scholarly journals 116 Retrospective Analysis of Clozapine Augmentation in Treatment-Resistant Schizophrenia in an Outpatient Setting

CNS Spectrums ◽  
2018 ◽  
Vol 23 (1) ◽  
pp. 73-74
Author(s):  
Charles Odom ◽  
Frozan Walyzada ◽  
Pankaj Manocha ◽  
Monika Gashi ◽  
Ashaki Martin ◽  
...  
Keyword(s):  
Retrospective Analysis ◽  
Treatment Options ◽  
D2 Receptor ◽  
Treatment Strategies ◽  
Outpatient Setting ◽  
Mood Stabilizers ◽  
Adjunctive Treatment ◽  
Supporting Evidence ◽  
Treatment Resistant ◽  
Augmentation Strategies

AbstractStudy ObjectivesThis retrospective analysis hopes to add to the literature about Treatment Resistant Schizophrenia (TRS), augmentation strategies with antipsychotics used in our patient population with the hopes of clarifying what possibilities should be further studied. In addition, we aim to emphasize the need for focusing on individualized treatment and multidisciplinary efforts to ensure compliance and appropriate disposition options.MethodWe reviewed retrospectively 3025 charts of patients between January 2017 to March 2017 in our outpatient department establishing which antipsychotic clozapineaugmentation strategies were being used. We also did a literature review to establish what augmentation strategies are recommended. These patients will then be compared to a random sample of patients in the clinic who were not prescribed clozapine and compared for readmission rate, side effect profile, length of stay while admitted, frequency of clinic attendance and compliance with outpatient appointments.ResultsOut of 3025 patients 35 were prescribed Clozapine as monotherapy and 5 patients had clozapine plus psychopharmacological augmentation. Ages ranged from 21-86. Out of the 39 patients, there were 13 male and 26 female. The predominant diagnosis was mood disorder or MDD with psychotic features followed by schizophrenia. The augmentation antipsychotics used were aripiprazole and risperidone. In the literature, the most frequent augmentation strategy for TRS is adding another antipsychotic with more D2 receptor blockade. Other strategies involve identifying and treating the symptoms not controlled by clozapine.ConclusionsCurrently augmentation of Clozapine in TRS is highly individualized due to lack of supporting evidence to state the contrary. When working with treatmentresistant patients who are not responding to clozapine alone, it is imperative to thoroughly review and consider all treatment options and augmentation strategies. More studies should be done in controlled settings to better evaluate possibilities as well as more evaluations to be done on other ways of augmentation of clozapine. Literature has stated between 20-60% of patients are defined as TRS. Clozapine is considered as one of the most effective treatment available at present time for TRS. Recent literature suggests despite its superior efficacy, as many as 70% of those suffering from TRS on clozapine continue to suffer from positive, negative or cognitive symptoms. The literature has abundant adjunctive treatment strategies such as the addition of antipsychotics, mood stabilizers, antidepressants, or even with the use of electroconvulsive therapy. We emphasize the importance of correctly identifying TRS patients who may benefit from the initiation of clozapine, what would be beneficial for them if they do not respond, how to tailor their treatment to target symptoms not being ameliorated, and recommend treatment in these complex cases be multidisciplinary.Funding AcknowledgementsNo funding.

Treatment resistance in Schizophrenia

2011 ◽  
Vol 26 (S2) ◽  
pp. 2023-2023
Author(s):  
W. Fleischhacker
Keyword(s):  
Rating Scales ◽  
Treatment Options ◽  
Treatment Strategies ◽  
Treatment Resistance ◽  
Mood Stabilizers ◽  
General View ◽  
Treatment Resistant ◽  
Research Strategies ◽  
Adequate Dose ◽  
Large Patient

