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Lecture timetable
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Centres of Excellence for Relapse Prevention
CENTRES OF EXCELLENCE FOR RELAPSE PREVENTION
Seminar 1:
’Atypical’CERP CERP
antipsychotics
Centre of Excellence for Relapse Prevention
Focus on Schizophrenia Centre of Excellence for Relapse Prevention
Focus on Schizophrenia
1. The 3 swirls convey fluidity and movement. 2. Humanistic approach. Each circle and curve represents
The ellipse shape represents a centre of excellence from a person while the central circle represents the centre of
which knowledge is shared and disseminated. excellence. This icon symbolizes a group of people coming
together to share information.
Sydney-Santiago 2015
FOR RE
CERP
CE
EN LA
LL P
4a. Existing colouration
E
SE
NTRE OF EXC
PRE
Focus on Schizophrenia
CE
CERP
Focus on Schizophrenia
4b. Red colouration
CERP
Centre of Excellence for Relapse Prevention
Focus on Schizophrenia
3. A global icon. The circles and lines represents a network 4. The circle within the centre of the letter C represents
from which knowledge is shared and disseminated. excellence within the field of Schizophrenia.
Context/background
COMPLEXITY
The illnesses; the patient; the health system
COMORBIDITIES CHRONICITY
Multiple systems, pathologies Dynamic
SEVERITY
Mensuration;domain spans; interactions
FUNCTION/OUTCOME
Biological; social; psychological;
multidimensional
6
6
6
Clinical imperatives
• Arguably, the three main areas that require increased
clinical and research focus and attention in psychosis are
the following:
Phase of illness
2 3
t
en
m
Vocation /
at
Ps
social role
tre
yc
al
ho
gic
so
Social and family
olo
cia
functioning
ac
lt
re
m
at
ar
m
ph
Behavioural
en
ho
ts
yc
1
Ps
Suicidality
Symptom factors
(Positive, negative, cognitive, affective, excited)
Antipsychotic development 8
8 phases
FGAs SGAs
orals then orals then
depots LANAs
4 LA-SGA
3 SGA ('atypicals')
1 FGA ('typicals')
Dopamine blockers 9
Overactivity of DA Overactivity
Striatal DAergic
in these
projections
of systems
DA inare
associated with
thought to be these
movement
associated with disorders, and
positive projections
some cognitive
Mesolimbic symptoms Basal thought
function to be
associated
Hypofunction of with positive
DA acts as the
PFCMesolimbic
(possibly PRIF
through underactive symptoms
(neurohormone).
D1 mediated Affected by DA
circuits) underlies blockade by low
negative, Ki antipsychotics
Mesocortical cognitive, some Pituitary
mood symptoms.
Basal
FGAs or SGAs?
19
Many potentially severe side effects (risks) with reduced benefits (directly
contributing to reduced adherence)
Based on: Lambert & Castle. Med J Australia (2003) 178(9 Suppl): S57-61
NIDS 21
21
Mental
Neuroleptic side effect Negative symptom
function
Vigilance Drowsiness, somnolence Attentional impairment
Reduced speed of thinking
Alogia
Concentration difficulties
Poverty of speech
Cognition “Narrowing of mind”
“Fuzzy head”
Apathy
Avolition, apathy
Conation Lack of energy
Diminished sense of purpose
“Weak, tired”
Flat affect
Affective blunting
Affectivity Indifference Restricted affect
Lack of feeling
Emotionality Dysphoria
Diminished emotional range
“Dead inside”
Anhedonia, asociality
Anhedonia
Curbing of interest
Motivation Reduced drive
Diminished social drive
Reduced initiative
Diminished curiosity
Lewander, 1994.
23
23
Proposed advantages of SGAs
24
24
Proposed advantages of SGAs
19 Naber, D. & Karow, European Neuropsychopharmacology. 11, S391-6 (2001). 20 Naber, D. et al, Schizophr Res 50,
79-88 (2001). 21 Leucht, S. et al. Am J Psychiatry 160, 1209-1222 (2003). 22 Bagnall, A. M. et al. Health Technol
Assess 7, 1-193 (2003)
26
26
On the other hand….
