Why are anticholinergics used more often than Amantadine, for drug-induced Parkinsonism?

[Iparksiako]

What the title says.

Anticholinergics have a burden on memory, and cognition in general.

While amantadine doesn't seem to.

However, almost every psychiatrist I know, use anticholinergics to avoid extrapyramidal symptoms.

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[splik]

Because amantadine is not effective for drug-induced parkinsonism. BTW amantadine also has some anticholinergic action albeit less than things like benztropine and trihexyphenidyl. They should be used to treat these symptoms, not "avoid" or prevent them.

 

[Iparksiako]

Because amantadine is not effective for drug-induced parkinsonism. BTW amantadine also has some anticholinergic action albeit less than things like benztropine and trihexyphenidyl. They should be used to treat these symptoms, not "avoid" or prevent them.

Thanks for the answer.

Ah that explains why I never see it being used.

So amantadine has no role in psychiatry? It works best for Parkinsons disease?

 

[splik]

amantadine is not typically used to treat Parkinson's disease these days as there are many more effective meds. Most often in PD it is used to treat levodopa-induced dyskinesias. Sometimes amantadine is used in psychiatry to treat tardive dyskinesia though it isn't particularly effective there either. I often use amantadine to help with irritability/aggression in patients with traumatic brain injury, sometimes to help with attentional/executive dysfunction problems (usually not as good a psychostimulants), and we also use it as a 3rd line agent in the treatment of catatonia. So it does have some uses in psychiatry.

 

[Liquid8]

Sometimes amantadine is used in psychiatry to treat tardive dyskinesia though it isn't particularly effective there either.

Anyone had much success or experience with amantadine or tetrabenazine for TD? Am considering these options for one of my patients.

 

[mistafab]

The expensive -benazine drugs supposedly work for TD. I heard of two recent cases in our clinic where there were remarkable effects… and the patient could afford it. Not sure which part is more remarkable.

I hope to get some first hand experience on this.

 

[hallowmann]

The expensive -benazine drugs supposedly work for TD. I heard of two recent cases in our clinic where there were remarkable effects… and the patient could afford it. Not sure which part is more remarkable.

I hope to get some first hand experience on this.

They work. I saw a patient with severe TD, schizophrenia, as well as SUD and he would frequently be admitted in the setting of discontinuing his meds in part due to the TD. Multiple peer to peers later we finally got insurance to cover it and it helped a lot. Still had TD but a ton better and less hospitalizations (but not 0).

 

[deleted1100659]

The expensive -benazine drugs supposedly work for TD. I heard of two recent cases in our clinic where there were remarkable effects… and the patient could afford it. Not sure which part is more remarkable.

I hope to get some first hand experience on this.

this is a minsconception, about being able to obtain them. Ingrezza and austedo both have excellent patient support programs. If someone doesnt have insurance I can get them on it for free, and it gets delivered to their house. Now used to, when they first came out, totally different story.

I have very strong experience with ingrezza, and probably roughly 1/3 of my patients are on either ingrezza or austedo. If im picking between the two, i usually go with ingrezza though. Simple reason: if one of my patients had TD then its likely due to being heavily medicated most of their life. By then, giving specific instructions on titrations, verbal or written is not always useful. THOUGH, one thing I really like, on the sample pack of austedo the titration schedule is on the box for the patient. But, its taken BID, and in schizophrenia i prefer qd dosing.

If someone has TD that is impairing their ability to function, and they want help with it, these medications are strongly worth considering. It can change some people's lives. TD is really a miserable thing for a lot of people to deal with, and probably undertreated.

I dont like talking to reps half the times, but its worth reaching out to your local drug rep. The ingrezza rep here has been very useful getting people on the med.

 

[ObsequiousAplomb]

What the title says.

Anticholinergics have a burden on memory, and cognition in general.

While amantadine doesn't seem to.

However, almost every psychiatrist I know, use anticholinergics to avoid extrapyramidal symptoms.

From what I recall and have experienced, the blanket use of anticholinergics to avoid extrapyramidal symptoms actually increases the risk of EPS. I only use them for prophylaxis in limited situations:
- Very high risk demographics for acute dystonic reaction in patients requiring parenteral high-dose haloperidol / fluphenazine for whom there are no better options
- Patients who have a clear history of acute EPS with that particular antipsychotic and a history of poor response to alternative agents, and lowering the dose of that particular antipsychotic is contraindicated due to history and current symptoms

Otherwise, I just use Cogentin to treat acute dystonia and DIP that looks like fully syndromal Parkinsons (as opposed to DIP that has one or two symptoms). I haven't found it helpful at all for akathisia or TD.

If I'm giving parenteral APs to someone acutely agitated, I usually give Ativan with the AP and that seems to work just fine. I've given plenty of agitated people less than 5 mg of Haldol IM with nothing else and never seen acute EPS from that, either.