DiagnosisThe diagnosis of treatment resistant schizophrenia generally follows two not always consistent lines of thinking: one is based on research strategies, the other one on every day clinical practice. Both require a failure to respond to at least two (sometimes three) treatment attempts of adequate duration with an adequate dose of an antipsychotic.In research, one needs to define clearly operationalized criteria which can be applied and reproduced in different settings. Response data are usually operationalized using rating scales scores. Under routine treatment conditions physicians often have to rely upon poor drug response histories or less than perfect chart notes. A more general view of the patient's condition, often including social functioning and quality of life, will then be amalgamated for the clinical diagnosis of treatment resistant schizophrenia.ManagementOnce the diagnosis has been established, alternative treatment strategies can be discussed. The treatment option which is substantiated by the largest research base is clozapine.If a trial with clozapine is unsuccessful, various alternatives are currently discussed. These range from adding another antipsychotic, mood stabilizers, benzodiazepines, serotonin antagonists, serotonin reuptake-inhibitors, glutamatergic drugs to dopaminergic agents and electroconvulsive therapy. None of these have proved unequivocally efficacious in sufficiently large patient samples. There is some evidence, that treatment resistant patients need more time until they show a positive response. Although this evidence is tentative, for practical matters last resort trials will be extended anyway since very little treatment options remain after these have failed.

Emerging Treatment Options in Treatment-Resistant Depression and Anxiety Disorders

CNS Spectrums ◽  
2002 ◽  
Vol 9 (S14) ◽  
pp. 25-32
Author(s):  
Waguih William IsHak ◽  
Mark H. Rapaport ◽  
Jennifer G. Gotto
Keyword(s):  
Anxiety Disorders ◽  
Treatment Options ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Depression And Anxiety ◽  
Treatment Resistant Depression ◽  
Treatment Resistant ◽  
Augmentation Strategies ◽  
Resistant Depression ◽  
New Treatment

ABSTRACTManagement strategies for treatment-resistant depression and anxiety disorders have evolved over the last decade. Our understanding of the factors that impair recovery from an episode of major depression has increased, leading to the development of more precise diagnostic methodology that highlight the presence of comorbid conditions. New medications, creative uses of existing medications, increased empirical data about augmentation strategies, and the development of innovative nonpharmacologic interventions are responsible for a marked expansion in treatment options. Traditionally, augmentations with lithium, thyroid hormones, or electroconvulsive therapy have demonstrated effectiveness in some patients with treatment-resistant mood disorders. Among the promising treatments in both depression and anxiety is augmentation using low-dose antipsychotics medications, combining antidepressants of different classes, and the addition of psychotherapy. Nonpharmacologic interventions that may have potential include transcranial magnetic stimulation, deep-brain stimulation, and vagus-nerve stimulation. This article provides a brief review of the available data summarizing existing and new treatment strategies in depression and anxiety disorders.

Augmentation Strategies for Clozapine-Resistant Patients with Schizophrenia

2020 ◽  
Vol 26 (2) ◽  
pp. 218-227
Author(s):  
Yi-Hang Chiu ◽  
Chia-Yueh Hsu ◽  
Mong-Liang Lu ◽  
Chun-Hsin Chen
Keyword(s):  
Sample Size ◽  
Repetitive Transcranial Magnetic Stimulation ◽  
Mood Stabilizers ◽  
Treatment Resistant ◽  
Double Blind ◽  
Beneficial Effects ◽  
Augmentation Strategies ◽  
Pubmed Database ◽  
Augmentation Strategy ◽  
Larger Sample

Background: Clozapine has been used in treatment-resistant patients with schizophrenia. However, only 40% of patients with treatment-resistant schizophrenia have response to clozapine. Many augmentation strategies have been proposed to treat those clozapine-resistant patients, but the results are inconclusive. In this review, we intended to review papers dealing with the augmentation strategies in the treatment of clozapineresistant patients with schizophrenia. Method: We reviewed randomized, double-blind, placebo- or sham-controlled trials (RCT) for clozapine-resistant patients with schizophrenia in Embase, PsycINFO, Cochrane, and PubMed database from January 1990 to June 2019. Results: Antipsychotics, antidepressants, mood stabilizers, brain stimulation, such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation, and other strategies, were used as an augmentation in clozapine-resistant patients with schizophrenia. Except for better evidence in memantine with 2 RCTs and cognitive behavior therapy in 2 studies to support its effectiveness, we found that all the other effective augmentations, including sulpiride, ziprasidone, duloxetine, mirtazapine, ECT, sodium benzoate, ginkgo biloba, and minocycline, had only one RCT with limited sample size. Conclusion: In this review, no definite effective augmentation strategy was found for clozapine-resistant patients. Some potential strategies with beneficial effects on psychopathology need further studies with a larger sample size to support their efficacy.

