FDA Provides New Guidance on Antipsychotic Usage During

Clinical News Peter F. Buckley, MD Editor-in-Chief FDA Provides New Guidance on impact of prolonged exposure to antipsychotic medications Antipsychotic Usage during upon total brain volume, as well as both gray matter and Pregnancy caudate-putamen volumes. Modest volumetric reductions were observed. There appeared to be a dose effect of antipsy- The U.S. Food and Drug Administration (FDA), tak- chotics as well. Although the effects were not independent ing stock of all available and new pharmacoepidemiological of other factors that are known to influence potential brain information on antipsychotic medication use, has provided changes—namely, duration of follow-up, illness severity, and updated guidance on prescribing antipsychotics during and comorbid substance abuse—the effect of medications per- immediately after pregnancy. Firstly, the FDA report affirms sisted even when these other influences were taken into ac- the long-held clinical message that untreated psychosis in count statistically. This is a noteworthy observation. the expectant mother is associated with (far) greater risk While the results are still open to other interpretations, than the risks associated with continued use of antipsychot- the observations for this study are sobering. They are also ics. Nevertheless, the report cautions about risks of antipsy- in line with earlier preclinical studies from the University chotic medications for extrapyramidal side effects (EPS) and of Pittsburgh that have demonstrated potential neurotoxic withdrawal side effects in the newborn. The report cites out- effects of antipsychotic medication upon selective neurons. comes for 69 instances of EPS and withdrawal side effects Nevertheless, the “jury is still out” on this contentious top- that were reported to the FDA up until the fall of 2008. The ic, especially since other imaging studies have highlighted data affirm the occurrence and anticipated profile of these neurodegenerative changes that appear to be intrinsic to adverse effects, although, interestingly, a number of con- the illness and, in particular, changes that are aggravated founding effects (e.g., prematurity, polypharmacy) is also by repeated relapse. Accordingly, the benefit of long-term noted. In addition to identifying these risks, the FDA also antipsychotic therapy remains a complex consideration of cautions the abrupt discontinuation of antipsychotic medi- risk. Additionally, this study was undertaken across a period cations, and the need for clinicians to continue reporting se- (1991–2009) of substantial change in the use of first- and rious side effects from the use of antipsychotic drugs to the second-generation antipsychotic medications. The authors FDA MedWatch program. For clinicians who are interested also highlight the relevance of their findings as another in additional information, it is worthwhile to consult the cautionary observation concerning off-label use of anti- FDA website at www.accessdata.fda.gov/scripts/medwatch/ psychotic medications. medwatch-online.htm. Ho BC, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term antipsychotic treatment and brain volumes: a longitudinal study of first-episode Antipsychotics and Long-Term schizophrenia. Arch Gen Psychiatry 2011;68(2):128-137. Brain Changes Another provocative brain imaging report by colleagues Cannabis and Schizophrenia from the University of Iowa—with the senior author being The role of cannabis as a risk factor for schizophrenia our CS Editorial Board member, Dr. Nancy Andreasen—ad- has been highlighted in prior issues of CS. A recent meta- dresses the vexing issue of whether long-term use of anti- analysis (Large et al.) confirms a powerful effect of cannabis psychotic medication is helpful, or harmful, over the course in at least bringing on schizophrenia earlier than might oth- of illness. The article appeared in the February ’11 issue of erwise have occurred. In a meta-analysis of 43 studies, the Archives of General Psychiatry. This topic of antipsychotic- age of onset of psychosis was 2.7 years earlier among can- related brain changes has been featured in previous issues nabis abusers than in patients who did not abuse cannabis. of CS, and there are studies for and against the proposition The analysis was—as is often the case—complicated by the that these drugs might cause brain changes in people with concomitant use of other illicit drugs and of alcohol. How- schizophrenia. The most notable effect has been enlarge- ever, alcohol use did not appear to impact age of onset, and ment of the caudate nucleus, which appears to be at least the effect of “all drug abuse” was considerably less powerful in part related to the dopaminergic receptor affinity across than that of cannabis upon age of onset. The findings are first- and second-generation antipsychotic medications. In salutary and add to the further growing weight of evidence this study, which followed up over 211 patients after their that cannabis is an important risk factor for developing first episode of psychosis, the authors documented an schizophrenia. 