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Canadian Journal of Psychiatry. Revue... Mar 2012This article seeks to provide the practising clinician with guidance on the pharmacological management of tic disorders in children and adults. We performed a systematic... (Review)
Review
This article seeks to provide the practising clinician with guidance on the pharmacological management of tic disorders in children and adults. We performed a systematic review of the literature on the treatment of tic disorders. A multi-institutional group of 14 experts in psychiatry, child psychiatry, neurology, pediatrics, and psychology engaged in a consensus meeting. The evidence was presented and discussed, and nominal group techniques were employed to arrive at consensus on recommendations. A strong recommendation is made when the benefits of treatment clearly outweigh the risks and burdens, and can apply to most patients in most circumstances without reservation. With a weak recommendation, the benefits, risks, and burdens are more closely balanced, and the best action may differ depending on the circumstances. Based on these principles, weak recommendations were made for the use of pimozide, haloperidol, fluphenazine, metoclopramide (children only), risperidone, aripiprazole, olanzapine, quetiapine, ziprasidone, topiramate, baclofen (children only), botulinum toxin injections, tetrabenazine, and cannabinoids (adults only). Strong recommendations were made for the use of clonidine and guanfacine (children only). While the evidence supports the efficacy of many of the antipsychotics for the treatment of tics, the high rates of side effects associated with these medications resulted in only weak recommendations for these drugs. In situations where tics are not severe or disabling, the use of a medication with only a weak recommendation is not warranted. However, when tics are more distressing and interfering, the need for tic suppression to improve quality of life is stronger, and patients and clinicians may be more willing to accept the risks of pharmacotherapy.
Topics: Adrenergic alpha-2 Receptor Agonists; Adult; Antipsychotic Agents; Canada; Child; Clonidine; Evidence-Based Medicine; Guanfacine; Humans; Practice Guidelines as Topic; Tic Disorders; Tourette Syndrome
PubMed: 22397999
DOI: 10.1177/070674371205700302 -
The Cochrane Database of Systematic... Jul 2006Non-antiepileptic drugs have been used in trigeminal neuralgia management since the 1970s. (Review)
Review
BACKGROUND
Non-antiepileptic drugs have been used in trigeminal neuralgia management since the 1970s.
OBJECTIVES
The objective was to review systematically the efficacy of non-antiepileptic drugs for trigeminal neuralgia.
SEARCH STRATEGY
We searched the Cochrane Neuromuscular Disease Group Register, MEDLINE, EMBASE, and LILACS (all to August 2005) and the Chinese Biomedical Retrieval System, the database of the Chinese Cochrane Center (The Cochrane Library, Issue 1 2005), conference paper databases and checked bibliographies. We handsearched ten Chinese journals.
SELECTION CRITERIA
We searched for randomized or quasi-randomized controlled trials.
DATA COLLECTION AND ANALYSIS
Two authors decided which trials fitted the inclusion criteria and graded methodological quality independently.
MAIN RESULTS
Nine trials of different non-antiepileptic drugs involving 223 participants were included. Each trial investigated one non-antiepileptic drug. Two trials tested baclofen. In one, more people gained 50% reduction from baseline than with placebo (relative risk 15.00, 95% CI 0.97 to 231.84, P value = 0.05). In the other, slightly more participants on baclofen had a 75% reduction in attacks on the 10th day compared with carbamazepine (relative risk 2.38, 95% CI 0.83 to 6.85, P value = 0.11). One trial showed no significant difference in reduction in average daily frequency of attacks with L-Baclofen compared with racemic baclofen. Tizanidine was investigated in two trials. In one, the proportion of people with reduction in the average number of paroxysms per day increased with tizanidine compared with placebo (relative risk 8.00, 95% CI 1.21 to 52.69, P value = 0.03). In the other, one of five participants improved in visual analog scale score with tizanidine and four of six with carbamazepine (relative risk 0.30, 95% CI 0.05 to 1.89, P value = 0.20). One study showed that the improvement in mean values of pain scores with tocainide was similar to that of carbamazepine. In one study more participants improved during the pimozide than the carbamazepine period (relative risk 1.78, 95% CI 1.39 to 2.28). In one study, proparacaine hydrochloride 0.5% instillation into the eyes was not significantly different from placebo (relative risk 1.06, 95% CI 0.37 to 2.99, P value = 0.92). In another, there was moderate or marked improvement in seven of nine participants treated with clomipramine and three of nine with amitriptyline after a 12-week treatment (RR 2.33, 95% CI 0.87 to 6.27).