Lithium and valproate-induced tremors

2012 ◽  
Vol 1 (7) ◽  
pp. 174-176 ◽  
Author(s):  
Jacquelyn E. Canning ◽  
Stephanie Burton ◽  
Beth Hall
Keyword(s):  
Side Effect ◽  
Treatment Options ◽  
Time Frame ◽  
Mood Stabilizers ◽  
Treatment Modalities ◽  
Adjunctive Treatment ◽  
Expected Time

Lithium and valproate are mood stabilizers known to cause tremor. This article concisely addresses etiological questions, expected time frame of tremor onset, and treatment options for this medication-induced side effect. Along with dosage modifications of the tremor-inducing medication, authors review evidence from small trials of adjunctive treatment modalities.

Clozapine augmentation strategies – a systematic meta-review of available evidence. Treatment options for clozapine resistance

2019 ◽  
Vol 33 (4) ◽  
pp. 423-435 ◽  
Author(s):  
Elias Wagner ◽  
Lisa Löhrs ◽  
Dan Siskind ◽  
William G Honer ◽  
Peter Falkai ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Electroconvulsive Therapy ◽  
Second Generation ◽  
Treatment Options ◽  
Symptom Improvement ◽  
Positive Symptoms ◽  
Supporting Evidence ◽  
Augmentation Strategies ◽  
Second Generation Antipsychotics ◽  
Meta Analyses

Background: Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse. Aims: We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice. Methods: We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified. Results: Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C–D criteria only. Conclusion: More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.

scholarly journals Review of treatment for late-life depression

2013 ◽  
Vol 19 (4) ◽  
pp. 302-309 ◽  
Author(s):  
Charlotte L. Allan ◽  
Klaus P. Ebmeier
Keyword(s):  
Selective Serotonin Reuptake Inhibitors ◽  
Treatment Options ◽  
Treatment Strategies ◽  
Late Life ◽  
Line Treatment ◽  
Late Life Depression ◽  
Nonpharmacological Treatment ◽  
Augmentation Strategies ◽  
Treatment Of Depression ◽  
Favourable Side Effect Profile

SummaryDepressive disorder in those over the age of 60 has many clinical similarities to depression in younger adults, but biological changes related to ageing may necessitate a different approach to treatment. We present an evidence-based review of treatment for late-life depression, focusing on pharmacological approaches, including monotherapy, combination and augmentation strategies. Selective serotonin reuptake inhibitors such as sertraline and citalopram are well tolerated, have the advantage of a favourable side-effect profile, and are good options for first-line treatment. Second-line treatment options include combination therapy with a second antidepressant, or treatment augmentation with an antipsychotic or lithium. We also consider evidence for nonpharmacological treatment strategies, including psychological therapy and neurostimulation. Finally, we summarise evidence for treatment of depression in patients in dementia.

A Review of the STAR*D Trial

2006 ◽  
Vol 19 (6) ◽  
pp. 353-360
Author(s):  
Megan J. Ehret ◽  
Benjamin Chavez
Keyword(s):  
Major Depressive Disorder ◽  
Depressive Disorder ◽  
Treatment Options ◽  
Treatment Strategies ◽  
Treatment Resistant ◽  
First Line ◽  
Major Depressive ◽  
Treatment Of Depression ◽  
Clinical Strategies ◽  
Resistant Depression

Major depressive disorder is a common disorder that affects 5% to 13% of medical outpatients. The treatment of depression can be challenging, with many first-line options and even more second-line or next-step options. The STAR*D trial was the first of its kind developed to evaluate clinical strategies to improve outcomes for patients with treatment-resistant depression and determining the best next-step treatment option for patients who did not respond adequately to earlier treatment attempts. The trial included a widely representative group of outpatients so as to be applicable to the current practice in the treatment of depression. The trial consisted of 4 different treatment strategies with both switching and augmentation options. Patients were permitted to select treatment options at each of the levels that they themselves selected, creating a “realworld” setting in the trial. Patients were recommended to continue through each level until remission was reached. The study, though limited in size at each level, has provided much-needed information for the continued treatment of major depressive disorder.

scholarly journals Management of treatment-resistant generalized anxiety disorder

