Objective: We describe a single-center cohort of Parkinson patients in crisis with troublesome psychosis unresponsive to quetiapine and pimavanserin, who were rescued by treatment with clozapine.
Background: Troublesome hallucinations, delusions, paranoia, and impulsivity can prevent Lewy-body and Parkinson-dementia patients from living safely at home. Quetiapine and pimavanserin are typically used as first-line agents as they do not require blood monitoring. If they fail to control symptoms, patients and families face a crisis—unless neurobehavioral symptoms can be controlled, patients may require placement in a care facility.
Method: Retrospective, single-center, review of 26 patients with Parkinson’s disease with troublesome psychosis unresponsive to quetiapine and pimavanserin, treated with clozapine over six years.
Results: Prior to treatment with clozapine, 25 patients (96%) had agitation, 23 (88%) insomnia, and 14 (54%) aggression. 25 (96%) tried and failed quetiapine, and 7 (27%) tried and failed pimavanserin at therapeutic doses. Clozapine was titrated slowly to achieve control of psychosis or troublesome behaviors. Doses were typically small: 25mg (31%), 50mg (23%), 37.5mg (19%), 75mg (8%), 100mg (8%), 25mg twice daily (4%), 62.5mg (4%), and one patient with high dose (200mg in the morning and 300mg at night) (4%). Clozapine was begun at 12.5mg qhs, with weekly 12.5mg increase as needed for symptomatic control. Out of the symptomatic patients, 4 (15%) experienced full resolution of hallucinations, 20 (77%) relief of bothersome hallucinations, 17 (74%) subjective improvement in sleep, 18 (72%) improvement in agitation, and 9 (64%) improvement in aggression. Twenty (77%) patients were able to remain at home with their families. Six (23%) discontinued clozapine due to burden of monitoring, constipation (4%), hospitalist non-preference (4%), end of life transition (8%), or patient decision (4%). One patient (4%) experienced agranulocytosis which resolved when the drug was stopped.
Conclusion: Disinhibited behaviors, delusions and psychosis may prevent Parkinson patients from remaining at home with their families. Our real-world, single-center, practical experience suggests that clozapine is a unique drug, one that keeps patients out of nursing facilities when quetiapine and pimavanserin fail.
To cite this abstract in AMA style:J. Iseringhausen, G. Riboldi, K. Astudillo, S. Frucht. Keeping patients out of care facilities— clozapine rescues Parkinson’s patients with troublesome psychosis unresponsive to quetiapine and pimavanserin. [abstract]. Mov Disord. 2023; 38 (suppl 1). https://www.mdsabstracts.org/abstract/keeping-patients-out-of-care-facilities-clozapine-rescues-parkinsons-patients-with-troublesome-psychosis-unresponsive-to-quetiapine-and-pimavanserin/. Accessed September 22, 2023.
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MDS Abstracts - https://www.mdsabstracts.org/abstract/keeping-patients-out-of-care-facilities-clozapine-rescues-parkinsons-patients-with-troublesome-psychosis-unresponsive-to-quetiapine-and-pimavanserin/