(Dosing, switching, and other practical information).

Dosing, switching, and other practical information by Stephen M. Stahl

Dosing, switching, and other practical information by Stephen M. Stahl

Copyright 2013. Arbor Scientia. All rights reserved. No part of this document may be reproduced or transmitted in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of Arbor Scientia or the author Dr. Stephen M. Stahl, MD, PhD.

“Funding for this Pocket Guide was provided by Janssen Pharmaceutica NV, Belgium.”

2

Table of Contents amisulpride (SOLIAN®) ............................................................................5 aripiprazole (ABILIFY®) ............................................................................17 clozapine (e.g. CLOZARIL®, LEPONEX®) .............................................29 olanzapine (ZYPREXA®) ..........................................................................41 olanzapine pamoate monohydrate (ZYPADHERA®) .....................51 paliperidone ER (INVEGA®) ....................................................................63 paliperidone palmitate (XEPLION®) ...................................................79 quetiapine fumarate (SEROQUEL®) ....................................................95 risperidone (e.g. RISPERDAL®) ..............................................................107 risperidone long-acting injectable (RISPERDAL CONSTA®) .......121 ziprasidone (e.g. GEODON®, ZELDOX®).............................................131 Class Warnings ...........................................................................................141

3

4

Amisulpride is an atypical antipsychotic agent indicated for*: 1. The treatment of schizophrenia in adults with: –

positive symptoms such as delusions, hallucinations, thought disorders, hostility, suspiciousness

–

negative symptoms (deficit syndrome) such as blunted affect, emotional and social withdrawal

Mechanism of Action1, 2, 3 The therapeutic activity of amisulpride is mediated through a combination of D2 and D3 dopamine receptor antagonism. Unlike classical and atypical neuroleptics, amisulpride displays low affinity for serotonergic, α-adrenergic, histaminergic receptor subtypes, and muscarinic receptors and sigma sites. Amisulpride is also an antagonist at 5HT7 receptors.

AMISULPRIDE

Indications and Usage1

*Licenses differ between countries. Please refer to local Product Information guides.

5

AMISULPRIDE

Dosing and Administration1 Indication Schizophrenia in Adults Schizophrenia with Predominant Negative Symptoms

Initial Dose

Titration

Maximum Dose

400–800 mg/day*

No Titration Required

1200 mg/day

50–300 mg/day

No Titration Required

300 mg/day

*Amisulpride should be administered twice daily for doses above 300 mg. Doses above 800 mg/day have shown no significant improvement over lower doses.

6

Amisulpride induces a dose-dependent prolongation of QT interval, which potentiates the risk of serious ventricular arrhythmias such as torsades de pointes.

AMISULPRIDE

Special Considerations1

The following factors could favor the occurrence of this rhythm disorder: • bradycardia < 55 bpm • cardiac disease or family history of sudden death or QT prolongation • electrolyte imbalance, in particular hypokalaemia • congenital prolonation of the QT interval • on-going treatment with a medicinal production likely to produce pronounced bradycardia (< 55 bpm), hypokalaemia, decreased intracardiac conduction, or prolongation of the QT interval The dose of amisulpride should be reduced if QT is prolonged and discontinued if QTc is >500 ms. Baseline ECG is recommended prior to treatment in all patients especially in the elderly and patients with a positive personal or family history of cardiac disease or abnormal findings on cardiac clinical examination. During therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed on an individual patient basis. Periodic electrolyte monitoring is recommended particularly if the patient is taking diuretics or during intercurrent illness. Concomitant antipsychotics should be avoided. Caution should be also exercised when prescribing amisulpride to patients with Parkinson’s disease since it may cause worsening of the disease. Amisulpride should be used only if antipsychotic treatment cannot be avoided. Amisulpride may lower the seizure threshold. Therefore patients with a history of epilepsy should be closely monitored during amisulpride therapy.

7

AMISULPRIDE

Pharmacokinetics1

Time to Peak Plasma Concentration

Mean Elimination Half-Life

Time to Steady-State Concentration

3–4 hrs

12 hrs

48–60 hrs

% of Administered CYP450 Enzymes Dose Excreted as Responsible for Unchanged Drug Biotransformation 50 %

— CYP450 = Cytochrome P450

8

Renal Impairment

AMISULPRIDE

Pharmacokinetics in Special Populations1

Use with caution in patients with renal insufficiency. Amisulpride is renally eliminated, and in patients with renal insufficiency, systemic clearance is reduced by a factor of 2.5 to 3. The AUC in mild renal failure is increased two-fold and almost tenfold in moderate renal failure. Although there is no data to support clearance and AUC alterations for doses above 50 mg/day in patients with renal impairment, it is recommended to adjust dosage as follows:

• In patients with creatinine clearance 30 ≥ CLcr ≤ 60 mL/min, use half of the recommended dose • In patients with creatinine clearance 10 ≥ CLcr ≤ 30 mL/min, use one third of the recommended dose • Amisulpride should not be used in patients with severe renal impairment (CLcr < 10 ml/min) Hepatic Impairment No dose adjustment required for patients with hepatic impairment. CLcr = Creatinine Clearance, AUC = Area Under the Curve

9

AMISULPRIDE

Pharmacodynamics1, 2, 3 HIGH

D2 D3

1

0.1 High Affinity

10

LOW

Relative Binding Affinities

5HT7

10 Moderate Affinity

100

1,000 Low Affinity

The efficacy of amisulpride in the treatment of schizophrenia was established in four short-term controlled trials of inpatients who met DSM-III-R or DSM-IV criteria for schizophrenia. Psychiatric signs and symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS), Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impression (CGI). Study

Doses Tested

Adult DSM-III-R or DSM-IV criteria for schizophrenia

100 mg/day 400 mg/day 800 mg/day 1200 mg/day 800 mg/day

Duration

Main Endpoints

AMISULPRIDE

Efficacy4

Dose-related improvement  400 and 800 mg/day superior to lower doses; all doses were as effective as the comparative treatment (haloperidol 16 mg/day)

4 wks

PANSS, BPRS, CGI

 equivalent to comparative treatment in efficacy (20 mg/day haloperidol); improved response rate with CGI vs. haloperidol

