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P.3.d.032 Therapeutic strategies to potentiate refractory schizophrenia
S540
P.3.d. Psychotic disorders and treatment − Treatment (clinical)
palmitate is 150 mg on day 1 and 100 mg on day 8, administered in the deltoid muscle to attain therapeutic concentrations rapidly. The recommended monthly maintenance dose is 75 mg but some patients may benefit from lower or higher doses within the recommended range of 25–150 mg. Monthly maintenance doses can be administered in either the deltoid or gluteal muscle. It is the only monthly atypical long-acting injection, no oral supplementation is required during initiation, no refrigeration is needed and no reconstitution as the syringe is prefilled [1]. The aim of this audit was to assess the use of paliperidone palmitate in clinical practice, using consecutive sampling. Data was collected from the patient records on patient characteristics and treatment. 35 patients were included that had been treated with paliperidone palmitate: 68.6% were male and the mean age was 42.7 years (range 18−86 years). The most common diagnosis was schizophrenia (n = 30, 85.7%) and the mean duration of illness was 13.8 years (range 1−38 years). The most common reasons for switching to paliperidone palmitate were lack of efficacy to previous treatment (n = 35, 100%), poor adherence (n = 28, 80%) and frequency of dose (n = 20, 57.1%); please note that more than one reason was given for all patients. At the time of the audit, 85.7% (n = 30) of patients were continuing treatment with paliperidone palmitate and the mean treatment duration was 15.3 months (range 1−29 months). Female patients had a modal dose of 75 mg (mean 77.5 mg) and male patients had a modal dose of 100 mg or 150 mg (mean 107.5 mg). Seven patients relapsed whilst being treated with paliperidone palmitate, of which five resulted in hospital admission. In the CATIE trial [2], discontinuation is used as the primary outcome measure as a global measure of effectiveness that reflects patients’ and clinicians’ judgments of efficacy and tolerability. This naturalistic study looking at the use of paliperidone palmitate in clinical practice found that most patients (85.7%) were continuing treatment, suggesting that it was efficacious and well tolerated. We also found that female patients required a lower dose than male patients. In a similar naturalistic study, 65% of patients were continuing treatment with paliperidone palmitate at one year [3]. The benefits of paliperidone palmitate compared to RLAI include four weekly vs. two weekly injection which may be more convenient for some patients; in addition, paliperidone palmitate does not require cold storage and this reduces wastage due to a break in the cold chain as well as storage and transport costs. Based on our experience, paliperidone palmitate could be considered the next step when there is a partial response with the maximum dose of RLAI. References [1] Xeplion Summary of Product Characteristics. [2] Lieberman, J.A., Stroup, T.S., McEvoy, J.P., Swartz, M.S., Rosenheck, R.A., Perkins, D.O., Keefe, R.S., Davis, S.M., Davis, C.E., Lebowitz, B.D., Severe, J., Hsiao, J.K., 2005. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 353(12), 1209−23. [3] Attard, A., Olofinjana, O., Cornelius, V., Curtis, V., Taylor, D., 2013. Paliperidone palmitate long-acting injection − prospective year-long follow-up of use in clinical practice. Acta Psychiatr Scand, 1−6. Disclosure statement: Supported by funding from Janssen authors of the poster retained full editorial control.
