Guidance for switching from off-label antipsychotics to pimavanserin for Parkinson's disease psychosis: an expert consensus.
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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.
Practice Guidelines as Topic
Serotonin 5-HT2 Receptor Antagonists
Published Version (Please cite this version)10.1017/s1092852918001359
Publication InfoBlack, Kevin J; Nasrallah, Henry; Isaacson, Stuart; Stacy, Mark; Pahwa, Rajesh; Adler, Charles H; ... Stahl, Stephen M (2018). Guidance for switching from off-label antipsychotics to pimavanserin for Parkinson's disease psychosis: an expert consensus. CNS spectrums, 23(6). pp. 402-413. 10.1017/s1092852918001359. Retrieved from https://hdl.handle.net/10161/21261.
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Assistant Professor of Neurology
I see patients with a broad range of movement disorders, including Parkinson's disease, tremors, ataxia, dystonia, tics, and Huntington's disease. I employ deep brain stimulation (DBS) therapy for selected patients with Parkinson's disease, tremor, or dystonia, and use botulinum toxin injections for certain patients with dystonia, tremors, or tics. I work with an interdisciplinary team of physicians, therapists, and other healthcare providers, with the overall goal of helping to improve the live
Professor of Psychiatry and Behavioral Sciences
Professor of Neurology
Mark Stacy has clinical trial efforts concentrated on Neuroprotective and Neuro-regenerative therapies in PD, and developing biomarkers for early diagnosis in PD. He has extensive experience with Glial Derived Neurotrophic Factor (GDNF), neuroimmunophyllins (GPI-1046, AMG-474), jnk inhibitors (CEP-1347, TCH-346), and viral vectors (Ceregene). His independent research interests in Parkinson’s disease include motor and non-motor symptoms of wearing off, and pathological gambling and oth
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