Antipsychotics: The Essentials. Module 5: A Primer on Selected Antipsychotics

Transcription

1 Antipsychotics: The Essentials Module 5: A Primer on Selected Antipsychotics

2 Slide 1 Recently approved antipsychotics Iloperidone (Fanapt) Asenapine (Saphris, Sycrest) Lurasidone (Latuda) Now we ll discuss three recently approved antipsychotics: Iloperidone (Fanapt) Asenapine (Saphris, Sycrest) Lurasidone (Latuda) Slide 2 Iloperidone Binding Profile - 5HT2A/D2 antagonist - D3 antagonist a 1 antagonist Iloperidone is a 5HT2A/D2 antagonist and D3 antagonist. In the case of Iloperidone, alpha 1 antagonism has direct implications regarding dose titration. Weiden PJ. PJ. Clinical schizophrenia & related psychoses 2012;6:

3 Slide 3 Iloperidone Prescribing Facts Dosage range: 12 mg (6 mg bid) 24 (12 mg bid) Dosage forms: Tablets: 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg and 12 mg. Weiden PJ. PJ. Clinical schizophrenia & related psychoses 2012;6: The dosage range of Iloperidone goes from to 12 mg/ day (divided in two doses of 6 mg) to 24 mg/day (divided in two doses of 12 mg). Iloperidone is available as tablets for oral administration of 1, 2, 4, 6, 8, 10 and 12 mg. Slide 4 Iloperidone Clinical Profile Low risk of EPS (probably similar to quetiapine) Orthostatic hypotension can be problematic: Needs slow dose titration Associated with greater QT prolongation than other antipsychotics. Weiden PJ. PJ. Clinical schizophrenia & related psychoses 2012;6: Iloperidone has a low risk (probably similar to quetiapine) Because of its high affinity for alpha receptors, orthostatic hypotension can be problematic. This the reason why iloperidone needs slow dose titration. Iloperidone is associated with greater QT prolongation that other antipsychotics. 2

4 Slide 5 Asenapine Binding Profile - 5HT2A/D2 antagonist - 5HT1A partial agonist - Antagonist at at 5HTR :: 5HT2B, 5HT2C, 5HT5A, 5HT6, 5HT7 a 1 antagonist - H1 antagonist McIntyre RS, RS, Wong R. R. Clinical schizophrenia & related psychoses 2012;5:217 Asenapine is a 5HT2A/D2 antagonist that is also a partial agonist at 5HT1A receptors. It is an antagonist at a number of serotonin receptors, including 5HT2B, 5HT2C, 5HT5A, 5HT6, 5HT7. It also has antagonist actions at alpha 1 and histamine 1 receptors. Slide 6 Asenapine Prescribing Facts Dosing range: 5-10 mg BID Dosage form: Sublingual tablets: 5 mg, mg The only antipsychotic that requires sublingual administration Asenapine is is absorbed through the oral mucosa Sublingual tablets are ineffective if if swallowed Eating and drinking should be be avoided after asenapine administration McIntyre RS, RS, Wong R. R. Clinical schizophrenia & related psychoses 2012;5:217 Asenapine is dosed between 5-10 mg BID. Asenapine is unique in terms of formulation. The drug is available as sublingual tablets of 5 and 10 mg. This is the only antipsychotic that requires sublingual administration. Asenapine is absorbed through the oral mucosa. Sublingual tablets are ineffective if swallowed Eating and drinking should be avoided after asenapine administration 3

5 Slide 7 Asenapine Clinical Profile Approved for bipolar 1 disorder and schizophrenia A post hoc analysis suggests that asenapine is highly efficacious in mitigating depressive symptoms in acutely manic patients Associated with sedation and EPS in some patients acutely manic patients McIntyre RS, RS, Wong R. R. Clinical schizophrenia & related psychoses 2012;5:217 I ve highlighted some relevant clinical information from the paper by McIntyre. Asenapine is approved for bipolar 1 disorder and schizophrenia A post hoc analysis suggests that asenapine is highly efficacious in mitigating depressive symptoms in Asenapine is associated with sedation and EPS in some patients Slide 8 Asenapine Clinical Profile Can result in unpleasant taste and/or oral hypoesthesia in approximately 5 % of treated subjects A black cherry formulation is available in the US as an alternative McIntyre RS, RS, Wong R. R. Clinical schizophrenia & related psychoses 2012;5:217 The use of asenapine can result in unpleasant taste and/or oral hypoesthesia in approximately 5 % of treated subjects A black cherry formulation is available in the US as an alternative. 4