27
27
SGAs: evidence and uptake policy
1. Adams, C.E.; Tharyan, P.; Coutinho, E.S.; & Stroup, T.S. (2006) The schizophrenia drug-treatment paradox:
Pharmacological treatment based on best possible evidence may be hardest to practice in high-income
countries. British Journal of psychiatry, 189, 391–392.
• Only 4 studies existed and SFX including CMRFs were not considered
sufficiently.
Horvitz-Lennon, M., Iyer, N., & Minoletti, A. (2013). Do Low- and Middle-Income Countries Learn from the
Experience of High-Income Countries? Lessons from the Use of Atypical Antipsychotics for Treatment of
Schizophrenia. International Journal of Mental Health, 42(1), 33-50.
Meta-analysis1 29
Effect size in each study (solid circles) for 10 drugs, with better second-generation antipsychotic efficacy
indicated by positive effect sizes. The mean effect size of each drug is indicated by a short horizontal bar.
1. Davis JM, et al. Arch Gen Psychiatry. 2003;60:553-564.
Meta-analysis1 30
Magnitude descriptors
Effect size
Test
Statistic
Small Medium Large
Injectable
Risperidone, long acting 50 mg/two weekly Requires antipsychotic cover (oral or previous depot) for three
(Risperdal Consta) to six weeks until a steady state is reached
* Based on reference 18. The near-maximal effective dose is the threshold dose necessary to produce all or almost all the clinical responses for each drug. These values are not
inconsistent with maintenance doses for patients with multiepisode schizophrenia.
†
Upper limit not yet clearly defined.
practical advice for professionals and for ules that a patient can fill out in the waiting medications requires careful monitoring
From:Lambert T. Atypical antipsychotics in schizophrenia: a guide for GPs. (2006). Medicines Today. 7(1):
consumers and carers can be downloaded room may provide an efficient method of of adherence, outcomes, mental state, and
55-58; * Davis & Chen. J Clin Psychopharm 2004;24:192-208
from www.psychiatry.unimelb.edu.au/ identifying issues that are of immediate physical health status so that the risks and
open/ diabetes_consensus.) The principles importance to the patient. An example is benefits are balanced. For most patients
outlined in the consensus statement are the Liverpool University Neuroleptic Side with schizophrenia, treatment is long term,
consonant with those proposed by the Effect Rating Scale (LUNSERS), which can and forming an enduring relationship
RACGP.23 be completed in about three minutes.24-25 with a GP will enhance the possibility of
However, many side effects are not simply recovery by maximising the potential of
What about side effects? attributable to antipsychotics: psychotropic treatment. MT
It is important to enquire about common polypharmacy is common in mental health
side effects of antipsychotics because these settings and contributes substantially to A list of references is available on request
have an impact on quality of life and daily side effects such as weight gain and seda- to the editorial office.
function and, subsequently, adherence to tion. Polypharmacy should be avoided
treatment. Sedation, weight gain, akathisia, whenever clinically possible. DECLARATION OF INTEREST: Associate Professor
and sexual side effects often cause much Lambert has been a member of advisory boards for
distress. Patients may experience long-term Conclusion Janssen-Cilag, Eli Lilly, Pfizer, Lundbeck, Sanofi,
extrapyramidal side effects, such as tardive GPs care for a substantial proportion of Novartis and Faulding. He has received funding for
dyskinesia, but they might not complain patients with schizophrenia, and many unrestricted research from Eli Lilly, Novartis, Janssen-
of these spontaneously. atypical antipsychotics are now available Cilag, Bristol-Myers Squibb, Pfizer and AstraZeneca,
Many GPs have limited time to investi- for treating this illness. Selecting medica- and travel assistance to attend meetings from Eli Lilly,
Olanzapine 18.1
Risperidone 4.1
Clozapine 418
Quetiapine 511
Amisulpride 650*
Aripiprazole 19.1*
Risperidone LAI2 46 q2
1. SGA doses from audit of adult community patients in Victoria with schizophrenia (2005); 2 Average q2 dose
IM from HIC, IMS, and audit data (2006); * doses may be supra Maximal Effective Dose (MED) proposed by
Davis and Chen (op cit.)