1000 mg/day

 equivalent to comparative treatment in efficacy (25 mg/day flupenthixol)

800 mg/day

 equivalent to comparative treatment in efficacy (8 mg/day risperidone)

11

AMISULPRIDE 12

Efficacy4 Three trials were conducted versus placebo in schizophrenic patients with predominant negative symptoms according to DSM-III and DSM-III-R, showing that low doses of amisulpride are active against negative symptoms. Psychiatric signs and symptoms were assessed using the Clinical Global Impression (CGI), Scale for the Assessment of Negative Symptoms (SANS), Montgomery–Åsberg Depression Rating Scale (MADRS), and Global Assessment of Functioning (GAF). Study

Doses Tested

Duration

Main Endpoints

Dose-related improvement

Adult DSM-III-R or DSM-III criteria for schizophrenia

100 mg/day 300 mg/day

6 wks

SANS

 100 and 300 mg/day vs. placebo

50 mg/day 100 mg/day

3 months

CGI, MADRS

 50 and 100 mg/day vs. placebo

100 mg/day

6–12 months

CGI, SANS, GAF

 100 mg/day maintained improvement of negative symptoms and prevented recurrence of positive symptoms vs. placebo

Percent of Patients Reporting Placebo Amisulpride (n=202) (n=921) Extrapyramidal disorder

2

11

Insomnia

7

10

Anxiety

5

7

Weight increase

5

6

Agitation

3

5

AMISULPRIDE

Safety and Tolerability4

Adverse reactions reported by ≥ 5% of patients treated with amisulpride in a 6-week, double-blind, placebo-controlled trial.

13

AMISULPRIDE

Switching2 Switching from Oral Antipsychotics to Amisulpride dose

Target dose amisulpride

aripiprazole 1 week

dose

Target dose paliperidone ER risperidone ziprasidone

* amisulpride 1 week

dose

Target dose

dose

Target dose clozapine

1 week

14

It is advisable to begin amisulpride at an intermediate dose and build the dose rapidly over 3-7 days. Clinical experience has shown that quetiapine and olanzapine should be tapered off slowly over a period of 3-4 weeks, to allow patients to readapt to the withdrawal of blocking cholinergic, histaminergic, and alpha-1 receptors.

*

quetiapine olanzapine 1 week

Begin amisulpride at middle dose.

amisulpride 1 week

1 week

1 week

* amisulpride 1 week

1 week

1 week

1 week

Clozapine should always be tapered off slowly, over a period of 4 weeks or more. * Benzodiazepine or anticholinergic medication can be administered during cross-titration to help alleviate side effects such as insomnia, agitation, and/or psychosis.

1. Amisulpride prescribing information, electronic Medicines Compendium, July 31, 2012.

AMISULPRIDE

References

2. Stahl SM. Stahl's Essential Psychopharmacology 3rd ed. 2008, Cambridge University Press, New York, pgs. 408–422, 431–436. 3. Abbas AI et al. Amisulpride is a potent 5-HT7 antagonist: relevance for antidepressant actions in vivo, 2009, Psychopharmacology, 205:119–128. 4. SOLIAN prescribing information, Sanofi-Aventis Pharmaceuticals, Ltd. June 2012.

15

16

AMISULPRIDE

Aripiprazole is an atypical antipsychotic agent indicated for*: 1. The treatment of schizophrenia in: – –

adults adolescents above 15 years of age

Mechanism of Action1, 2 The therapeutic activity of aripiprazole is mediated through a combination of 5HT2A, 5HT2C, and 5HT7 serotonin, D3 and D4 dopamine, H1 histamine, and α1-adrenergic receptor antagonism. Aripiprazole also acts as a partial agonist for D2 dopamine, and 5HT1A serotonin receptor.

ARIPIPRAZOLE

Indications and Usage1

2. The treatment of symptoms of bipolar I disorder, including: – –

moderate to severe manic episodes prevention of recurrence of manic episodes

*Licenses differ between countries. Please refer to local Product Information guides.

17

ARIPIPRAZOLE

Dosing and Administration1 Indication

Initial Dose

Titration

Target Dose

Effective Dose Range

10 or 15 mg/day

—

10–15 mg/day*

10–30 mg/day*

Schizophrenia in Adolescents

2 mg/day

2 mg/day for 2 days 5 mg/day for 2 days

10 mg/day**

10–30 mg/day**

Bipolar disorder manic episodes

15 mg/day

15 mg/day

15–30 mg/day*

Schizophrenia in Adults

Aripiprazole dose (mg/day)

Titration for Treatment of Schizophrenia in Adolescents 12 10 8 6 4 2 0 0

1

2

3

4

5

6

Day *Doses above 15 mg given once daily demonstrated no significant improvement over lower doses, although some patients may do better on higher dose. Do not exceed 30 mg/day. **Doses above 10 mg demonstrated no significant improvement in adolescent patients, although some patients may benefit from higher doses. When appropriate, increases in dosage should be made in increments of 5 mg/day. Do not exceed 30 mg/day.

18

ARIPIPRAZOLE

Pharmacokinetics1

Time to Peak Plasma Concentration

Mean Elimination Half-Life

Time to Steady-State Concentration

3–5 hrs

75 hrs

14 days

% of Administered CYP450 Enzymes Dose Excreted as Responsible for Unchanged Drug Biotransformation

18%

CYP2D6 CYP3A4 CYP450 = Cytochrome P450

When concomitant administration of potent CYP3A4 or CYP2D6 inhibitors with aripiprazole occurs, the aripiprazole dose should be reduced. When the concomitant administration of CYP3A4 inducers with aripiprazole occurs, the aripiprazole dose should be increased. When the CYP3A4 inducer is withdrawn from the combination therapy, the aripiprazole dose should then be reduced to the recommended dose.

19

ARIPIPRAZOLE

Pharmacokinetics in Special Populations1

Renal Impairment

CLcr (mL/min)

% Decrease in CLcr

Increase in AUC

Recommended Initial Dose

Titration

Max Dosage

Mild Moderate

No dose adjustment needed for renal impairment.

