Safety and tolerability of antipsychotic polypharmacy

Abstract

Introduction Antipsychotic polypharmacy (APP), the concomitant use of ≥2antipsychotics, is common in clinical practice. Prior reviews have focused on the efficacy of APP, but no systematic review exists regarding the safety and tolerability of this practice. Areas covered in this review We conducted a systematic review of adverse effects associated with APP. Case series with ≥2 patients, chart reviews, naturalistic, data base, cohort and randomized studies that reported on the association between APP in general or specific APP combinations and global or specific adverse effect were included. We discuss methodological limitations of available studies and provide recommendations for clinicians and future research. Expert Opinion Across mostly small and uncontrolled studies, APP has been associated with increased global side effect burden, rates of Parkinsonian side effects, anticholinergic use, hyperprolactinemia, sexual dysfunction, hypersalivation, sedation/somnolence, cognitive impairment, and diabetes. Effects on akathisia and mortality were inconclusive. Although some combinations, particularly aripiprazole augmentation of an agent with greater side effect burden, may reduce weight gain, dyslipidemia, hyperprolactinemia and sexual dysfunction, APP should remain a last resort treatment option after monotherapy, switching and non-antipsychotic combinations have failed. More and high quality data are needed to further inform the individualized risk-benefit evaluation of APP.

The Development of the Japanese Psychiatric Nursing Assessment Classification System (PsyNACS<sup>©</sup>)

“…Antipsychotic polypharmacy was associated with increased side effect burden, increasing rates of Parkinsonian side effects, anticholinergic symptoms, hyperprolactinemia, sexual dysfunction, hypersalivation, sedation/somnolence, cognitive impairment, and diabetes [35]. Although the events concerning sexuality tends to be considered less serious in the hospital than in the community society, "Interest toward sexuality" was regarded as "important" not only for the young, but also by the elderly; therefore, it is necessary to include "Sexual behavior problems" as a very important assessment data as this condition sometimes occur because of inappropriate judgments owing to the psychiatric symptom in psychiatric wards.…”

Será que as medicações anticolinérgicas estão sendo bem utilizadas? uma revisão sistemática

“…A escolha do tratamento farmacológico com dois ou mais ATP recebe o nome de PAP e pode ser utilizada com expectativa de abreviar o tempo de início do efeito terapêutico, tratar sintomas residuais, reduzir a dose e efeitos colaterais da primeira medicação, e como medida após falha de clozapina e/ou eletroconvulsoterapia 15 . Por outro lado, permanece, em geral, desaconselhada por diretrizes de tratamento para esquizofrenia 14,16 .…”

“…Por outro lado, permanece, em geral, desaconselhada por diretrizes de tratamento para esquizofrenia 14,16 . A PAP está associada a aumento de uso de MAC 15,[17][18][19] , talvez pelo aumento de dose equivalente de clorpromazina vinculado à PAP (≥ 1.000 mg de equivalentes de clorpromazina) [18][19][20] 19 descreveram que a associação de ATP parece ser muito utilizada para pacientes refratários, inclusive antes do uso da clozapina. Nesse estudo, os clínicos prescritores não foram entrevistados quanto ao processo de decisão, o que torna possível que a clozapina aparente ser subutilizada por possuir riscos potencialmente graves, por opção do paciente ou dos familiares e/ou por ausência de adesão do paciente.…”

“…Há evidências que suportam a ideia de que a maioria dos pacientes ou uma considerável parcela poderiam ser convertidos de PAP para monoterapia 15,17 .…”

Prioritizing Patient Assessment Data (PAD) Using the Japanese Psychiatric Nursing Assessment Classification System (PsyNACS)©

“…However, both "interests toward sexuality" and "sexual function" were assessed only as "quite important" in all unit functions, and both were scored lowest in the DCU, in particular. Antipsychotic drug has been associated with increased global side effect burden, rates of Parkinsonian side effects, anticholinergic use, hyperprolactinemia, sexual dysfunction, hypersalivation, sedation/somnolence, cognitive impairment, and diabetes [32]. Although the event concerning sexuality tends to be considered less serious in the hospital than in community society, "interest toward sexuality" has been regarded as important not only for the young, but also the elderly, therefore, it is necessary to place importance on it in the future.…”