[Antipsychotic prescribing in adults : what to watch out for ?] / Prescription d'antipsychotiques chez les adultes : à quoi faut-il être attentif ?

Antipsychotics are known to produce frequent and/or potentially serious adverse effects, including neurological, cardiovascular, metabolic and endocrine effects. The side-effects of antipsychotics vary according to their affinity for different central and peripheral receptors, and individual vulnerabilities. Some of these side-effects are dose-dependent, while others are little or not ; thus, management strategies need to be adapted. Good management of adverse events is important to encourage patients' medication adherence and to reduce the cardiovascular morbidity and mortality of side effects. Good collaboration between psychiatrists and general practitioners or specialists is essential.

Les antipsychotiques sont connus pour engendrer des effets indésirables fréquents et/ou potentiellement graves, notamment neurologiques, cardiovasculaires, métaboliques et endocriniens. Les effets secondaires des antipsychotiques varient selon leur profil d'affinités pour les différents récepteurs cérébraux et périphériques et selon les vulnérabilités individuelles. Certains d'entre eux sont dose-dépendants, d'autres peu ou pas ; les stratégies de prise en charge sont donc à adapter. Une bonne gestion des effets indésirables est importante pour favoriser l'adhésion médicamenteuse des patients et atténuer leur impact en termes de morbimortalité. Une bonne collaboration entre médecins psychiatres et généralistes ou spécialistes est nécessaire.

Insomnia disorders are associated with increased cardiometabolic disturbances and death risks from cardiovascular diseases in psychiatric patients treated with weight-gain-inducing psychotropic drugs: results from a Swiss cohort.

STUDY OBJECTIVES: Insomnia disorders as well as cardiometabolic disorders are highly prevalent in the psychiatric population compared to the general population. We aimed to investigate their association and evolution over time in a Swiss psychiatric cohort. METHODS: Data for 2861 patients (8954 observations) were obtained from two prospective cohorts (PsyMetab and PsyClin) with metabolic parameters monitored routinely during psychotropic treatment. Insomnia disorders were based on the presence of ICD-10 "F51.0" diagnosis (non-organic insomnia), the prescription of sedatives before bedtime or the discharge letter. Metabolic syndrome was defined using the International Diabetes Federation definition, while the 10-year risk of cardiovascular event or death was assessed using the Framingham Risk Score and the Systematic Coronary Risk Estimation, respectively. RESULTS: Insomnia disorders were observed in 30% of the cohort, who were older, predominantly female, used more psychotropic drugs carrying risk of high weight gain (olanzapine, clozapine, valproate) and were more prone to suffer from schizoaffective or bipolar disorders. Multivariate analyses showed that patients with high body mass index (OR = 2.02, 95%CI [1.51-2.72] for each ten-kg/m2 increase), central obesity (OR = 2.20, [1.63-2.96]), hypertension (OR = 1.86, [1.23-2.81]), hyperglycemia (OR = 3.70, [2.16-6.33]), high density lipoprotein hypocholesterolemia in women (OR = 1.51, [1.17-1.95]), metabolic syndrome (OR = 1.84, [1.16-2.92]) and higher 10-year risk of death from cardiovascular diseases (OR = 1.34, [1.17-1.53]) were more likely to have insomnia disorders. Time and insomnia disorders were associated with a deterioration of cardiometabolic parameters. CONCLUSIONS: Insomnia disorders are significantly associated with metabolic worsening and risk of death from cardiovascular diseases in psychiatric patients.

[Treatment of insomnia, with what to start ?] / Traitement de l'insomnie, par quoi commencer ?

Confronted with a complaint of insomnia, several points must be considered before prescribing a specific treatment. In particular, it is necessary to optimize the management of somatic and psychiatric comorbidities that can affect sleep and to review the intake of sleep-disrupting substances and drugs. The current guidelines for insomnia rank treatment options based on the quality of the evidence. They all agree to recommend cognitive behavioural therapy for insomnia as first-line treatment. Pharmacological treatment should only be considered if this therapy fails. We then propose to start with the drugs presenting the best safety profile before prescribing, if necessary, those having better effectiveness evidence but carrying a greater risk of side effects.

Face à une plainte d'insomnie, plusieurs points sont à prendre en compte avant d'envisager un traitement spécifique, notamment l'optimisation de la prise en charge des comorbidités somatiques et psychiatriques pouvant péjorer le sommeil et la revue de la prise de substances et médicaments le perturbant. Les recommandations sur l'insomnie classent les options thérapeutiques selon la qualité des études à disposition. Elles s'accordent toutes à recommander la thérapie cognitivo-comportementale spécifique pour l'insomnie en première intention. Un traitement pharmacologique ne devrait être envisagé qu'en cas d'échec de cette thérapie. Nous proposons alors de débuter avec les molécules présentant le meilleur profil de sécurité avant de passer, si nécessaire, à celles ayant mieux démontré leur efficacité mais comportant un plus grand risque d'effets secondaires.