Severe

Hepatic Impairment No dose adjustment is required for patients with mild to moderate hepatic impairment. Use 30 mg/day dose with caution in patients with severe hepatic impairment. (There is insufficient data to establish dose recommendations for these patients.) CLcr = Creatinine Clearance, AUC = Area Under the Curve

20

HIGH

D2 D3

1

0.1 High Affinity

LOW

Relative Binding Affinities

5HT1A 5HT2C 5HT2A 5HT7 D4

α1

10 Moderate Affinity

ARIPIPRAZOLE

Pharmacodynamics1, 2, 3, 4

H1

100

1,000 Low Affinity

21

ARIPIPRAZOLE

Efficacy3 The efficacy of aripiprazole in the treatment of schizophrenia was established in five short-term controlled trials of inpatients who met DSM-III-R or DSM-IV criteria for schizophrenia. Psychiatric signs and symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression (CGI). Study Adult DSM-III-R or DSM-IV criteria for schizophrenia

Doses Tested

Duration

Main Endpoints

Dose-related improvement

15 mg/day 30 mg/day

4 wks

PANSS, CGI

 15 and 30* mg/day vs. placebo

20 mg/day 30 mg/day

4 wks

PANSS, CGI

 20 and 30 mg/day vs. placebo

10 mg/day 15 mg/day 20 mg/day

6 wks

PANSS

 10, 15, and 20* mg/day vs. placebo

2 mg/day 5 mg/day 10 mg/day

6 wks

PANSS

 10 mg/day vs. placebo

5–30 mg/day

4 wks

CGI

 All doses superior to placebo*

*Across studies, higher doses did not demonstrate superior efficacy compared to lower doses.

22

A longer-term trial enrolled 310 inpatients or outpatients meeting DSM-IV criteria for schizophrenia who were, based on medical history, symptomatically stable on other antipsychotic medications for periods of 3 months or longer. These patients were discontinued from their antipsychotic medications and randomized to 15 mg/day aripiprazole or placebo for up to 26 weeks of observation for relapse. Study Adult DSM-IV criteria for schizophrenia

Doses Tested

Duration

Main Endpoints

Dose-related improvement

15 mg/day

26 wks

PANSS, CGI

 15 mg/day demonstrated longer time to relapse compared to placebo

ARIPIPRAZOLE

Efficacy3

The efficacy of aripiprazole in the treatment of schizophrenia in pediatric patients (13 to 17 years of age) was evaluated in one 6-week, placebo-controlled trial of outpatients who met DSM-IV criteria for schizophrenia. Study

Doses Tested

Duration

Main Endpoints

Dose-related improvement

Adolescent DSM-IV criteria for schizophrenia

10 mg/day 30 mg/day

6 wks

PANSS

 10 and 30 mg/day vs. placebo; no significant advantage of 30 mg/day compared to 10 mg/day

23

ARIPIPRAZOLE

Safety and Tolerability3 Percent of Patients Reporting Placebo (n=1166)

Aripiprazole (n=1843)

Headache

23

27

Agitation

17

19

Insomnia

13

Anxiety

Percent of Patients Reporting Placebo (n=1166)

Aripiprazole (n=1843)

Dyspepsia

4

7

Fatigue

4

6

18

Dry mouth

4

5

13

17

Extrapyramidal sypmtoms

3

5

Nausea

11

15

Somnolence

3

5

Constipation

7

11

Restlessness

3

5

Tremor

3

5

Vomiting

6

11

Dizziness

7

10

Akasthisia

4

10

Adverse reactions reported by ≥ 5% among patients treated with aripiprazole in a 6-week, double-blind, placebocontrolled trial.

24

ARIPIPRAZOLE

Safety and Tolerability in Adolescents3 Percent of Patients Reporting Placebo (n=97)

Aripiprazole (n=197)

Somnolence

3

23

Extrapyramidal disorder

3

20

Fatigue

4

11

Nausea

4

11

Akathisia

2

10

Blurred vision

0

8

Salivary hypersecretion

0

6

Dizziness

1

5

The following findings are based on one 6-week, placebo-controlled trial in which oral aripiprazole was administered in doses ranging from 2 mg/day to 30 mg/day. This table represents adverse reactions reported by ≥ 5% of aripiprazole-treated adolescent patients (13–17 years of age) with schizophrenia.

25

ARIPIPRAZOLE

Special Considerations1 Aripiprazole should be used with caution in patients with : • known cardiovascular disease (history of myocardial infarction or ischaemic heart disease, heart failure, or conduction abnormalities) • cerebrovascular disease • conditions which would predispose patients to hypotension (dehydration, hypovolemia, and treatment with antihypertensive medicinal products) or • hypertension, including accelerated or malignant Aripiprazole should be used with caution in patients who have a history of seizure disorder or have conditions associated with seizures.

26

Switching from Oral Antipsychotics to Aripiprazole dose

Target dose

* amisulpride

aripiprazole 1 week

dose

Target dose paliperidone ER ziprasidone risperidone

* aripiprazole 1 week

dose

Target dose

Clinical experience has shown that olanzapine and quetiapine should be tapered off over a period of 3–4 weeks due to the risk of withdrawal symptoms associated with cholinergic, histaminergic, and alpha–1 receptor blocking.

* quetiapine olanzapine 1 week

Target dose dose

It is advisable to begin aripiprazole at an intermediate dose and build the dose rapidly over 3–7 days.

ARIPIPRAZOLE

Switching2

aripiprazole 1 week

1 week

1 week

* clozapine 1 week

aripiprazole 1 week

1 week

1 week

Clozapine should always be tapered off gradually, over a period of 4 weeks or more. * Benzodiazepine or anticholinergic medication can be administered during crosstitration to help alleviate side effects such as insomnia, agitation, and/or psychosis.

27

ARIPIPRAZOLE

References 1. ABILIFY prescribing information, Otsuka Pharmaceuticals Europe Ltd., European Medicines Agency, http://www.ema.europa.eu/ 2. Stahl SM. Stahl's Essential Psychopharmacology 3rd ed. 2008, Cambridge University Press, New York, pgs. 408-422, 431-436. 3. ABILIFY prescribing information, Otsuka Pharmaceuticals Co., Ltd, February 2012. 4. Correll CU. From receptor pharmacology to improved outcomes: individualising the selection, dosing, and switching of antipsychotics, 2010, European Psychiatry, 25, S12-S21.

