Guidance for switching from off-label antipsychotics to pimavanserin for Parkinson's disease psychosis: an expert consensus.
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.
Type
Journal articleSubject
HumansParkinson Disease
Urea
Piperidines
Antiparkinson Agents
Antipsychotic Agents
Consensus
Psychotic Disorders
Practice Guidelines as Topic
Off-Label Use
Drug Substitution
Serotonin 5-HT2 Receptor Antagonists
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https://hdl.handle.net/10161/21261Published Version (Please cite this version)
10.1017/s1092852918001359Publication Info
Black, 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.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Jeffrey W Cooney
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
Ashwin Anand Patkar
Professor of Psychiatry and Behavioral Sciences
Mark Allen Stacy
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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