is not interpreted as an indication that caution and restraint are not necessary when considering the use of antipsychotics in this vulnerable patient population.From The University of Iowa College of Public Health, Department of Epidemiology, Iowa City, Iowa.Dr. Carnahan reports no financial relationships with commercial interests. He has received funding for research and education related to antipsychotic use in dementia from the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, and the Patient Centered Outcomes Research Institute.References1 Lopez OL, Becker JT, Chang YF, Sweet RA, Aizenstein H, Snitz B, Saxton J, McDade E, Kamboh MI, DeKosky ST, Reynolds CF, Klunk WE: The long-term effects of conventional and atypical antipsychotics in patients with probable Alzheimer’s disease. Am J Psychiatry 2013; 170:1051–1058Link, Google Scholar2 Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, Brookhart MA: Risk of death in elderly users of conventional vs atypical antipsychotic medications. N Engl J Med 2005; 353:2335–2341Crossref, Medline, Google Scholar3 Ray WA: Evaluating medication effects outside of clinical trials: new-user designs. Am J Epidemiol 2003; 158:915–920Crossref, Medline, Google Scholar4 Schneider LS, Dagerman KS, Insel P: Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005; 294:1934–1943Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 171Issue 2 February 2014Pages 227-227 Metrics PDF download History Accepted 1 December 2013 Published online 1 February 2014 Published in print 1 February 2014

Body Mass Index, Obesity, and Psychopathology in Patients With Schizophrenia

A number of studies have reported that patients with schizophrenia have a higher body mass index (BMI) than the general population. Few Asian studies have examined BMI in patients with schizophrenia. The aims of the current study were to evaluate the distribution of BMI and prevalence of obesity in a large sample of Chinese patients with schizophrenia (n = 973) and to examine the sociodemographic and clinical correlates of overweight (BMI ≥ 25 kg/m) and obesity (BMI ≥ 30 kg/m). There was a preponderance of patients who were overweight (58.7%) and obese (73.6%) as compared with control subjects. Regression modeling of clinical and symptom factors in schizophrenia patients revealed that females were almost twice as likely to be obese compared with males and patients with comorbid medical conditions were more likely to be obese compared with those who did not have a comorbid medical condition (odds ratio, 1.6). Those prescribed typical antipsychotic medications were 1.7 times more likely to be obese, whereas individuals prescribed with both typical and atypical antipsychotic medications were 2.2 times more likely to be obese as compared with those prescribed atypical antipsychotics. A significant predictor interaction for obesity was observed between sex and typical antipsychotics, sex and comorbid medical conditions, and years of education and comorbid medical conditions. The higher prevalence of obesity in patients with schizophrenia is a matter of clinical and public health concern; interventions to reduce weight to healthy levels would result in both improved health and quality of life among patients with schizophrenia.

Management of Adverse Effects of Second-generation Antipsychotics in Youth

Second-generation antipsychotics (SGAs) have been proven effective in treating several psychiatric conditions in children and adolescents. These atypical antipsychotic medications are being used with increasing frequency in Europe, the U.S., and Canada. We aim to expose short-term and long-term adverse effects (AEs) of SGAs in youth populations and to provide management recommendations for major adverse effects. These proposals are based on (1) an in-depth literature review of both short- and long-term studies on the use of SGAs in youth; (2) our own clinical experience in managing such treatment in this population; and (3) the work of the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA). AEs are frequent in youth treated with SGAs, and include primarily weight gain, metabolic and hormonal changes, somnolence, extrapyramidal syndrome, and QT modifications. However, frequency and type of AE vary according to compound, and each compound’s AE profile is specific. Acknowledgment of these distinct profiles should aid clinicians in making treatment decisions. After an SGA is prescribed, routine monitoring of AEs is recommended, and should an AE occur, clinical management recommendations should be followed. To date, there are no clinically validated monitoring recommendations.