2020 ◽  
Vol 10 (6) ◽  
pp. 326-334
Author(s):  
Elayne D. Ansara
Keyword(s):  
Anxiety Disorder ◽  
Generalized Anxiety Disorder ◽  
Treatment Options ◽  
Generalized Anxiety ◽  
Gamma Aminobutyric Acid ◽  
Treatment Resistant ◽  
Residual Symptoms ◽  
Adequate Dose ◽  
Augmentation Strategies ◽  
Recommended Therapy

Abstract Generalized anxiety disorder (GAD) is characterized by persistent and excessive worry. Around half of the patients treated for GAD will fail to respond to initial treatment. Treatment-resistant (or refractory) GAD is defined as failure to respond to at least 1 trial of antidepressant therapy at adequate dose and duration. Review of the literature indicates several potential medication classes and individual agents that can be used as augmentation strategies to treat residual symptoms when recommended therapy per clinical practice guidelines fails. A thorough literature search revealed 2 medication classes with the largest amount of data to support their use in treatment-resistant GAD treatment: gamma-aminobutyric acid–related agents and atypical antipsychotics. This article focuses on evidence-based recommendations for the use of these agents as adjunctive therapies for patients with treatment-resistant GAD. Different pharmacologic approaches to use these agents are demonstrated through 2 patient cases in which patients have failed first-line treatment options.

Using Naïve Bayes Algorithm to Estimate the Response to Drug in Lung Cancer Patients

2019 ◽  
Vol 21 (10) ◽  
pp. 734-748 ◽  
Author(s):  
Baoling Guo ◽  
Qiuxiang Zheng
Keyword(s):  
Lung Cancer ◽  
Side Effects ◽  
Cancer Patients ◽  
Drug Response ◽  
Treatment Options ◽  
Clinical Manifestations ◽  
Treatment Strategies ◽  
Cancer Resistance ◽  
Lung Cancer Patients ◽  
Bayes Algorithm

Aim and Objective: Lung cancer is a highly heterogeneous cancer, due to the significant differences in molecular levels, resulting in different clinical manifestations of lung cancer patients there is a big difference. Including disease characterization, drug response, the risk of recurrence, survival, etc. Method: Clinical patients with lung cancer do not have yet particularly effective treatment options, while patients with lung cancer resistance not only delayed the treatment cycle but also caused strong side effects. Therefore, if we can sum up the abnormalities of functional level from the molecular level, we can scientifically and effectively evaluate the patients' sensitivity to treatment and make the personalized treatment strategies to avoid the side effects caused by over-treatment and improve the prognosis. Result & Conclusion: According to the different sensitivities of lung cancer patients to drug response, this study screened out genes that were significantly associated with drug resistance. The bayes model was used to assess patient resistance.

Safety of a Clozapine Trial Following Quetiapine-Induced Leukopenia: A Case Report

2019 ◽  
Vol 14 (1) ◽  
pp. 80-83 ◽  
Author(s):  
Asma H. Almaghrebi
Keyword(s):  
Treatment Options ◽  
Young Female ◽  
Similar Reaction ◽  
Careful Monitoring ◽  
Treatment Resistant ◽  
Blood Cell Count ◽  
Antipsychotic Medications ◽  
Case Presentation ◽  
Clozapine Treatment ◽  
History Of

Background: The clozapine-derivative quetiapine has been shown in some cases to cause leukopenia and neutropenia. Case Presentation: We reported on a case of a young female diagnosed with treatment-resistant schizophrenia. After failed trials of three antipsychotic medications and despite a history of quetiapineinduced leukopenia, clozapine treatment was introduced due to the severity of the patient’s symptoms, the limited effective treatment options, and a lack of guidelines on this issue. Result: Over a ten-week period of clozapine treatment at 700 mg per day, the patient developed agranulocytosis. Her white blood cell count sharply dropped to 1.6 &#215; 10<sup>9</sup> L, and her neutrophils decreased to 0.1 &#215; 10<sup>9</sup> L. There had been no similar reaction to her previous medications (carbamazepine, risperidone, and haloperidol). Conclusion: The safety of clozapine in a patient who has previously experienced leukopenia and neutropenia with quetiapine requires further investigation. Increased attention should be paid to such cases. Careful monitoring and slow titration are advisable.

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