SGA doses from audit of adult community patients in Victoria with schizophrenia (2005); 2 Average q2 dose IM
from HIC, IMS, and audit data (2006); * doses may be supra Maximal Effective Dose (MED) proposed by
Davis and Chen (op cit.)^ partial dopamine agonist; equivalence is approximate from practice. Leucht et al’s
values are here for comparison and do raise a number of questions.
35
Mechanisms
35
Potential clinical
Mechanisms Potential consequences
efficacy
EPS
D 2R ↑ Negative symptoms
↓ positive symptoms
antagonism ↑ Cognitive symptoms
↑ PRL
↓ positive symptoms
D2R partial Little or no EPS
↓ negative symptoms
agonism Behavioral activation
↓ cognitive deficits
ACh release in
↓ cognitive deficits ?
the PFC
↓ negative symptoms
↓ cognitive symptoms
5-HT1A partial
↓ anxiety symptoms
??? activation
agonism
↓ depressive
symptoms
↑ Anticholinergic
Muscarinic R symptoms e.g. dry
↓ EPS
antagonism mouth, constipation
tachycardia, cognitive
↓ positive symptoms
↓ negative symptoms
Apoptosis /
Glutamate modulation
↓ cognitive deficits
neurodegeneration
↓ illness progression
FGA affinities1 39
39
1 Strong
M1 10 Moderate
M4 100 Mild
42
42
Use of pharmacological parameters
Risks (Safety)
Risks
43
45
EPS
45
Type Comment
Four components: rigidity, bradykinesia,
Parkinsonism tremor, postural stability.
± bradyphrenia
Three components: subjective (feelings of
Acute
Akathisia inner restlessness), objective (motor signs);
akathisic distress (subjective)
Twisting, pulling or squeezing; involuntary,
Dystonia
often within 96 hrs of Rx; variable sustain
Two broad co-occuring subtypes: choreic;
Dyskinesia athetoid (snake-like); may blend with t.
akathisia and t. dystonia
Tardive
Dystonia This sometimes conceptualised as a dyskinetic
variant
Akathisia
Consequences of EPS 47
47
occupied in BG,
parkinsonism
will follow.
• This sets the upper
threshold of the SGA
‘reference range’
Kapur, S., et al (2000). Relationship between dopamine D(2) occupancy, clinical response, and side effects: a
double-blind PET study of first-episode schizophrenia. Am J Psychiatry, 157(4), 514-520.; Seeman, P. &
Tallerico, T. (1998). Antipsychotic drugs which elicit little or no parkinsonism bind more loosely than dopamine
to brain D2 receptors, yet occupy high levels of these receptors. Mol Psychiatry, 3(2), 123-134.
1 Iqbal et al (2007) CNS Spectr. 2007;12(9 Suppl 14):1-16; 2 Weiden, P. J. (2007). EPS profiles: the atypical
antipsychotics are not all the same. J Psychiatr Pract, 13(1), 13-24; 3 Correll, C. U., Leucht, S., & Kane, J. M.
(2004). Lower risk for tardive dyskinesia associated with second-generation antipsychotics: a systematic review
of 1-year studies. Am J Psychiatry, 161(3), 414-425.
Moderators/effectors of EPS 51
51
Modulator SGA
M1 antagonism CLOZ, OLZ
Neuropeptides ?