AUTHORS' CONCLUSIONS
There is insufficient evidence from randomized controlled trials to show significant benefit from non-antiepileptic drugs in trigeminal neuralgia. More research is needed.
Topics: Amitriptyline; Baclofen; Carbamazepine; Clomipramine; Clonidine; Humans; Pimozide; Propoxycaine; Randomized Controlled Trials as Topic; Tocainide; Trigeminal Neuralgia
PubMed: 16856027
DOI: 10.1002/14651858.CD004029.pub2 -
Neurosciences (Riyadh, Saudi Arabia) Jul 2012This study aimed to systematically review the data related to the treatment of tic disorders through aripiprazole administration, an atypical antipsychotic. The... (Review)
Review
This study aimed to systematically review the data related to the treatment of tic disorders through aripiprazole administration, an atypical antipsychotic. The databases of MEDLINE/PubMed and Google Scholar were searched using the key words: "aripiprazole," "tic," and "Tourette," and the relevant titles retrieved. Thirty-five articles met the inclusion criteria and were further scrutinized. Most of the articles were case reports, and only 2 published trials included control groups. The number of randomized double-blind controlled clinical trials was zero, therefore, no strong evidence, provided by one, or more well-designed randomized controlled clinical trials, was found. Current evidence suggests that aripiprazole is effective for treating tic and Tourette disorders in both children and adolescents. Moreover, it seems that its adverse effect profile is safer than pimozide and some other antipsychotics. Therefore, double-blind randomized placebo-controlled studies are needed to provide strong evidence on the issue.
Topics: Adolescent; Child; Humans; Antipsychotic Agents; Aripiprazole; Databases, Factual; Pediatrics; Piperazines; Quinolones; Tic Disorders
PubMed: 22772923
DOI: No ID Found -
International Review of Neurobiology 2013Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS),... (Review)
Review
Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.
Topics: Animals; Dopamine; Dopamine Agents; Humans; Tourette Syndrome
PubMed: 24295625
DOI: 10.1016/B978-0-12-411546-0.00010-X -
The Cochrane Database of Systematic... 2000Pimozide was first formulated in the late 1960s and marketed for the care of those with schizophrenia or related psychoses such as delusional disorder. (Review)
Review
BACKGROUND
Pimozide was first formulated in the late 1960s and marketed for the care of those with schizophrenia or related psychoses such as delusional disorder.
OBJECTIVES
To assess the effects of pimozide for people with schizophrenia, non-affective psychotic mental illness and delusional disorder in terms of clinical, social and economic outcomes.
SEARCH STRATEGY
Electronic searches of Biological Abstracts (1982-1995), The Cochrane Schizophrenia Group's Register, EMBASE (1980-1995), Janssen-Cilag UK's register of studies (1999), MEDLINE (1966-1995), PsycLIT (1974-1995), hand-searching the references of all included studies and contacting the manufacturers of the compound.
SELECTION CRITERIA
All randomised trials relating to people with schizophrenia, or similar disorders comparing pimozide to other drug treatments were sought. Studies where randomisation was implied rather than stated were included if they did not change the results. Primary outcomes were clinically significant change in global function, mental state, relapse, hospital admission, death, adverse events and acceptability of treatment.
DATA COLLECTION AND ANALYSIS
Studies were selected, rated and data extracted. For dichotomous data Relative Risks (RR) based on a random effects model with the 95% confidence intervals (CI) were estimated. The number needed to treat statistic (NNT) was calculated where indicated. Analysis was by intention-to-treat.
MAIN RESULTS
This review currently includes 34 studies focusing on those with schizophrenia, none on people with delusional disorder. Few people have been randomised to pimozide versus placebo, but data from three longer term studies does suggest that the active drug prevents relapse (RR 0.59 CI 0.4-0.8, NNT 4 CI 2-13). Pimozide has similar efficacy to that of typical antipsychotic drugs for the outcomes of change in global functioning, mental state, relapse and leaving the study early. People allocated to pimozide did not have a higher mortality than those taking other antipsychotics. Pimozide was more likely to cause parkinsonian tremor (RR 1.6 CI 1.1-2.3, NNH 6 CI 3-44) and lead to a requirement for antiparkinsonian medication more frequently (RR 1.8, CI 1.2-2.6, NNH 3 CI 2-5) than other drugs. It was, however, less likely to cause sedation (RR 0.38 CI 0.2-0.7, NNH 6 CI 4-16).