28

Clozapine is an atypical antipsychotic agent indicated for*: 1. The treatment of schizophrenia in: –

–

Patients who have severe, untreatable, neurological adverse reactions to other antipsychotic agents Treatment-resistant patients

Mechanism of Action1, 2, 3

CLOZAPINE

Indications and Usage1

The therapeutic activity of clozapine is mediated through a combination of 5HT1, 5HT2, 5HT3, 5HT6, 5HT7 serotonin, D4 dopamine, M1 muscarinic, H1 histamine, and α1-adrenergic receptor antagonism. It also has weak D2 blocking properties.

2. Psychotic disorders occurring during the course of Parkinson’s disease, in cases where standard treatment has failed.

*Licenses differ between countries. Please refer to local Product Information guides.

29

CLOZAPINE

Dosing and Administration1

Indications

Initial Dose Day 1

Second Dose Day 2

Titration

Target dose

Dose Range

Maximum Dose

Schizophrenia (Adults)

12.5 mg administered once or twice

25 mg administered once or twice

25–50 mg/day over 2–3 weeks

300 mg/day within 2–3 weeks of initial dose

200–450 mg/day may be given in divided doses with larger dose given at bedtime

900 mg/day*

*Daily dose may be increased to maximum after achieving target dose. Increase in increments of 50 to 100 mg at halfweekly or, preferably, weekly intervals. Increased adverse reactions (in particular seizures) are possible at doses over 450 mg/day. Maintenance Dosing: • After achieving maximum therapeutic benefit, many patients can be maintained effectively on lower doses. • Careful downward titration is recommended when reducing dose. • For effective doses < 200 mg/day, once-daily administration in evening may be appropriate. Use in Elderly: • Initiation of treatment is recommended at 12.5 mg once daily, with subsequent dose increments restricted to 25 mg/day.

30

CLOZAPINE

Special Considerations1 WBC and differential blood counts must be performed within 10 days prior to initiating clozapine treatment. Only patients with normal WBC counts and ANC (WBC count ≥ 3500/mm3 (3.5x109/l) and ANC ≥ 2000/mm3 (2.0x109/l)) should receive clozapine. After the start of clozapine treatment, the WBC count and ANC must be monitored weekly for the first 18 weeks, and at least four-week intervals thereafter. Seizures have been associated with the use of clozapine with a greater likelihood at higher clozapine doses. Caution should be used when administering clozapine to patients having a history of seizures or other predisposing factors. Cardiovascular and respiratory effects include myocarditis, orthostatic hypotension, respiratory and/or cardiac arrest, especially when clozapine is administered with benzodiazepines or other psychotropic drugs. Orthostatic hypotension is more likely to occur during initial titration.

31

CLOZAPINE

Pharmacokinetics1 Time to Peak Plasma Concentration (Hours)

Time to Steady-State Concentration (Days)

Mean Elimination Half-Life (Hours)

2.5

8–10*

12

Oral Bioavailability

Bioavailability with Food

% of Administered Dose Excreted as Unchanged Drug

CYP450 Enzymes Responsible for Biotransformation

27%

27%

50%

CYP1A2, CYP2D6, CYP3A4

CYP450 = Cytochrome P450 *Time to reach clozapine steady state concentrations exceeds 4-5 half-lives because of required titration.

32

CLOZAPINE

Pharmacokinetics in Special Populations1

Renal Impairment Mild Moderate Severe

CLcr (mL/min)

% Decrease in CLcr

Elimination T1/2 (Hours)

Increase in AUC

Recommended Initial Dose (mg/day)

Maximum Recommended Dose (mg/day)

No significant reduction in clearance (Bennett 1997). Use with caution, due to possibility of interstitial nephritis. Not recommended

Hepatic Impairment Caution is advised in patients using clozapine who have concurrent hepatic disease. Hepatitis has been reported in both patients with normal and preexisting liver function abnormalities. In patients who develop nausea, vomiting, and/or anorexia during clozapine treatment, liver function tests should be performed immediately. If the elevation of these values is clinically relevant or if symptoms of jaundice occur, treatment with clozapine should be discontinued. CLcr = Creatinine Clearance, AUC = Area Under the Curve, T1/2 = Mean Elimination Half-Life

33

CLOZAPINE

Pharmacodynamics1, 2, 3, 4 HIGH

M1 5HT2A

H1

0.1

α1

α2

1 High Affinity

34

LOW

Relative Binding Affinities

D4

5HT2C 5HT6 5HT7

10 Moderate Affinity

5HT1A 5HT2B 5HT2E 5HT3

100

D1 D2 D3 D5

Low Aĸnity 1,000 Low Affinity

CLOZAPINE

Efficacy: Treatment-Resistant Schizophrenia5 The effectiveness of clozapine in a treatment-resistant schizophrenic population was demonstrated in a 6-week study comparing clozapine and chlorpromazine. Patients meeting DSM-III criteria for schizophrenia and having a mean BPRS total score of 61 were demonstrated to be treatment resistant by history and by open prospective treatment with haloperidol before entering into the double-blind phase of the study. Efficacy was evaluated using the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression Scale (CGI).

Kane et al. 1988 BPRS Baseline Scorea BPRS End Point Scorea CGI Scale Baseline Scorea CGI Scale End Point Scorea

clozapine 500 mg/day (n=126)

chlorpromazine 1000 mg/day* (n=139)

61 (12) 45 (13) 5.6 (0.7) 4.4 (1.1)

61 (11) 56 (12) 5.7 (0.7) 5.3 (0.8)

p-valueb

< 0.001 < 0.001

a

Mean (Standard Deviation), bBased on two-tailed analysis of covariance model with criterion variables and drug as covariates, demonstrating superiority of clozapine over chlorpromazine. *Plus 6 mg/day benztropine mesylate.

35

CLOZAPINE

Efficacy: Suicide Prevention6 The International Suicide Prevention Trial (InterSePT) was a randomized, international, parallel-group comparison of clozapine vs. Zyprexa in reducing the risk of recurrent suicidal behavior in patients diagnosed with schizophrenia (62% of patients) or schizoaffective disorder (28% of patients) (n = 980)*.