[Gabapentinoids : misuses and addictions]. / Gabapentinoïdes : mésusages et addictions.

Cases of addictions and misuses on gabapentinoids are increasingly reported. But the underlying pharmacological mechanism is not completely understood. Here is an uptodate of the current knowledges on this dependence and its management.

Des cas de mésusages et d'addictions aux gabapentinoïdes sont de plus en plus fréquemment rapportés, sans que le mécanisme pharmacologique sous-jacent ne soit complètement compris. Nous faisons un état des lieux des connaissances sur cette dépendance et sa prise en charge.

[Recommendations for management of misuses and addictions to benzodiazepines]. / Recommandations de prise en charge des mésusages et addictions aux benzodiazepines.

The management of patients who have become dependent on benzodiazepines and analogues is a problem frequently encountered in both somatic and psychiatric medicine. No pharmacological treatment is currently recognized as effective in the management of these addictions, apart from a gradual reduction of doses. We propose practical strategies for the implementation of gradual dose reduction and choice of molecules while promoting individual adaptation to the withdrawal symptoms presented by the patient.

La prise en charge de patients ayant développé une dépendance aux benzodiazépines et analogues est une problématique rencontrée fréquemment tant en médecine somatique que psychiatrique. Aucun traitement pharmacologique n'est actuellement reconnu comme efficace dans la prise en charge de ces dépendances, en dehors d'une réduction progressive des doses. Nous proposons des stratégies pratiques de mise en œuvre de réduction progressive des doses et de choix de molécules tout en favorisant une adaptation individuelle aux symptômes de sevrage présentés par le patient.

[Rapid tranquilisation in adults†: algorithm proposed for psychopharmacological treatment]. / Agitation aiguë chez l'adulte†: proposition d'un algorithme de traitement psychopharmacologique.

Acute treatment of agitation in psychiatry is one of the urgent situations for which management recommendations are needed. Various existing international recommendations have been evaluated and adapted to our clinical practice and to the drugs available in Switzerland in order to propose a uniform management strategy in our hospital. This strategy includes a treatment choice algorithm with different options depending on the clinical situation and the possible route of administration. Dose recommendations for the oral and intramuscular routes, certain pharmacokinetic parameters, as well as risks of interactions and important warnings are also included in this clinical recommendation.

Le traitement aigu de l'agitation en psychiatrie fait partie des situations urgentes pour lesquelles des recommandations de prise en charge sont nécessaires. Diverses recommandations internationales existantes ont été évaluées et adaptées à notre pratique clinique ainsi qu'aux médicaments disponibles en Suisse afin de proposer une stratégie de prise en charge uniformisée au sein de notre hôpital. Cette stratégie inclut un algorithme de choix de traitement avec différentes options selon la situation clinique et la voie d'administration possible. Des recommandations de doses pour les voies orale et intramusculaire, certains paramètres pharmacocinétiques, ainsi que les risques d'interactions et des mises en garde importantes figurent également dans cette recommandation clinique.

Associations Between High Plasma Methylxanthine Levels, Sleep Disorders and Polygenic Risk Scores of Caffeine Consumption or Sleep Duration in a Swiss Psychiatric Cohort.

Objective: We first sought to examine the relationship between plasma levels of methylxanthines (caffeine and its metabolites) and sleep disorders, and secondarily between polygenic risk scores (PRS) of caffeine consumption or sleep duration with methylxanthine plasma levels and/or sleep disorders in a psychiatric cohort. Methods: Plasma levels of methylxanthines were quantified by ultra-high performance liquid chromatography/tandem mass spectrometry. In inpatients, sleep disorder diagnosis was defined using ICD-10 "F51.0," sedative drug intake before bedtime, or hospital discharge letters, while a subgroup of sedative drugs was used for outpatients. The PRS of coffee consumption and sleep duration were constructed using publicly available GWAS results from the UKBiobank. Results: 1,747 observations (1,060 patients) were included (50.3% of observations with sleep disorders). Multivariate analyses adjusted for age, sex, body mass index, setting of care and psychiatric diagnoses showed that patients in the highest decile of plasma levels of methylxanthines had more than double the risk for sleep disorders compared to the lowest decile (OR = 2.13, p = 0.004). PRS of caffeine consumption was associated with plasma levels of caffeine, paraxanthine, theophylline and with their sum (ß = 0.1; 0.11; 0.09; and 0.1, pcorrected = 0.01; 0.02; 0.02; and 0.01, respectively) but not with sleep disorders. A trend was found between the PRS of sleep duration and paraxanthine levels (ß = 0.13, pcorrected = 0.09). Discussion: Very high caffeine consumption is associated with sleep disorders in psychiatric in- and outpatients. Future prospective studies should aim to determine the benefit of reducing caffeine consumption in high caffeine-consuming patients suffering from sleep disorders.