REVIEWER'S CONCLUSIONS
Although there are shortcomings in the data there is enough overall consistency, over different outcomes and time scales, to confirm that pimozide is a drug with similar efficacy to other more commonly used antipsychotics such as chlorpromazine for those with schizophrenia. There are no data to support or refute its use for those with delusional disorder.
Topics: Antipsychotic Agents; Humans; Pimozide; Psychotic Disorders; Schizophrenia; Schizophrenic Psychology
PubMed: 10796672
DOI: 10.1002/14651858.CD001949 -
Oral Surgery, Oral Medicine, Oral... May 2011Controversy exists about the effectiveness of anticonvulsants for the management of orofacial pain disorders. To ascertain appropriate therapies, a systematic review was... (Review)
Review
OBJECTIVE
Controversy exists about the effectiveness of anticonvulsants for the management of orofacial pain disorders. To ascertain appropriate therapies, a systematic review was conducted of existing randomized controlled trials.
STUDY DESIGN
Trials were identified from PubMed, Cochrane, and Ovid Medline databases from 1962 through March 2010, from references in retrieved reports, and from references in review articles. Eight useful trials were identified for this review. Six studies were randomized placebo-controlled trials and 2 studies were randomized active-controlled. Two independent investigators reviewed these articles by using a 15-item checklist.
RESULTS
Four studies were classified as "high quality." However, heterogeneity of the trials and the small sample sizes precluded the drawing of firm conclusions about the efficacy of the interventions studied on orofacial pain patients.
CONCLUSIONS
There is limited to moderate evidence supporting the efficacy of commonly used anticonvulsants for treatment of patients with orofacial pain disorders. More randomized controlled trials are needed on the efficacy of anticonvulsants.
Topics: Amines; Anticonvulsants; Burning Mouth Syndrome; Carbamazepine; Clonazepam; Cyclohexanecarboxylic Acids; Facial Pain; Gabapentin; Humans; Lamotrigine; Masticatory Muscles; Pimozide; Randomized Controlled Trials as Topic; Tocainide; Triazines; Trigeminal Neuralgia; gamma-Aminobutyric Acid
PubMed: 21497736
DOI: 10.1016/j.tripleo.2011.01.033 -
The Cochrane Database of Systematic... Jul 2007Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained deaths. Electrocardiogram monitoring is now required before and during use.
OBJECTIVES
To assess the clinical effects of pimozide for people with schizophrenia, non-affective psychotic mental illness and delusional disorder.
SEARCH STRATEGY
We searched the Cochrane Schizophrenia Group's Register (July 2005).
SELECTION CRITERIA
We sought all relevant randomised clinical trials comparing pimozide with other treatments.
DATA COLLECTION AND ANALYSIS
Working independently, we inspected citations, ordered papers, and then re-inspected and quality assessed the studies and extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), 95% confidence interval (CI), and, where appropriate, the number needed to treat (NNT) and the number needed to harm (NNH), on an intention-to-treat basis. We calculated weighted mean differences (WMD) for continuous data. We excluded data if loss to follow-up was greater than 50%.
MAIN RESULTS
We found 35 relevant studies (total n=1348), all including people with schizophrenia but none with delusional disorder. 123 people were randomised to pimozide versus placebo. Data suggest that pimozide prevents relapse (2 RCTs, n=66, RR 0.45 CI 0.2 to 0.9, NNT 4 CI 3 to 22). Compared with typical antipsychotic drugs, pimozide has similar efficacy for outcomes of change in global functioning, mental state, relapse and leaving the study early. People allocated to pimozide did not have a higher mortality than those taking other antipsychotic drugs. Pimozide was more likely than typical antipsychotic drugs to cause tremor in the short-term (6 RCTs, n=192, RR 1.6 CI 1.1 to 2.3, NNH 6 CI 3 to 44) and lead to need for antiparkinsonian medication (4 RCTs, n=124, RR 1.8 CI 1.2 to 2.6, NNH 3 CI 2 to 5) than other drugs. In the medium-term, however, pimozide was less likely to cause sedation (5 RCTs, n=231, RR 0.6 CI 0.5 to 0.9, NNH 6 CI 4 to 16).
AUTHORS' CONCLUSIONS
Although there are shortcomings in the data, there is enough overall consistency over different outcomes and time scales to confirm that pimozide is a drug with similar efficacy to other more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. There are no data to support or refute its use for those with delusional disorder.