Cumulative probability

0.5 clozapine Zyprexa

0.4

32%

0.3

24% 0.2 0.1

4

6

8

10

12

14

16

18

20

22

24

Time (months) Kaplan-Meier Estimates of Cumulative Probability of a Significant Suicide Attempt or Hospitalization to Prevent Suicide *27% of patients in this study were considered resistant to standard antipsychotic drug treatment

36

CLOZAPINE

Safety and Tolerability6 Percent of Patients Reporting (n=842) Drowsiness/Sedation

39

Percent of Patients Reporting (n=842) Tremor

6 6

Salivation

31

Syncope

Tachycardia

25

Sweating

6

Dizziness/vertigo

19

Dry mouth

6

Constipation

14

Nausea

5

Hypotension

9

Visual disturbances

5

Headache

7

Fever

5

Adverse reactions reported by ≥ 5% of clozapine-treated adult subjects with schizophrenia in premarket clinical trials. These rates are not adjusted for duration of exposure.

37

CLOZAPINE

Switching2 Immediate stop possible, begin clozapine at middle dose.

Switching from Oral Antipsychotics to Clozapine dose

Target dose

aripiprazole amisulpride paliperidone ER

* clozapine 1 week

1 week

dose

Target dose quetiapine olanzapine

*

clozapine

1 week

dose

Target dose risperidone ziprasidone 1 week

38

* 1 week

clozapine 1 week

1 week

Begin clozapine gradually, titrating over at least 2 weeks to allow patients to become tolerant to the sedating effect. * Benzodiazepine or anticholinergic medication administered during reduction of olanzapine, quetiapine, and clozapine can alleviate side effects such as insomnia, anxiety, agitation, and/or psychosis.

CLOZAPINE

References 1. CLOZARIL 25 mg and 100 mg Tablets, Novartis Pharmaceuticals, electronic Medicines Compendium, August 2012. 2. Stahl SM. Stahl's Essential Psychopharmacology 3rd ed. 2008, Cambridge University Press, New York, pgs. 408–422, 431–436. 3. Nasrallah HA, Atypical Antipsychotic-Induced Metabolic Side Effects: Insights from Receptor-Binding Profiles, 2008, Molecular Psychiatry, 13, 27–35. 4. Correll CU. From receptor pharmacology to improved outcomes: individualising the selection, dosing, and switching of antipsychotics, 2010, European Psychiatry, 25, S12-S21. 5. Kane J, Honigfeld G, Singer J, et al. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine, 1988, Arch Gen Psychiatry, 45, 789–796. 6. CLOZARIL Prescribing Information, Novartis Pharmaceuticals Corporation, October 2011.

39

40

CLOZAPINE

Olanzapine is an atypical antipsychotic agent indicated for*: 1. The treatment of schizophrenia in adults. 2. Maintaining clinical improvement during continuation therapy in adult patients with schizophrenia who have shown an initial treatment response.

Mechanism of Action1, 2 The therapeutic activity of olanzapine is mediated through a combination of 5HT2A, 5HT2C, 5HT6 serotonin, H1, H2 histamine, D1, D2, D3, D4, D5 dopamine, M5 muscarinic, α1, and α2-adrenergic receptor antagonism. It also has moderate M1, M2, and M3 blocking properties.

OLANZAPINE

Indications and Usage1

3. The treatment of symptoms of bipolar I disorder in adults, including: – –

Moderate to severe manic episodes Prevention of recurrence of manic episode

*Licenses differ between countries. Please refer to local Product Information guides.

41

OLANZAPINE

Dosing and Administration1 Indication

Initial dose

Effective dose

Maximum dose

Schizophrenia

10 mg once daily

5–20 mg/day

20 mg/day

Manic episode

15 mg once daily in monotherapy 10 mg once daily in combination therapy

5–20 mg/day

20 mg/day

During treatment for schizophrenia, daily dosage may subsequently be adjusted on the basis of individual clinical status within the range of 5–20 mg/day. Increase to a dose greater than recommended starting dose is advised only after clinical reassessment and should occur at intervals of not less than 24 hours. Gradual tapering should be considered when discontinuing.

42

Olanzapine is not approved for treatment of dementia-related psychosis, and is not recommended for the treatment of Parkinson’s disease symptoms.

OLANZAPINE

Special Considerations1

Caution is advised when prescribing for patients with prostatic hypertrophy, paralytic ileus and related conditions, and low leukocyte and/or neutrophil counts. Olanzapine is contraindicated for patients with known risk of narrow-angle glaucoma. A lower starting dose should be considered in patients who are using fluvoxamine or any other CYP1A2 inhibitors such as ciprofloxacin.

43

OLANZAPINE

Pharmacokinetics1

Dose

Time to Peak Plasma Concentration

Mean Elimination Half-Life (hrs)

Time to Steady-State Concentration

% of Administered Dose Excreted as Unchanged Drug

Creatinine Clearance (L/hr)

10 mg

6 hrs

30

1 week (pooled data)

7%

18.2

CYP1A2, CYP2D6

Elderly (65 and over)

6 hrs

52

—*

7%

17.5

CYP1A2, CYP2D6

Smokers

6 hrs

39

—*

7%

Reduced 67%

CYP1A2, CYP2D6

Smokers with mild hepatic impairment

6 hrs

49

—*

7%

14

CYP1A2, CYP2D6

CYP450 Enzymes Responsible for Biotransformation

CYP450 = Cytochrome P450 *Time to steady-state concentration varies between populations.

44

OLANZAPINE

Pharmacokinetics in Special Populations1

Renal Impairment

CLcr (mL/min)

% Decrease in CLcr

Elimination T1/2 (Hours)

Increase in AUC

Recommended Initial Dose

Mild Moderate

Highly metabolized, dosing adjustment not required; 5 mg/day starting dose should be considered

5 mg/day

Severe CLcr = Creatinine Clearance, AUC = Area Under the Curve, T1/2 = Mean Elimination Half-Life Hepatic Impairment Transient, asymptomatic elevations of hepatic aminotransferases, ALT and AST, have been seen commonly, especially in early treatment. Starting dose should be 5 mg/day for patients with hepatic impairment, and only increased with caution. Caution should be exercised and follow-up organized in patients with elevated ALT and/or AST, in patients: • with signs and symptoms of hepatic impairment • with pre-existing conditions associated with limited hepatic functional reserve • who are being treated with potentially hepatotoxic medicines In cases where hepatitis (including hepatocellular, cholestatic, or mixed liver injury) has been diagnosed, olanzapine treatment should be discontinued.

45

OLANZAPINE

Pharmacodynamics2 HIGH

5HT2A 5HT2C 5HT6 H1

0.1

1 High Affinity

46

LOW

Relative Binding Affinities

D1 D2 D3 D5 α 1

M1 M2 M3 M4 M5

5HT1B 5HT7

α3 5HT3

10 Moderate Affinity

100

1,000 Low Affinity

OLANZAPINE

Efficacy3 Summary of Results for Efficacy in the Treatment of Schizophrenia Study

Doses Tested

Adult DSM-III-R criteria for schizophrenia

10 mg/day

Adult DSM-IV criteria for schizophrenia

5 ± 2.5 mg/day 10 ± 2.5 mg/day 15 ± 2.5 mg/day 10–20 mg/day

Duration

Main Endpoints

Dose-related improvement

6 wks

BRPS, PANSS, CGI-S

 10, 15 mg vs. placebo No advantage in medium vs. high dose

8 wks, observed for 8 months1

BPRS

 superior to placebo in time to relapse

1

Patients remained stable on olanzapine for 8 weeks and then were observed for relapse over an 8-month period. An excess of placebo relapses compared to olanzapine relapses resulted in early termination of the long-term study.

47

OLANZAPINE

Safety and Tolerability3

Somnolence Accidental injury Insomnia Dizziness Asthenia Dry mouth Constipation Dyspepsia Rhinitis Fever Abnormal gait Cough increased Back pain Ecchymosis Weight gain Extremity pain Joint pain

Percent of Patients Reporting Placebo Olanzapine (n=294) (n=160) 13 29 8 12 11 12 4 11 9 10 5 9 4 9 5 7 6 7 2 6 1 6 3 6 2 5 3 5 3 5 3 5 3 5 Adverse reactions reported by ≥ 5% among patients treated with oral olanzapine (doses ≥ 2.5 mg/day) in short-term, placebo-controlled trials.

48

OLANZAPINE

Switching2 Switching from Oral Antipsychotics to Olanzapine dose

Target dose aripiprazole amisulpride paliperidone ER

olanzapine 1 week

1 week

dose

Target dose quetiapine clozapine

olanzapine

Immediate stop possible, begin olanzapine at middle dose Begin olanzapine gradually, titrating over at least 2 weeks to allow patients to become tolerant to the sedating effect.

1 week dose

Target dose risperidone ziprasidone 1 week

olanzapine 1 week

1 week

1 week

49

OLANZAPINE

References 1. Olanzapine 15 mg Film-coated Tablets, Summary of Product Characteristics, Accord Healthcare Ltd, electronic Medicines Compendium, November 2012. 2. Stahl SM. Stahl's Essential Psychopharmacology 3rd ed. 2008, Cambridge University Press, New York, pgs. 408-422, 431-436. 3. ZYPREXA Prescribing Information, Lilly USA, LLC, June 2011.

50

Olanzapine pamoate monohydrate is a longacting injectable (LAI) atypical antipsychotic agent indicated for the maintenance treatment of adult patients with schizophrenia sufficiently stabilized during acute treatment with oral olanzapine*.

Mechanism of Action1, 2 The therapeutic activity of olanzapine is mediated through a combination of 5HT2A, 5HT2C, 5HT6 serotonin, H1, H2 histamine, D1, D2, D3, D4, D5 dopamine, M5 muscarinic, α1, and α2-adrenergic receptor antagonism. It also has moderate M1, M2, and M3 blocking properties.

OLANZAPINE LAI

Indications and Usage1

*Licenses differ between countries. Please refer to local Product Information guides.

51

OLANZAPINE LAI

Dosing and Administration1 Patients should be treated initially with oral olanzapine before administering olanzapine LAI to establish tolerability and response. Recommended dose scheme between oral olanzapine and olanzapine LAI Target oral olanzapine dose

Recommended starting dose of olanzapine LAI

Maintenance dose after 2 months of olanzapine LAI treatment

10 mg/day

210 mg/2 weeks or 405 mg/4 weeks

150 mg/2 weeks or 300 mg/4 weeks

15 mg/day

300 mg/2 weeks

210 mg/2 weeks or 405 mg/4 weeks

20 mg/day

300 mg/2 weeks

300 mg/2 weeks

After each injection, observe patient in a healthcare facility for at least 3 hours for signs and symptoms consistent with olanzapine overdose. Patients should be monitored carefully for signs of relapse during the first one to two months of treatment. During treatment, dose may subsequently be adjusted on the basis of individual clinical status within the range of 150 mg-300 mg every 2 weeks or 300–405 mg every 4 weeks.

52

olanzapine LAI vial strength (mg)

Volume of solvent to add, mL

210

1.3

300

1.8

405

2.3

OLANZAPINE LAI

Dosing and Administration1

Final olanzapine LAI Suspension Volume to Inject Dose (mg)

Final volume to inject (mL)

150

1.0

210

1.4

300

2.0

405

2.7

Olanzapine LAI should only be administered by deep intramuscular gluteal injection by a healthcare professional trained in the appropriate injection technique and in locations where post-injection observation and access to appropriate medical care in the case of overdose can be assured. If oral olanzapine supplementation is clinically indicated, then the combined total dose of olanzapine from both formulations should not exceed the corresponding maximum oral olanzapine dose of 20 mg/day.