12 • Clinical Schizophrenia & Related Psychoses April 2011 Clinical News Apr 11.indd 1 3/18/11 10:08 AM Peter F. Buckley Although the recent commentary by Drs. Csernansky the publication of several key articles that inform key areas and Smith in the February ’11 issue of The American Journal of neurobiological research in schizophrenia. In the Janu- of Psychiatry pertains to another study and is (seemingly) ary 1, 2011 issue of Biological Psychiatry, papers report new unrelated to the meta-analysis described above, the com- findings on two key areas of research: 7 nicotinic recep- mentary is well worth a read, as it calls for greater attention tors and novel pharmacological approaches to cognitive to the deleterious effects of illicit drugs upon mental health deficits in schizophrenia. Additionally, the same issue has and specifically upon psychotic symptoms. This is impor- several key papers on cognition and glutamate dysfunc- tant both from the causal risk perspective and from the tion in schizophrenia. These articles are complemented by capacity of drugs of abuse to worsen illness—attributes that three papers illustrating aspects of neural dysconnectivity in are often ill-informed among our patients and among the schizophrenia. community at large. The January 15th issue of Biological Psychiatry has a collection of key papers addressing postmortem research Large M, Sharma S, Compton MT, Slade T, Nielssen O. Cannabis use and earlier onset of psychosis: a systematic metaanalysis. Arch Gen Psychiatry in schizophrenia. The commentary by Paul Harrison is par- 2011. ticularly noteworthy and he lauds the greater use of “omics” Csernansky JG, Smith MJ. Thought, feeling, and action in real-time—moni- (proteomics, epigenomics) technologies in postmortem toring of drug use in schizophrenia. Am J Psychiatry 2011;168(2):120-122. research. Both of these issues of Biological Psychiatry pro- vide very nice overviews of complex areas of neurobiological Largest Ever Prospective research in schizophrenia, and I highly recommend these Schizophrenia Treatment Study to you. Examines Mortality N-Methyl-D-Aspartate receptor function and cortical connectivity in The results of the Ziprasidone Observational Study of schizophrenia. Biol Psychiatry 2011 Jan 1;69(1):A1-A12, 1-100. Cardiac Outcomes (ZODIAC) Trial showed comparable Postmortem studies of psychosis: status, opportunities, and challenges. Biol nonsuicide mortality rates among 18,154 patients with Psychiatry 2011 Jan 15;69(2):A1-A10, 101-194. schizophrenia who were randomized to treatment with ziprasidone or olanzapine. This is an enormous study span- New Information on Lurasidone ning 18 countries following, prospectively, a large cohort Results from the PEARL (Program to Evaluate the over one year inclusive of whether the patient remained on Antipsychotic Response to Lurasidone) Study 3 were the chosen treatment or not. The rate of all cause mortal- presented at the recent 49th Annual Meeting of the American ity was 1.13% in ziprasidone-treated patients and 1.12% in College of Neuropsychopharmacology. PEARL 3 comprised olanzapine-treated patients. The rate of nonsuicide mor- 488 patients with schizophrenia in a 6-week, double-blind tality was 0.91% and 0.90% respectively for ziprasidone- study evaluating 80 mg/day and 160 mg/day of lurasidone. treated and olanzapine-treated patients. The results suggest a A priori response criteria were achieved by 65% of patients low—and comparable—risk of serious cardiac events among receiving 80 mg/day of lurasidone and by 79% of patients patients who are treated with either ziprasidone or olanzap- being treated at the higher dose of 160 mg/day. The adverse ine. While these findings are encouraging and potentially effect profile on EPS, weight and metabolic measures was “debunk” the cardiac concerns originally attributable to generally comparable between the two doses. However, it is ziprasidone, it is nevertheless important to remember that important to recognize the FDA has approved lurasidone for patients with schizophrenia have a higher rate of sudden use up to 80 mg/day. It is important that clinicians follow death. This robust, epidemiological-clinical observation still these FDA recommendations. remains unexplained. Strom BL, Eng SM, Faich G, Reynolds RF, D’Agostino RB, Ruskin J, et al. British Study Provides New Findings Comparative mortality associated with ziprasidone and olanzapine in re- on Suicide in Schizophrenia al-world

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