P.3.d.032 Therapeutic strategies to potentiate refractory schizophrenia R. Ben Soussia1 ° , I. Marrag1 , K. Hajji1 , L. Zarrouk1 , S. Younes1 , M. Nasr1 1 University hospital of Mahdia, Department of Psychiatry, Mahdia, Tunisian Republic Objective: The aim of our study was to identify therapeutic strategies potentiating refractory schizophrenia depending on the clinical form. Methodology: This is a prospective descriptive study conducted on 80 patients who all met the diagnostic criteria for DSM-IVTR schizophrenia and were hospitalized in the department of psychiatry within the Dependent University Hospital of Mahdia, Tunisia. The study sample consisted of patients meeting the criteria for refractory schizophrenia as defined by NICE (National Institute for Clinical Excellence) and the prescription of clozapine has been indicated as a first line. Psychometric evaluation by BPRS scales, SANS and SAPS was performed for all patients over long periods of prescription of clozapine with a systematic dose rate of clozapine in blood. Results: The study sample consisted of 80 patients. The average age was 30 years, a male predominance was noted (85%), the majority of our patients were single (76.5%), they were without a professional activity in 91% and 20% of our patients had psychiatric family history. The majority of our patients were from urban areas (85%) and the average age of disease onset was 25 years. The mean duration of disease was 8 years with a number of hospitalizations ranging from 4 to 9. The prescribed doses of clozapine ranged between 400 and 800 mg/day, dose rate of clozapine in blood had returned between 291.5 and 633 mg/l. Of these patients, 55% had a good response to clozapine with clinical and psychometric improvement as evidenced by the scores of BPRS (a significant decrease >20% with values between 23.6% and 27.2%). Moreover, despite adequate doses of clozapine and good adherence, 36 patients were highly resistant (45%). Therapeutic strategies to potentiate the effect of clozapine were variable depending on the type of schizophrenia. For our patients, there were various clinical forms: 44% of undifferentiated schizophrenia (16 patients), 33% of disorganized dchizophrenia (12 patients) and 22% of paranoid schizophrenia (8 patients). In cases of undifferentiated schizophrenia, it potentiated the action of clozapine with ECT sessions for 12 patients (16 to 26 sessions) while 4 patients received the combination of risperidone. For disorganized schizophrenia (SANS between 68 and 82), we opted for potentiating amisulpiride (200 to 400 mg) and aripiprazole (10 to 15 mg). For the paranoid forms (SAPS between 49 and 72), we chose to combine risperidone (2 to 4 mg) and ECT (16−20 sessions). A psychometric and clinical improvement was noted with significant improvement of the BPRS scales ranging from 34 to 40%. Conclusion: This study demonstrates the efficiency of clozapine in the cases of resistant schizophrenia. Moreover, the prevalence of patients whose response seems insufficient is not negligible. Several therapeutic strategies potentiating the effect of clozapine by associations of atypical antipsychotics or ECT cures can be identified and they achieve a mitigation of psychotic symptoms.
P.3.d. Psychotic disorders and treatment − Treatment (clinical)
palmitate is 150 mg on day 1 and 100 mg on day 8, administered in the deltoid muscle to attain therapeutic concentrations rapidly. The recommended monthly maintenance dose is 75 mg but some patients may benefit from lower or higher doses within the recommended range of 25–150 mg. Monthly maintenance doses can be administered in either the deltoid or gluteal muscle. It is the only monthly atypical long-acting injection, no oral supplementation is required during initiation, no refrigeration is needed and no reconstitution as the syringe is prefilled [1]. The aim of this audit was to assess the use of paliperidone palmitate in clinical practice, using consecutive sampling. Data was collected from the patient records on patient characteristics and treatment. 35 patients were included that had been treated with paliperidone palmitate: 68.6% were male and the mean age was 42.7 years (range 18−86 years). The most common diagnosis was schizophrenia (n = 30, 85.7%) and the mean duration of illness was 13.8 years (range 1−38 years). The most common reasons for switching to paliperidone palmitate were lack of efficacy to previous treatment (n = 35, 100%), poor adherence (n = 28, 80%) and frequency of dose (n = 20, 57.1%); please note that more than one reason was given for all patients. At the time of the audit, 85.7% (n = 30) of patients were continuing treatment with paliperidone palmitate and the mean treatment duration was 15.3 months (range 1−29 months). Female patients had a modal dose of 75 mg (mean 77.5 mg) and male patients had a modal dose of 100 mg or 150 mg (mean 107.5 mg). Seven patients relapsed whilst being treated with paliperidone palmitate, of which five resulted in hospital admission. In the CATIE trial [2], discontinuation is used as the primary outcome measure as a global measure of effectiveness that reflects patients’ and clinicians’ judgments of efficacy and tolerability. This naturalistic study looking at the use of paliperidone palmitate in clinical practice found that most patients (85.7%) were continuing treatment, suggesting that it was efficacious and well tolerated. We also found that female patients required a lower dose than male patients. In a similar naturalistic study, 65% of patients were continuing treatment with paliperidone palmitate at one year [3]. The benefits of paliperidone palmitate compared to RLAI include four weekly vs. two weekly injection which may be more convenient for some patients; in addition, paliperidone palmitate does not require cold storage and this reduces wastage due to a break in the cold chain as well as storage and transport costs. Based on our experience, paliperidone palmitate could be considered the next step when there is a partial response with the maximum dose of RLAI. References [1] Xeplion Summary of Product Characteristics. [2] Lieberman, J.A., Stroup, T.S., McEvoy, J.P., Swartz, M.S., Rosenheck, R.A., Perkins, D.O., Keefe, R.S., Davis, S.M., Davis, C.E., Lebowitz, B.D., Severe, J., Hsiao, J.K., 2005. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 353(12), 1209−23. [3] Attard, A., Olofinjana, O., Cornelius, V., Curtis, V., Taylor, D., 2013. Paliperidone palmitate long-acting injection − prospective year-long follow-up of use in clinical practice. Acta Psychiatr Scand, 1−6. Disclosure statement: Supported by funding from Janssen authors of the poster retained full editorial control.