53

OLANZAPINE LAI

Special Considerations1 Olanzapine LAI should not be used to treat patients with schizophrenia who are in acutely agitated or severely psychotic state such that immediate symptom control is warranted. Olanzapine LAI is contraindicated for patients with known risk of narrow-angle glaucoma. Olanzapine is not approved for treatment of dementia-related psychosis, and is not recommended for the treatment of Parkinson’s disease symptoms. Caution is advised when prescribing for patients with prostatic hypertrophy, paralytic ileus and related conditions, and low leukocyte and/or neutrophil counts. A lower starting dose of olanzapine should be considered in patients who are using fluvoxamine or any other CYP1A2 inhibitors, such as ciprofloxacin. A decrease in the dose of olanzapine should be considered if treatment with an inhibitor of CYP1A2 is initiated. In cases where hepatitis (including hepatocellular, cholestatic, or mixed liver injury) has been diagnosed, olanzapine treatment should be discontinued.

54

Time to Peak Plasma Concentration

Mean Elimination Half-Life

Time to Steady-State Concentration

% of Administered Dose Excreted as Unchanged Drug

CYP450 Enzymes Responsible for Biotransformation

15–45 min

30 days

After 5 months*

7%

CYP1A2, CYP2D6

OLANZAPINE LAI

Pharmacokinetics1

CYP450 = Cytochrome P450 *Steady-state is reached after 5 months, although steady-state like concentrations are reached much faster.

55

OLANZAPINE LAI

Pharmacokinetics in Special Populations1

Renal Impairment

CLcr (mL/min)

% Decrease in CLcr

Elimination T1/2 (Hours)

Increase in AUC

Mild Moderate

< 10 mL/min

No significant difference in renally impaired versus healthy subjects.

Dosing

A well-tolerated and effective dosage regimen using oral olanzapine should be established in patients before treatment with olanzapine LAI. A lower starting dose (150 mg every 4 weeks) should be considered.

Severe

CLcr = Creatinine Clearance, AUC = Area Under the Curve, T1/2 = Mean Elimination Half-Life Hepatic Impairment Transient, asymptomatic elevations of hepatic aminotransferases, ALT, and AST have been seen commonly, especially in early treatment. In cases of moderate hepatic insufficiency (cirrhosis, Child-Pugh class A or B), the starting dose should be 150 mg every 4 weeks and only increased with caution. Caution should be exercised and follow-up organized in patients with elevated ALT and/or AST, in patients: • with signs and symptoms of hepatic impairment • with pre-existing conditions associated with limited hepatic functional reserve • who are being treated with potentially hepatotoxic medicines

56

HIGH

5HT2A 5HT2C 5HT6 H1

0.1

1 High Affinity

LOW

Relative Binding Affinities D1 D2 D3 D4 D5 α1

M1 M2 M3 M4 M5

5HT1B 5HT7

α2 5HT3

10 Moderate Affinity

OLANZAPINE LAI

Pharmacodynamics1, 2, 3

100

1,000

Low Affinity

57

OLANZAPINE LAI

Efficacy1 Summary of Results for Efficacy in the Treatment of Schizophrenia Study

Doses Tested

Duration

Main Endpoints

Dose-related improvement

8 wks

PANSS

 405 mg, 300 mg, 210 mg vs. placebo

24 wks

Exacerbation of schizophrenia symptoms*, BPRS Positive Scale

 150, 300, 405 mg non-inferior to oral olanzapine 10, 15, and 20 mg pooled doses

405 mg/4 weeks Adult schizophrenia

Adult schizophrenia stabilized on oral olanzapine for 4-8 weeks

300 mg/2 weeks 210 mg/2 weeks 150 mg/2 weeks 300 mg/2 weeks 405 mg/4 weeks

*Exacerbation was measured by worsening of items on PANSS and BPRS Positive Scale, and hospitalization due to worsening of positive psychotic symptoms.

58

Post-injection syndrome reactions have occurred with olanzapine LAI leading to symptoms consistent with olanzapine overdose: • • • • • • • • •

OLANZAPINE LAI

Safety and Tolerability1

Sedation (mild to coma) Delirium (including confusion, disorientation, agitation, anxiety, and other cognitive impairment) Extrapyramidal symptoms Dysarthria Ataxia Aggression dizziness Weakness Hypertension Convulsion

In clinical trials, the incidence of injection site-related adverse reactions was approximately 8%. The most commonly reported injection site-related adverse reaction was pain (5%). Other adverse reactions observed in patients treated with olanzapine LAI were similar to those seen with oral olanzapine.

59

Switching from Oral Antipsychotics to Olanzapine LAI Target dose dose

OLANZAPINE LAI

Switching2

aripiprazole amisulpride olanzapine paliperidone ER

olanzapine LAI

1 week

1 week

dose

Target dose quetiapine clozapine

olanzapine LAI 1 week

dose

Target dose risperidone ziprasidone 1 week

60

olanzapine LAI 1 week

1 week

1 week

Immediate stop possible for aripiprazole, amisulpride, oral olanzapine, and paliperidone ER. Begin olanzapine LAI at equivalent oral olanzapine dose. Patients should be treated initially with oral olanzapine before administering olanzapine LAI to establish tolerability and response.

1. ZYPADHERA 210 mg, 300 mg, and 405 mg, powder and solvent for prolonged release suspension for injection, Summary of Product Characteristics, Eli Lilly and Company Ltd., July 2012.

OLANZAPINE LAI

References

2. Stahl SM. Stahl's Essential Psychopharmacology 3rd ed. 2008, Cambridge University Press, New York, pgs. 408–422, 431–436.

61

62

OLANZAPINE LAI

Paliperidone ER is an oral atypical antipsychotic agent indicated for*: 1. The treatment of schizophrenia in adults.

Mechanism of Action1, 2 The therapeutic activity of paliperidone ER is mediated through a combination of serotonin 5HT2A, 5HT7, dopamine D2, and α1-adrenergic receptor antagonism. Paliperidone ER also blocks, to a lesser extent, histamine H1 and α2adrenergic receptors.

PALIPERIDONE ER

Indications and Usage1

2. The treatment of psychotic or manic symptoms of schizoaffective disorder in adults. (The effect on depressive symptoms has not been demonstrated.)

*Licenses differ between countries. Please refer to local Product Information guides.