6 Slide 9 Lurasidone Binding Profile - 5HT2A/D2 antagonist - 5HT1A partial agonist - 5HT7 antagonist a2c antagonist (moderate affinity) Citrome L. L. Clinical schizophrenia & related psychoses 2011;4: Lurasidone is the last antipsychotic in our list. As other second generation drugs, it s a 5HT2A/D2 antagonist. It is a partial agonist at 5HT1A receptors. Its antagonist actions at 5HT7 and alpha 2c receptors have been linked to symptom improvement in animal models of cognitive impairment. Slide 10 Lurasidone Prescribing Facts Dosage range: mg / day Dosage forms Tablets: 40 mg, 80 mg Does not require initial dose titration Should be given with food that provides 350 cal to improve medication absorption medication absorption. Citrome L. L. Clinical schizophrenia & related psychoses 2011;4: Lurasidone is dosed in the range of mg/day. It is available as tablets of 40 and 80 mg. It does not require initial dose titration and Should be given with food that provides 350 cal to improve 5

7 Slide 11 Lurasidone Clinical Profile Preclinical data from animal models suggests 5HT7 antagonism might play a role in cognition. Somnolence, akathisia, parkinsonism, nausea and agitation were the most commonly reported adverse reactions. Somnolence and akathisia appear dose related. Citrome L. L. Clinical schizophrenia & related psychoses 2011;4: Preclinical data from animal models suggests 5HT7 antagonism might play a role in cognition. Somnolence, akathisia, parkinsonism, nausea and agitation were the most commonly reported adverse reactions. Somnolence and akathisia appear dose related. Slide 12 Lurasidone Clinical Profile Considered to be weight neutral, does not have significant effects on serum lipids or glucose. Associated with increased prolactin, which appears to be greater in females and is dose dependent. Considered to be weight neutral, does not have significant effects on serum lipids or glucose. Associated with increased prolactin, which appears to be greater in females and is dose dependent. Citrome L. L. Clinical schizophrenia & related psychoses 2011;4:

8 References and Further Reading for Module 5 General Psychopharmacology Textbooks Tasman, A; Lieberman, J; Key, J; Maj, M. Psychiatry. 3rd ed. John Wiley & Sons, 2008 Schatzberg, AF, Nemeroff, CB. The American Psychiatric Publishing Textbook of Psychopharmacology. 4th ed.american Psychiatric Publishing, 2009 Stahl, S M. The Prescriber's Guide. 4thd ed. New York: Cambrigde University Press; 2011 Janicak, P G., Marder S R., and. Pavuluri M N. Principles and Practice of Psychopharmacotherapy. 5th ed. Philadelphia: Lippincott Williams & Wilkins, Clozapine Hennen J, Baldessarini RJ. Suicidal risk during treatment with clozapine: a meta-analysis. Schizophrenia research 2005 Conley RR, Buchanan RW. Evaluation of treatment-resistant schizophrenia. Schizophr Bull 1997 First Generation Antipsychotics Owens D. Meet the relatives: a reintroduction to the clinical pharmacology of typical antipsychotics (Part 1). Advances in Psychiatric Treatment 2012 Owens D. Meet the relatives: a reintroduction to the clinical pharmacology of typical antipsychotics (Part 2). Advances in Psychiatric Treatment 2012 New Antipsychotics McIntyre RS, Wong R. Asenapine: a synthesis of efficacy data in bipolar mania and schizophrenia. Clinical schizophrenia & related psychoses 2012;5: Weiden PJ. Iloperidone for the treatment of schizophrenia: an updated clinical review. Clinical schizophrenia & related psychoses 2012;6:34-44 Citrome L. Lurasidone for schizophrenia: a brief review of a new second-generation antipsychotic. Clinical schizophrenia & related psychoses 2011;4: