Welcome to the first edition of the CPNP electronic newsletter designed by CPNP members for CPNP members. This newsletter has been initiated as a means to keep members updated on CPNP and other news pertinent to psychiatric and neurologic pharmacists. CPNP Communications Committee combs through numerous journals and websites on a monthly basis to provide the CPNP membership with brief information and links to articles of interest.
There is much clinical debate as to whether the use of two antipsychotic agents simultaneously provides advantages for optimization of response in patients who fail prior therapies with single antipsychotic agents. There is minimal evidence that supports the use of multiple antipsychotic agents, even when utilizing agents with different mechanisms of action. The standard of care for the treatment of schizophrenia is to first utilize a monotherapy regimen of adequate dosing and duration, including a trial of clozapine before adding a second agent. In this particular case, we report on a patient who failed treatment with various antipsychotic agents as monotherapy but through combination therapy, experienced a significant reduction in psychotic symptoms which expedited the restoration of competency and subsequent hospital discharge.
Antipsychotic treatment is associated with metabolic abnormalities which increase the risk of cardiovascular disease. Routine medical monitoring for metabolic changes is essential to reduce risk. A longitudinal evaluation of adjunctive aripiprazole treatment on weight, lipids and glucose metabolism and symptom control was conducted. Data was collected from patients with severe and persistent mental illness.
Evaluation of the Role of Family History in the Development of Diabetes Among Patients With Schizophrenia Receiving Clozapine or Olanzapine
Patients with schizophrenia have a higher incidence of diabetes compared to the general population; however, the question of whether these patients have a higher prevalence of other predisposing risk factors, such as family history, has not yet been answered. The American Diabetes Association recognizes individuals who have a first degree relative with diabetes as being at greater risk for the development of diabetes. Further increasing the risk in this population is the use of atypical antipsychotics, a class of drugs associated with metabolic side effects and implicated in the development of diabetes. The role that family history plays in the development of diabetes among patients with schizophrenia receiving an atypical antipsychotic has not yet been answered.
Clozapine is considered the most effective antipsychotic medication in treatment resistant schizophrenia or schizoaffective disorder even though 40 to 70 percent of these patients are nonresponders or only partial responders to the medication. Considering this relative poor response to clozapine, many psychiatrists are faced with a difficult dilemma as to which medications to use in these refractory cases. Despite the lack of evidence to support a combination regimen, it is estimated that up to 35 percent of patients receiving clozapine are also receiving another antipsychotic. Aripiprazole is an activating atypical antipsychotic that could potentially benefit patients on clozapine therapy due to its unique mechanism of action and minimal side effect profile. Some psychiatrists have utilized this particular combination regardless of the lack of information to support this.
It is well known that clozapine is associated with drug interactions. Case reports also describe increased clozapine concentrations associated with acute infectious diseases. This is significant because high clozapine levels can increase the risk of seizures, myoclonus, and confusion.
Approximately 0.8% of patients treated with clozapine develop agranulocytosis. Because of this potentially life threatening adverse reaction, hematologic monitoring is required to facilitate timely identification. According to product labeling, patients with an absolute neutrophil count (ANC) below 1500 cells/mm3 should interrupt clozapine treatment.