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Re: QoL: Old versus atypical antipsychotics ed_uk

Posted by yxibow on October 12, 2006, at 2:53:10

In reply to Re: QoL: Old versus atypical antipsychotics yxibow, posted by ed_uk on October 11, 2006, at 12:34:15

> >A 3 point discontinuation rate between Geodon and Seroquel is within the margin of error.

> I wasn't comparing Seroquel with Geodon, just noting the very high drop out rate with Seroquel.

Fair enough

> >The dose range of perphenazine was chosen to minimize the potential for extrapyramidal symptoms that may have biased previous comparisons of first- and second-generation drugs" This suggests to me that the phenothiazine drug used in the study was used at its MED (minimum effective dose).
>
> Well yes, that's good, excessively high doses would have been inappropriate.

Oh, but the idea of dosing beyond the MED (minimum effective dose) is still in practice. Dial it up until something happens, even if it goes beyond what should be tolerable EPS.

> >Have you ever tried a bone chilling dose of Compazine, Ed ? Its staggering.
>
> No, I took a high dose of Thorazine though and it landed me in the hospital with VERY severe akathisia. I once took a low dose of Compazine (5mg orally) and didn't have any side effects. Side effects of neuroleptics are usually dose dependent.

True enough, but I was given a "normal" dose of Compazine in the hospital for uncontrollable vomiting due to flu. You go to a hospital to get sicker apparently, and it wasnt long before I hit the nurse button and they remembered to give me an IV of Benadryl. Wore off, akathisia was through the roof I couldnt think in the hospital signout desk, barely made it in a taxi home and I think my current beau/friend at the time came over to visit later in the morning while I was still writhing on the sofa. Finally got some Klonopin somehow from my psychiatrist.

> You seem to be missing the point. If typical APs are used, clearly they should not be given at 'bone chilling' doses.

Well it was.

> >I'm only glad that there are medications out there that have low EPS levels, regardless of how much I have to use the treadmill.
>
> I'm glad they're available too, but they are not *universally* superior to typicals.

Didn't say universally, but they are far less likely to cause TD over a long period of time.


> >TD rise markedly up to Risperdal, as well as to old line antipsychotics
>
> I don't actually know of any evidence that the risk of TD is any higher with Risperdal than with any of the other atypicals. Acute EPS seems to be more common with Risperdal but that does not necessarily apply to TD. The evidence I've seen suggests that the risk of TD is similar among all the atypicals, including Seroquel and Risperdal.

Mean rate aggregate chart, 2% across all studies. Elderly patients were found to be higher. One study of 1,964 patients found under 1%.
Am J Psychiatry 161:414-425, March 2004

> >This study also does not focus particularly on affective disorders, where neuroleptics weigh a heavier toll of EPS and TD
>
> I think this is probably a myth. Psychotic patients tend to be more ill and less capable of reporting EPS.

B*llshit, this is a disservice to the functioning of patients with schizophreniform disorders -- the same still applies, if you're really aware of something that is TD, it isn't likely to be so, and I think the average higher functioning person can definately complain about akathisia.

And it is not a myth that the brain structure of schizophrenic patients is different from those not psychotic with affective disorders (anxiety, depression). There is a difference, perhaps not completely understood, in the way that dopamine is manipulated, and rates of EPS and TD are higher among affective disorders treated with neuroleptics with higher D2 affinities.

> >I'm talking about effects in myself, not what others choose to take, what risks they take in informed consent (old line drugs which have now been out for 50 years show markedly higher TD rates than new medications that have been out for only a decade.)
>
> In the treatment of schizophrenia, I believe that an atypical AP should be used first-line. Among the atypicals, I would not choose Seroquel first.

Possibly, because it is the most sedating of all atypicals, I would agree, and less effective at lower doses for extremely psychotic patients.

On the other hand, Risperdal at its highest doses is basically its chemical cousin Haldol. At extremely low doses it can actually be a dopamine increaser.

My experience with a combination of Risperdal and Prozac is still 5 years later, my right index finger twitches uncontrollably, just slightly. We discontinued it after that. Alas, too late. Zyprexa was a bust with pseudoparkinsonism at any dose and the second time challenged at a lower dose, it took months for my hands to stop shaking when using power tools or under hot water in the shower.

So I'm now at Seroquel.

And across the pond there was a study of Zyprexa:

The British Journal of Psychiatry 174: 23-30 (1999)

"Based on data following the initial six weeks of observation (during which patients underwent medication change and AIMS assessments as frequently as every three days), the one-year risk was 0.52% with olanzapine (n = 513) and 7.45% with haloperidol (n = 114). The relative risk throughout this follow-up period was 11.37 (95% CI = 2.21-58.60). CONCLUSION: Our results indicated a significantly lower risk of tardive dyskinesia with olanzapine than with haloperidol."


So while there is no guarantees, I can live with Seroquel for the time being, not being a perfect drug -- Zyprexa would be. Extrapolating from that, Seroquel probably has a 1/4% risk or lower.
But who knows. I could always challenge with clozapine, but somehow the idea of peeing in my pants and $9000 a year monitoring is not in the cards. Not yet anyhow.


-- tidings

Jay

 

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