Topics: Antipsychotic Agents; Humans; Pimozide; Psychotic Disorders; Randomized Controlled Trials as Topic; Schizophrenia; Schizophrenic Psychology
PubMed: 17636692
DOI: 10.1002/14651858.CD001949.pub2 -
Drug Safety 2005The aim of this review was to determine the spectrum and severity of effects of unintentional antipsychotic poisoning in children. A computerised literature search of... (Review)
Review
The aim of this review was to determine the spectrum and severity of effects of unintentional antipsychotic poisoning in children. A computerised literature search of MEDLINE (1966 to February 2005) and EMBASE (1980 to February 2005) was undertaken. The Internet was searched using URL: www.google.com. The proceedings of the North American Congress of Clinical Toxicology (NACCT) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) were hand searched. All cases of unintentional antipsychotic (all classes) poisoning in children aged 0-6 years were included. The data extracted included the age, weight, antipsychotic, dose, clinical effects, treatment and outcomes. The toxic dose was estimated as the lowest dose causing objective adverse effects.Sixty-eight reports were identified. Few contained all of the required information. Most of the case series included multiple antipsychotics with limited information on individual drugs or all ages with limited paediatric information. For most antipsychotics the ingestion of one tablet caused symptoms that were sometimes severe and usually lasted from 1 to 3 days. Extrapyramidal symptoms (EPS) were often delayed for up to 12-24 hours. Chlorpromazine caused CNS depression, hypotension and miosis; EPS and cardiac effects were rare, and the toxic dose was estimated to be 15 mg/kg. Haloperidol caused drowsiness (rarely coma) and over one-half of patients had neuromuscular effects (mainly EPS), with a toxic dose estimated at 0.15 mg/kg. Thioridazine caused CNS depression and potentially cardiac effects, with a toxic dose of 1.4 mg/kg. Atypical antipsychotics caused significant CNS depression (except risperidone); EPS were less common. Toxic doses were clozapine 2.5 mg/kg, olanzapine 0.5 mg/kg and aripiprazole 3 mg/kg. EPS responded to anticholinergic drug treatment. In summary, unintentional antipsychotic ingestion in children can cause severe effects that last 1-3 days, often with one tablet. Children potentially ingesting a toxic dose or who are symptomatic should be considered for assessment in hospital. Most cases resolve with good supportive care. Toxic doses are only estimates that are based on limited data and should be used with caution until prospective studies are undertaken.
Topics: Antipsychotic Agents; Aripiprazole; Benzodiazepines; Child; Child, Preschool; Chlorpromazine; Clozapine; Dibenzothiazepines; Haloperidol; Humans; Infant; Infant, Newborn; Olanzapine; Pimozide; Piperazines; Poisoning; Quetiapine Fumarate; Quinolones; Risperidone
PubMed: 16231955
DOI: 10.2165/00002018-200528110-00004 -
The Cochrane Database of Systematic... 2000Pimozide was first formulated in the late 1960s and continues to be marketed for the care of those with schizophrenia or related psychoses such as delusional disorder.... (Review)
Review
BACKGROUND
Pimozide was first formulated in the late 1960s and continues to be marketed for the care of those with schizophrenia or related psychoses such as delusional disorder. Pimozide is generally well tolerated apart from extrapyramidal side effects. It has, however, been associated with cardiotoxicity and sudden unexplained deaths and electrocardiogram monitoring is now required before and during its use.
OBJECTIVES
To assess the effects of pimozide for people with schizophrenia, non-affective psychotic mental illness and delusional disorder in terms of clinical, social and economic outcomes.
SEARCH STRATEGY
Electronic searches of Biological Abstracts (1982-1995), The Cochrane Schizophrenia Group's Register, EMBASE (1980-1995), Janssen-Cilag UK's register of studies (1999), MEDLINE (1966-1995), PsycLIT (1974-1995), hand-searching the references of all included studies and contacting the manufacturers of the compound.
SELECTION CRITERIA
All randomised trials relating to people with schizophrenia, or similar disorders comparing pimozide to other drug treatments were sought. Studies where randomisation was implied rather than stated were included if they did not change the results. Primary outcomes were clinically significant change in global function, mental state, relapse, hospital admission, death, adverse events and acceptability of treatment.