• However, the
fast-off
antipsychotics
are usually
unable to
compete with
DA for D2R
sites
• Leads to low
EPS as DA
throughput is
OK
Kapur, S., et al (2000). Relationship between dopamine D(2) occupancy, clinical response, and side effects: a
double-blind PET study of first-episode schizophrenia. Am J Psychiatry, 157(4), 514-520.; Seeman, P. &
Tallerico, T. (1998). Antipsychotic drugs which elicit little or no parkinsonism bind more loosely than dopamine
to brain D2 receptors, yet occupy high levels of these receptors. Mol Psychiatry, 3(2), 123-134.
Tight/loose binding 53
53
Yamada, Y., et al. (2002). Prediction and assessment of extrapyramidal side effects induced by risperidone
based on dopamine D(2) receptor occupancy. Synapse, 46(1), 32-37.; Kapur, S. & Remington, G. (1996).
Serotonin-dopamine interaction and its relevance to schizophrenia. Am J Psychiatry, 153(4), 466-476.
Intrinsic activity
decreases the DA
antagonistic
effects
Based on: Yokoi, F., et al. (2002). Neuropsychopharmacology, 27(2), 248-259. Net effective occupancy
imputed from Shapiro, D. A., et al. (2003). Aripiprazole, a novel atypical antipsychotic drug with a unique
and robust pharmacology. Neuropsychopharmacology, 28(8), 1400-1411.
56
56
57
Mouth and Tongue: Pre
57
58
Mono-therapy: SGA 59
59
60
Mouth and tongue: post
60
Hands
61
Poly-antipsychotics: FGAs 62
62
Mono-therapy: SGA 63
63
Resource: GATES
65
65
• Structured interview to
generate standard scores
(BAS, AIMS, AS, etc).
• Training occurs when demand is
sufficient. Concord training will be in
July.
General Akathisia Tardive phenomena & Extrapyramidal rating Schedule – OBJective – v6.5 – © T Lambert 1999
“Have these [movements] started recently or been present for more than a few weeks”?
Examiner: Based on the patient’s report and any existing clinical knowledge, rate the acuteness of
the dystonia.
No neck dystonia 0
Acute neck dystonia 1
Persistent/chronic/tardive neck dystonia 2
Definite acute on chronic dystonia 3
Both the patient and the examiner raise their arms to shoulder height and then, on the command, let
them drop to their sides. If the patient can’t relax, stand behind and ask the patient to raise their
arms to shoulder height. Support their arms at the level of the mid forearm or elbow joint. Tell the
patient:
“I’m going to take my hands away. When I do, let your arms fall to your sides naturally – don’t
help them fall”.
[The patient may require to be distracted in order to relax. Asking the patient to make their limbs go
floppy, “like a rag doll”, sometimes helps].
Examiner: Grasp the patient’s elbow and hand. The elbow is flexed at 90°. Do the following to the
flexed arm.
Abduct it; adduct it; Externally and internally rotate it; Flex it; Extend it; shake the whole limb like a
floppy rag doll, ensuring that the shoulder joint is able to move and rotate freely.
General Akathisia Tardive phenomena & Extrapyramidal rating Schedule – OBJective – v6.5 – © T Lambert 1999
OBJECTIVE AKATHISIA
Examiner: You may later return to any of the items below and recode them if new phenomena
appear during the course of the examination. If you noticed any of these movements during the
preamble or, if completed, during the subjective questionnaire, please indicate below.
O1. ROCKING FROM FOOT TO FOOT/ WALKING ON THE SPOT
Examiner: watch the person for knee jiggling or other signs of restlessness which may occur
despite the soles of the feet remaining steady (milder cases). The patient may march on the spot
but doesn’t take a step off this spot (more marked cases).
None 0
Just noticeable 1
Mild 2
Moderate 3
Frequent and gross 4
Examiner: The patient may appear to step off the spot, shuffle a little, walk around the spot or
frankly pace the room, or even leave. This item is usually accompanied to some degree by
movements in the previous item (O1).
