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Selected Works of Kevin J. Black, MD
Unpublished Paper
Guidance for Switching from Off-Label Antipsychotics to Pimavanserin for Parkinson’s Disease Psychosis: An Expert Consensus
(2018)
  • Kevin J Black, Washington University in St. Louis
  • Henry Nasrallah, Saint Louis University
  • Stuart Isaacson, Parkinson’s Disease and Movement Disorders Center of Boca Raton
  • Mark Stacy, Brody School of Medicine, East Carolina University
  • Rajesh Pahwa, University of Kansas Medical Center
  • Charles H Adler, Mayo Clinic College of Medicine, Scottsdale, AZ
  • Gustavo Alva, University of California, Riverside
  • Jeffrey W Cooney, Duke University School of Medicine
  • Daniel Kremens, Sidney Kimmel Medical School at Jefferson University
  • Matthew A Menza, Rutgers Robert Wood Johnson Medical School
  • Jonathan M Meyer, University of California, San Diego
  • Ashwin A Patkar, Duke University Medical Center
  • Tanya Simuni, Northwestern University Feinberg School of Medicine
  • Debbi A Morrissette, Neuroscience Education Institute, Carlsbad, CA
  • Stephen Stahl, Neuroscience Education Institute, Carlsbad, CA
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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/complications,
  • Psychotic Disorders/therapy,
  • Antipsychotic Agents,
  • pimavanserin
Disciplines
Publication Date
July 21, 2018
Comments
When posted here, this was a submitted manuscript under review at CNS Spectrums that had not been accepted for publication. It has since been accepted for publication, and the final version appears at https://doi.org/10.1017/S1092852918001359 .
A read-only, full-text version of the article is provided by the publisher at the following URL: http://bit.ly/2BWRCPG
Citation Information
Kevin J Black, Henry Nasrallah, Stuart Isaacson, Mark Stacy, et al.. "Guidance for Switching from Off-Label Antipsychotics to Pimavanserin for Parkinson’s Disease Psychosis: An Expert Consensus" (2018)
Available at: http://works.bepress.com/kjb/68/
Creative Commons License
Creative Commons License
This work is licensed under a Creative Commons CC_BY International License.