DATA COLLECTION AND ANALYSIS
Studies were selected, rated and data extracted. For dichotomous data Relative Risks (RR) based on a random effects model with 95% confidence intervals (CI) were estimated. The number needed to treat statistic (NNT) was calculated where indicated. Analysis was by intention-to-treat.
MAIN RESULTS
This review currently includes 34 studies focusing on those with schizophrenia, none on people with delusional disorder. Few people have been randomised to pimozide versus placebo. Data from two longer term studies does suggest that the active drug prevents relapse (n=66, RR 0.45 CI 0.24-0.86, NNT 4, CI 3-22) but the confidence interval is wide. Pimozide has similar efficacy to that of typical antipsychotic drugs for the outcomes of change in global functioning, mental state, relapse and leaving the study early. People allocated to pimozide did not have a higher mortality than those taking other antipsychotics. Pimozide was more likely to cause parkinsonian tremor (RR 1.6 CI 1.1-2.3, NNH 6 CI 3-44) and lead to a requirement for antiparkinsonian medication more frequently (RR 1.8, CI 1.2-2.6, NNH 3 CI 2-5) than other drugs. It was, however, less likely to cause sedation (RR 0.38 CI 0.2-0.7, NNH 6 CI 4-16).
REVIEWER'S CONCLUSIONS
Although there are shortcomings in the data there is enough overall consistency, over different outcomes and time scales, to confirm that pimozide is a drug with similar efficacy to other more commonly used antipsychotics such as chlorpromazine for those with schizophrenia. There are no data to support or refute its use for those with delusional disorder.
Topics: Antipsychotic Agents; Humans; Pimozide; Psychotic Disorders; Schizophrenia; Schizophrenic Psychology
PubMed: 10908518
DOI: 10.1002/14651858.CD001949 -
The Annals of Pharmacotherapy Nov 2006To determine which antipsychotic is associated with the greatest efficacy and safety when used for the pharmacotherapeutic management of delirium in medically or... (Comparative Study)
Comparative Study Review
OBJECTIVE
To determine which antipsychotic is associated with the greatest efficacy and safety when used for the pharmacotherapeutic management of delirium in medically or surgically ill patients.
DATA SOURCES
MEDLINE, Current Contents, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Biological Abstracts, Cochrane Central Register of Controlled Trials, and EMBASE databases (all to July 2006) were searched for trials evaluating the pharmacologic treatment of delirium in medically or surgically ill patients. The key terms used included delirium, agitation, or acute confusion, and antipsychotics, phenothiazine, butyrophenone, perphenazine, fluphenazine, clozapine, trifluorophenazine, loxapine, thioridazine, pimozide, molindone, haloperidol, methotrimeprazine, chlorpromazine, prochlorperazine, droperidol, risperidone, quetiapine, ziprasidone, amisulpride, or olanzapine.
STUDY SELECTION AND DATA EXTRACTION
Prospective, randomized, controlled trials comparing the clinical effects of antipsychotic therapy with placebo or comparing 2 antipsychotic treatments in an acute care setting were selected. Studies involving dementia-associated delirium, Alzheimer's disease-associated delirium, emergency department-associated acute agitation, acute brain trauma-associated agitation, or agitation secondary to underlying psychiatric afflictions such as depression or schizophrenia were excluded. All studies were evaluated independently by the 3 authors using a validated evaluation tool. Outcomes related to both efficacy and safety were collected. Four prospective trials were included in this systematic review.
DATA SYNTHESIS
Antipsychotic agents, either atypical or typical, were effective compared with baseline for the treatment of delirium in medically or surgically ill patients without underlying cognitive disorders. Oral haloperidol was associated with more frequent extrapyramidal side effects, but overall, all agents were well tolerated. Interpretation of the published evidence is limited by the small sample sizes, varied patient populations, and comparative agents of the studies reviewed.
CONCLUSIONS
The comparative studies evaluated here suggest that antipsychotic drugs are efficacious, when compared with baseline, and safe for the treatment of delirium. Haloperidol remains the most studied agent. Recommendation of one antipsychotic over another as a first-line pharmacologic intervention in the treatment of hospital-associated delirium is limited by the quality and quantity of data available. Better designed and larger studies evaluating the addition of antipsychotic agents to nonpharmacologic treatments are needed to measure the true effect of pharmacologic treatment.
Topics: Antipsychotic Agents; Delirium; Haloperidol; Hospital Departments; Hospitalization; Humans; Surgery Department, Hospital
PubMed: 17047137
DOI: 10.1345/aph.1H241