None 0
Oscillates, walks a pace or two 1
Walks around the room 2
Paces 3
Urgently paces or leaves room 4
69
Prolactin
Freeman ME, Kanyicska B, Lerant A, et al. Prolactin: structure, function and regulation of
secretion. Physiol Rev 2000; 80: 1523-31.; Gudelsky GA. Tuberoinfundibular dopamine neurons
and the regulation of prolactin secretion. Psychoneuroendocrinology 1981; 6: 3-16
Neurohormone effects of DA 71
71
antagonism
• Inhibiting factors:
Dopamine; (Ach;GAP)
• DA acts as a neurohormone
(prolactin-release inhibiting
factor) to prevent the release
of prolactin by binding to DA
receptors.
Freeman ME, Kanyicska B, Lerant A, et al. Prolactin: structure, function and regulation of secretion. Physiol Rev
2000; 80: 1523-31.; Gudelsky GA. Tuberoinfundibular dopamine neurons and the regulation of prolactin
secretion. Psychoneuroendocrinology 1981; 6: 3-16
Hyperprolactinaemia 72
72 side effects
Gynecomastia 5%
Galactorrhoea 7%
Loss libido 50%
Orgasm Disorder 18%
Amenhorrhoea 35%
?
Osteporosis
0 20 40 60 80
73
74
74
PRL: FGAs and SGAs
75
75
PRL: background1
• Prolactin sparing: ARI,ZIP,CLOZ,OLZ,QUET
• Prolactin raising: FGAs, RIS, AMI, ?PALI
• 60% female, 40% male had elevated PRL levels on PRL-raising drugs
• Direct (PRL) and indirect (hypogonadism) effects
• HyperPRL may be symptomatic or asymptomatic
• In the young, these consequences may play an over-determined role
in discontinuation (and nonadherence)2
77
Cognitive
77
80
80
Patients and sedation
1 Hofer, A. et al. (2002). J Clin Psychiatry, 63(1), 49-53.; 2 Seale et al. Social science & medicine (2007). 65 (4)
pp. 698-711; 3 Lambert, M. et al. (2004). Eur Psychiatry, 19(7), 415-422.; 4 Angermeyer, M. C. et al. (2001).
Psychol Med, 31(3), 509-517.; 5 Angermeyer, M. C. et al. (1999). Psychiatr Prax, 26(4), 171-174.
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Cognitive deficits:FGA=SGA😞
• Cognition is a significant focus as a treatment target in schizophrenia.
• Typically, neither first- nor second-generation antipsychotics have a
clinically meaningful beneficial effect on cognition in schizophrenia.
• There is a gap between the beneficial effects of second-generation antipsychotics observed in animal studies
using tests of very specific behavioral abilities and the modest to negligible effects in global
neuropsychological function seen in clinical studies that remains to be fully understood.
• There is a need for greater validation of standardized neuropsychological batteries (i.e., the Measurement
and Treatment Research to Improve Cognition in Schizophrenia program) as an approach for assessing
cognitive outcomes in comparison to other approaches rooted in cognitive neuroscience.
• Other valid methodologies for evaluating cognitive treatment effects, such as those grounded in
translational neuroscience, have not been utilized frequently or effectively.
• For future research and drug development, a translational/biomarker approach may be more effective.
• Significant hurdles to obtaining an indication for cognitive enhancement include validation of functional
outcome measures and understanding the time and psychosocial supports needed for cognitive changes to
translate into improved community function.
• Developing approaches for using cognitive profiles and pharmacogenetics to individualize treatment
selection are promising strategies for potential advancement in this area.
Hill, S. K., Bishop, J. R., Palumbo, D., & Sweeney, J. A. (2010). Effect of second-generation antipsychotics
on cognition: current issues and future challenges. Expert Review of Neurotherapeutics, 10(1), 43–57.