Acute Hyperglycemia Associated with Short-Term Use of Atypical Antipsychotic Medications

The prevalence of metabolic disturbances associated with long-term use of antipsychotic medications has been widely reported in the literature. The use of atypical antipsychotics for the treatment of delirium in the intensive care unit (ICU) has gained popularity due to a lower potential for adverse effects compared with conventional antipsychotics. However, current studies evaluating safety and efficacy of antipsychotics in the ICU setting do not include metabolic parameters as a potential adverse effect that requires monitoring. It is thought that long-term adverse effects of antipsychotics may be out of context for the intensive care setting. A literature review was conducted to investigate the prevalence of acute hyperglycemia associated with short-term use of antipsychotics, with the purpose of reviewing evidence that hyperglycemia may occur even with short-term use of atypical antipsychotics. A MEDLINE search for acute hyperglycemia from short-term use of antipsychotics resulted in studies involving animal models and healthy volunteers. These studies indicate that acute hyperglycemia may occur after short-term treatment. A review of the literature shows preliminary evidence to suggest that atypical antipsychotics impact glucose sensitivity and induce insulin resistance even after a single dose. Although no studies have been conducted evaluating the impact of hyperglycemia in critically ill patients from the short-term use of atypical antipsychotics for the treatment of delirium, the potential to affect clinical outcomes exist and warrants further research in this area.

Increase in mortality rate in patients with dementia treated with atypical antipsychotics: a cohort study in outpatients in Central Italy.

The purpose of this study was to investigate the risk of death among elderly outpatients (>65 years) with a dementia diagnosis treated with atypical antipsychotics. We conducted a cohort study of 696 patients who entered the Unit of Alzheimer Evaluation (UVA) of Teramo Hospital in Central Italy, during a 3-year period (January 2007-December 2009). Among these patients, 375 were treated with atypical antipsychotics (quetiapine, risperidone and olanzapine). Data were collected from record files sent to the pharmaceutical service of the hospital. Patients taking atypical antipsychotic medication were associated with a significantly higher mortality rate than patients not taking antipsychotics. The relative risk of death in patients treated with antipsychotics compared to control patients was 2.354 (95% CI 1.704-3.279). The greatest increases in mortality rate occurred close to the last drug supply, and declined exponentially as time passed from the last drug supply in patients who stopped drug assumption. Quetiapine was the most commonly prescribed drug and higher doses of this drug were associated with higher mortality rates. These results are in line with the April 2005 warning of the Food and Drug Administration (FDA) that among elderly patients with dementia, the treatment of behavioural disorders with atypical antipsychotics is associated with a higher mortality rate. Given the potential risks of mortality with antipsychotics, and since antipsychotic medications may benefit only a minority of patients, new approaches are clearly needed to manage the neuropsychiatric symptoms of dementia.

Minimizing Cardiovascular Adverse Effects of Atypical Antipsychotic Drugs in Patients with Schizophrenia

The use of atypical antipsychotic agents has rapidly increased in the United States and worldwide in the last decade. Nonetheless, many health care practitioners do not appreciate the significance of the cardiovascular side effects that may be associated with their use and the means to minimize them. Thus, atypical antipsychotic medications can cause cardiovascular side effects such as arrhythmias and deviations in blood pressure. In rare cases, they may also cause congestive heart failure, myocarditis, and sudden death. Patients with schizophrenia have a higher risk of cardiovascular mortality than healthy individuals, possibly because of excessive smoking, the underlying disorder itself, or a combination of both factors. Increased awareness of these potential complications can allow pharmacists and physicians to better manage and monitor high risk patients. Accurate assessments are very important to avoid medications from being given to patients inappropriately. Additionally, monitoring patients regularly via blood draws and checking blood pressure, heart rate, and electrocardiogram can help catch any clinical problems and prevent further complications. Finally, patient and family-member education, which pharmacists in particular can play key roles in, is central for the management and prevention of side effects, which is known to reflect positively on morbidity and mortality in these patients.