63

PALIPERIDONE ER

Dosing and Administration1 Initial Dose

Recommended Dose Range

Schizophrenia (Adults)

6 mg/day

3–12 mg/day

Acute Schizophrenia (Adults)*

9 mg/day

9–12 mg/day

Schizoaffective Disorder (Adults)

6 mg/day

6–12 mg/day * Based on clinical experience/trials.

64

TWO LASER-DRILLED DELIVERY ORIFICES DRUG COMPARTMENT 1

Invega uses OROS® technology to deliver paliperidone ER at a controlled rate via osmotic pressure.

PALIPERIDONE ER

Dosing and Titration3

DRUG COMPARTMENT 2 POLYMER ‘PUSH’ COMPARTMENT SEMIPERMEABLE MEMBRANE 1

In the gastrointestinal tract, osmotic pressure pulls water into the tablet core.

2

As water enters the core, it is absorbed by the push layer. The push layer expands, forcing INVEGA® from drug compartment 1 through the holes in the dome.

3

Over time, the push layer continues to expand. This expansion forces INVEGA® from drug compartment 2, providing continued release for up to 24 hours.

(1) In the gastrointestinal tract, the water-dispersible colour overcoat erodes quickly. (2) Water is then absorbed through the semipermeable membrane at a controlled rate, which then controls the rate of drug delivery. (3) The hydrophilic polymers of the core hydrate and swell, creating a gel containing paliperidone ER that is then pushed out through the tablet orifices.

65

Main plasma concentration (ng/mL)

PALIPERIDONE ER

Dosing and Titration4 60

INVEGA® (n=37)

Risperidone IR (n=37)

50 40 30 20 10 0 1

2

3

4 5 Time (days)

6

7

IR=immediate-release Reprinted from: Birnbaum M, Sharif Z. Medication adherence in schizophrenia: patient perspectives and the clinical utility of paliperidone ER. Patient Preference and Adherence 2008 2: 233–240. With permission from Dove Medical Press Ltd

66

The constant rate of release minimizes the fluctuations associated with immediaterelease second-generation antipsychotic agents.

Because the paliperidone ER tablet is non-deformable and does not change shape in the gastrointestinal tract, it should not ordinarily be administered to patients with preexisting severe gastrointestinal narrowing (pathologic or iatrogenic) or in patients with dysphagia or significant difficulty in swallowing tablets.

PALIPERIDONE ER

Special Considerations1

Antipsychotic medicinal products (including risperidone) with α-adrenergic blocking effects have been reported to induce priapism. Patients should be informed to seek urgent medical care in case that priapism has not been resolved within 3-4 hours. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency, or glucose-galactose malabsorption should not take this medicine. Caution is advised when prescribing with medicines known to prolong the QT interval, e.g., class IA antiarrhythmics (e.g., quinidine, disopyramide) and class III antiarrhythmics (e.g., amiodarone, sotalol), some antihistaminics, some other antipsychotics and some antimalarials (e.g., mefloquine). Paliperidone ER may induce orthostatic hypotension in some patients based on its alphablocking activity, and should be used with caution in patients with known cardiovascular disease (e.g., heart failure, myocardial infarction or ischaemia, conduction abnormalities), cerebrovascular disease, or conditions that predispose the patient to hypotension (e.g. dehydration and hypovolemia).

67

PALIPERIDONE ER

Pharmacokinetics1 Time to Peak Plasma Concentration (Hours)

Time to Steady-State Concentration (Days)

Mean Elimination Half-Life (Hours)

24

4–5

24

Oral Bioavailability

Bioavailability with Food

% of Administered Dose Excreted as Unchanged Drug

28%

42%

59%

CYP450 Enzymes Responsible for Biotransformation N/A CYP450 = Cytochrome P450

68

Renal Impairment

CLcr (mL/min)

% Decrease in CLcr

Elimination T1/2 (Hours)

Increase in AUC

Recommended Initial Dose (mg/day)

Maximum Recommended Dose (mg)

Mild

≥50 - 4 mg/day

37.5 mg/2 weeks

37.5 mg/2 weeks*

50 mg/2 weeks*

* Some patients may benefit from the higher doses of 37.5 or 50 mg/2 weeks. Upward dosage adjustment should not be made more frequently than every 4 weeks. No additional benefit was observed with 75 mg in clinical trials. The effect of dose adjustment should not be anticipated earlier than 3 weeks after the first injection with the higher dose. The main release of risperidone starts from Week 3 onwards, is maintained from 4-6 weeks, and subsides by Week 7. Therefore, sufficient antipsychotic coverage should be provided for the first 3-weeks.

122

Sufficient antipsychotic coverage with oral risperidone or the previous antipsychotic should be ensured during the three-week lag period following the first risperidone LAI injection. Risperidone LAI is not indicated for use in elderly patients with dementia.

RISPERIDONE LAI

Special Considerations1

Risperidone should be used cautiously in patients with a history of seizures or other conditions that potentially lower the seizure threshold. Priapism and orthostatic hypertension may occur with risperidone treatment due to its alpha-adrenergic blocking effects. Risperidone should be used with caution in patients with pre-existing hyperprolactinaemia and in patients with possible prolactin-dependent tumors. Carbamazepine, rifampicin, phenytoin, phenobarbital, and other medications that induce CYP3A4 hepatic enzyme have been shown to decrease the plasma concentrations of the active antipsychotic fraction of risperidone. When carbamazepine or other CYP3A4 hepatic enzyme/P-glycoprotein (P-gp) inducers are initiated or discontinued, the physician should re-evaluate the dosing of risperidone LAI. Fluoxetine and paroxetine, CYP2D6 inhibitors, increase the plasma concentration of risperidone, but less so of the active antipsychotic fraction. When concomitant fluoxetine, paroxetine, or other CYP2D6 inhibitors are initiated or discontinued, the physician should reevaluate the dosing of risperidone LAI.

123

RISPERIDONE LAI

Pharmacokinetics1

Time to Peak Plasma Concentration

Bioavailability

Mean Elimination Half-Life

Time to Steady-State Concentration

CYP450 Enzymes Responsible for Biotransformation

*

100%

3–6 days

8 weeks (after 4 injections)

CYP2D6 CYP450 = Cytochrome P450

*After a single intramuscular injection with risperidone LAI, the release profile consists of a small initial release of risperidone (