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Guidance for switching from off-label antipsychotics to pimavanserin for Parkinson’s disease psychosis: an expert consensus

Published online by Cambridge University Press:  27 December 2018

Kevin J. Black Open the ORCID record for Kevin J. Black [Opens in a new window] ,
Henry Nasrallah Open the ORCID record for Henry Nasrallah [Opens in a new window] ,
Stuart Isaacson ,
Mark Stacy ,
Rajesh Pahwa ,
Charles H. Adler ,
Gustavo Alva ,
Jeffrey W. Cooney ,
Daniel Kremens  and
Matthew A. Menza
...Show all authors
Kevin J. Black*
Affiliation:
Departments of Psychiatry, Neurology, Radiology, and Neuroscience, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
Henry Nasrallah
Affiliation:
Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St. Louis, Missouri, USA
Stuart Isaacson
Affiliation:
Parkinson’s Disease and Movement Disorders Center of Boca Raton, Boca Raton, Florida, USA
Mark Stacy
Affiliation:
Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
Rajesh Pahwa
Affiliation:
Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
Charles H. Adler
Affiliation:
Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, Arizona, USA
Gustavo Alva
Affiliation:
Department of Psychiatry and Neuroscience, University of California, Riverside, Riverside, California, USA ATP Clinical Research, Costa Mesa, California, USA
Jeffrey W. Cooney
Affiliation:
Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
Daniel Kremens
Affiliation:
Comprehensive Parkinson’s Disease and Movement Disorders Center at the Vickie and Jack Farber Center for Neurosciences at the Sidney Kimmel Medical School at Jefferson University, Philadelphia, Philadelphia, USA
Matthew A. Menza
Affiliation:
Department of Psychiatry, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
Jonathan M. Meyer
Affiliation:
California Department of State Hospitals, Sacramento, California, USA Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
Ashwin A. Patkar
Affiliation:
Department of Psychiatry & Community and Family Medicine, Duke University Medical Center, Durham, North Carolina, USA
Tanya Simuni
Affiliation:
Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
Debbi A. Morrissette
Affiliation:
Neuroscience Education Institute, Carlsbad, California, USA
Stephen M. Stahl
Affiliation:
Department of Psychiatry, University of California, San Diego, La Jolla, California, USA Neuroscience Education Institute, Carlsbad, California, USA
*
*Address for correspondence: Kevin J. Black, MD, Campus Box 8134, 660 S. Euclid Ave., St. Louis, MO 63110-1093, USA. (Email: kevin@wustl.edu)
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Abstract

Patients with Parkinson’s disease psychosis (PDP) are often treated with an atypical antipsychotic, especially quetiapine or clozapine, but side effects, lack of sufficient efficacy, or both may motivate a switch to pimavanserin, the first medication approved for management of PDP. How best to implement a switch to pimavanserin has not been clear, as there are no controlled trials or case series in the literature to provide guidance. An abrupt switch may interrupt partially effective treatment or potentially trigger rebound effects from antipsychotic withdrawal, whereas cross-taper involves potential drug interactions. A panel of experts drew from published data, their experience treating PDP, lessons from switching antipsychotic drugs in other populations, and the pharmacology of the relevant drugs, to establish consensus recommendations. The panel concluded that patients with PDP can be safely and effectively switched from atypical antipsychotics used off label in PDP to the recently approved pimavanserin by considering each agent’s pharmacokinetics and pharmacodynamics, receptor interactions, and the clinical reason for switching (efficacy or adverse events). Final recommendations are that such a switch should aim to maintain adequate 5-HT2A antagonism during the switch, thus providing a stable transition so that efficacy is maintained. Specifically, the consensus recommendation is to add pimavanserin at the full recommended daily dose (34 mg) for 2–6 weeks in most patients before beginning to taper and discontinue quetiapine or clozapine over several days to weeks. Further details are provided for this recommendation, as well as for special clinical circumstances where switching may need to proceed more rapidly.

Keywords

Parkinson Disease:complicationspsychotic disorders:therapyantipsychotic agentspimavanserin
Type
Guidelines
Information
CNS Spectrums , Volume 23 , Special Issue 6: Theme: Neuropsychiatry , December 2018 , pp. 402 - 413
Copyright
© Cambridge University Press 2018 

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Footnotes

Previous errors have been corrected. See doi: 10.1017/S1092852919000932.

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