83
83
Adherence in psychosis
• 80% of patients with
schizophrenia are non-
adherent at some stage of
1
their illness
1 Corrigan, P. W. et al. (1990). Hosp Community Psychiatry, 41(11), 1203-1211. 2 Williams CL et al. 1999. Med
Care, 37(4 Suppl Lilly), AS81-6.; 3 Velligan et al(2003) op. Cit.; 4 Oehl, M. et al. (2000). Acta Psychiatrica
Scandinavica, Supplementum, 102(407), 83-86
84
84
SGA adherence
1 Velligan, D. I., et al(2003). Psychiatric Services, 54(5), 665-667.; 2 Byerly et al quoted in Marder SR.
(2003). The Journal of clinical psychiatry, 64 Suppl 16, 3-9.
Nonadherence: 86
86 consequences
CENTRES OF EXCELLENCE FOR RELAPSE PREVENTION
Nonadherence: 87
87 consequences
CENTRES OF EXCELLENCE FOR RELAPSE PREVENTION
• The FGA-LAIs are all oil-based. The current and forthcoming SGA-LAIs (LANAs) no longer rely on
the older oil paradigm
• RLAI is an interim delivery formulation, being based on microsphere technology whilst those that
follow are based on crystal technology
90
90
Benefits of SGA-LAIs
Source: The Lundbeck Education Program on FGA-LAI Antipsychotics CD-ROM Addat Pty Ltd
92
92
FGA-LAI Kinetics
• Real world and computer
models agree that steady
state occurs in ~2-3
months.
Source: The Lundbeck Education Program on FGA-LAI Antipsychotics © Tim Lambert 1999
93
Microsphere action 93
• Reduced peak to
trough (less side
effects)
• Mean plasma
levels towards
the lower side
(hypofrontal
targeting)
© Tim Lambert 2009-2015
CERP Workshop
4
0
3
Median 5
[PLAI]
(ng/ 3
mL) 0
2
5
2
0
1
5
1 Oral 6 mg paliperidone ER
0 Oral 12 mg paliperidone ER
Paliperidone palmitate
5
Estimated oral 6 mg steady-state
© Tim Lambert 2009-2015
CERP Workshop
1 4 8 15 22 36 50 64 78 92
35
(paliperidone or active moiety)
30
Plasma concentration ng/mL
25
20
15
10
RLAI (+ oral risperidone*) RLAI injections
5 Paliperidone palmitate (+ oral placebo*) Paliperidone palmitate injections
0
1 4 8 15 22 36 50 64 78 92
Time (days)
© Tim Lambert 2009-2015
*Oral risperidone received for first three weeks and then again at dose change (ie not given for the duration of trial)
100
80
Olanzapine (ng/ml)
60
40
20
0
0 4 8 12 16 20 24
© Tim Lambert 2009-2015
98
98
SGAs and cardiometabolic risk
99
Centres of Excellence for Relapse Prevention
CENTRES OF EXCELLENCE FOR RELAPSE PREVENTION
Seminar 1:
’Atypical’CERP CERP
antipsychotics
Centre of Excellence for Relapse Prevention
Focus on Schizophrenia Centre of Excellence for Relapse Prevention
Focus on Schizophrenia
1. The 3 swirls convey fluidity and movement. 2. Humanistic approach. Each circle and curve represents
The ellipse shape represents a centre of excellence from a person while the central circle represents the centre of
which knowledge is shared and disseminated. excellence. This icon symbolizes a group of people coming
together to share information.
Sydney-Santiago 2015
FOR RE
CERP
CE
EN LA
LL P
4a. Existing colouration
E
SE
NTRE OF EXC
PRE
Focus on Schizophrenia
CE
CERP
Focus on Schizophrenia
4b. Red colouration
CERP
Centre of Excellence for Relapse Prevention
Focus on Schizophrenia
3. A global icon. The circles and lines represents a network 4. The circle within the centre of the letter C represents
from which knowledge is shared and disseminated. excellence within the field of Schizophrenia.