P.3.d.032 Therapeutic strategies to potentiate refractory schizophrenia R. Ben Soussia1 ° , I. Marrag1 , K. Hajji1 , L. Zarrouk1 , S. Younes1 , M. Nasr1 1 University hospital of Mahdia, Department of Psychiatry, Mahdia, Tunisian Republic Objective: The aim of our study was to identify therapeutic strategies potentiating refractory schizophrenia depending on the clinical form. Methodology: This is a prospective descriptive study conducted on 80 patients who all met the diagnostic criteria for DSM-IVTR schizophrenia and were hospitalized in the department of psychiatry within the Dependent University Hospital of Mahdia, Tunisia. The study sample consisted of patients meeting the criteria for refractory schizophrenia as defined by NICE (National Institute for Clinical Excellence) and the prescription of clozapine has been indicated as a first line. Psychometric evaluation by BPRS scales, SANS and SAPS was performed for all patients over long periods of prescription of clozapine with a systematic dose rate of clozapine in blood. Results: The study sample consisted of 80 patients. The average age was 30 years, a male predominance was noted (85%), the majority of our patients were single (76.5%), they were without a professional activity in 91% and 20% of our patients had psychiatric family history. The majority of our patients were from urban areas (85%) and the average age of disease onset was 25 years. The mean duration of disease was 8 years with a number of hospitalizations ranging from 4 to 9. The prescribed doses of clozapine ranged between 400 and 800 mg/day, dose rate of clozapine in blood had returned between 291.5 and 633 mg/l. Of these patients, 55% had a good response to clozapine with clinical and psychometric improvement as evidenced by the scores of BPRS (a significant decrease >20% with values between 23.6% and 27.2%). Moreover, despite adequate doses of clozapine and good adherence, 36 patients were highly resistant (45%). Therapeutic strategies to potentiate the effect of clozapine were variable depending on the type of schizophrenia. For our patients, there were various clinical forms: 44% of undifferentiated schizophrenia (16 patients), 33% of disorganized dchizophrenia (12 patients) and 22% of paranoid schizophrenia (8 patients). In cases of undifferentiated schizophrenia, it potentiated the action of clozapine with ECT sessions for 12 patients (16 to 26 sessions) while 4 patients received the combination of risperidone. For disorganized schizophrenia (SANS between 68 and 82), we opted for potentiating amisulpiride (200 to 400 mg) and aripiprazole (10 to 15 mg). For the paranoid forms (SAPS between 49 and 72), we chose to combine risperidone (2 to 4 mg) and ECT (16−20 sessions). A psychometric and clinical improvement was noted with significant improvement of the BPRS scales ranging from 34 to 40%. Conclusion: This study demonstrates the efficiency of clozapine in the cases of resistant schizophrenia. Moreover, the prevalence of patients whose response seems insufficient is not negligible. Several therapeutic strategies potentiating the effect of clozapine by associations of atypical antipsychotics or ECT cures can be identified and they achieve a mitigation of psychotic symptoms.