For patients in the state hospital setting that have been chronically taking Cogentin 2 QID with their AP and have what appears to be anticholinergic cognitive adverse effects I have switched them over to amantadine. None of them had major motor symptoms of EPS after the switch and all of them seemed to improve in cognition. I would never use amantadine for acute EPS or routine prophylaxis in all patients taking oral APs, but that's because I don't give anything for routine prophylaxis in all patients taking oral APs. I prefer to have the staff call me if they think someone needs an anticholinergic, since when I've written orders for PRN anticholinergics for dystonic reactions, the Cogentin ends up being given for any manner of non-EPS complaints.

In the outpatient setting, I don't routinely give prescriptions for Cogentin. I instruct them to call with a concern and take oral Benadryl en route to the ER if they have acute EPS. None of the patients have ever needed to do that.

While we're on the topic though, I see a lot of people giving Cogentin with Zyprexa. From what I understand Zyprexa is more anticholinergic than Cogentin. Does anybody have a good idea for why providers might be doing that? They tend to be IP providers that are never available when I try to contact them. If there's something they know that I don't I'd like to learn it.

 

[Stagg737]

amantadine is not typically used to treat Parkinson's disease these days as there are many more effective meds. Most often in PD it is used to treat levodopa-induced dyskinesias. Sometimes amantadine is used in psychiatry to treat tardive dyskinesia though it isn't particularly effective there either. I often use amantadine to help with irritability/aggression in patients with traumatic brain injury, sometimes to help with attentional/executive dysfunction problems (usually not as good a psychostimulants), and we also use it as a 3rd line agent in the treatment of catatonia. So it does have some uses in psychiatry.

Interesting, I've never used amantadine for catatonia or even really thought about it. If we're getting to 3rd/4th line options we usually just get them into ECT. Strangely, one of the insurance companies here now requires patients to have a trial of Amantadine for AD before they'll cover benztropine. We're all baffled by this logic, but it seems to be effective for the people we've had to switch to amantadine.

this is a minsconception, about being able to obtain them. Ingrezza and austedo both have excellent patient support programs. If someone doesnt have insurance I can get them on it for free, and it gets delivered to their house. Now used to, when they first came out, totally different story.

I have very strong experience with ingrezza, and probably roughly 1/3 of my patients are on either ingrezza or austedo. If im picking between the two, i usually go with ingrezza though. Simple reason: if one of my patients had TD then its likely due to being heavily medicated most of their life. By then, giving specific instructions on titrations, verbal or written is not always useful. THOUGH, one thing I really like, on the sample pack of austedo the titration schedule is on the box for the patient. But, its taken BID, and in schizophrenia i prefer qd dosing.

If someone has TD that is impairing their ability to function, and they want help with it, these medications are strongly worth considering. It can change some people's lives. TD is really a miserable thing for a lot of people to deal with, and probably undertreated.

I dont like talking to reps half the times, but its worth reaching out to your local drug rep. The ingrezza rep here has been very useful getting people on the med.

Interesting, is this because you have a significant supply of samples, or are there other programs for non-insured patients? I agree that it's worth a try for the right people, even with the relatively low percentage of people seeing a clinical difference in the original studies. I've had a couple patients where the results were pretty incredible and really allowed them to become functional again.

+1 for the Ingrezza reps as well. I've actually talked to quite a few reps through our CMHC clinic and in med school, and the Ingrezza and Belsomra reps were always really good, informative and knowledgeable but not pushy. I also like Ingrezza because I have a high number of patients with liver problems, which makes Austedo a no-go.

Anyone had much success or experience with amantadine or tetrabenazine for TD? Am considering these options for one of my patients.

The expensive -benazine drugs supposedly work for TD. I heard of two recent cases in our clinic where there were remarkable effects… and the patient could afford it. Not sure which part is more remarkable.

I hope to get some first hand experience on this.

They can be hit or miss, but when they work the results can be dramatic. I don't prescribe them in patients with mild TD, but if they have significant symptoms and are really distressed about them, imo they're worth a try. Biggest responses I've had were a couple of people through the VA whose AIMS went from ~20 to low single digits on tetra/deutetrabenazine. I've also had a bunch of patients who saw no benefit at all.

 

[deleted1100659]

Interesting, I've never used amantadine for catatonia or even really thought about it. If we're getting to 3rd/4th line options we usually just get them into ECT. Strangely, one of the insurance companies here now requires patients to have a trial of Amantadine for AD before they'll cover benztropine. We're all baffled by this logic, but it seems to be effective for the people we've had to switch to amantadine.



Interesting, is this because you have a significant supply of samples, or are there other programs for non-insured patients? I agree that it's worth a try for the right people, even with the relatively low percentage of people seeing a clinical difference in the original studies. I've had a couple patients where the results were pretty incredible and really allowed them to become functional again.

+1 for the Ingrezza reps as well. I've actually talked to quite a few reps through our CMHC clinic and in med school, and the Ingrezza and Belsomra reps were always really good, informative and knowledgeable but not pushy. I also like Ingrezza because I have a high number of patients with liver problems, which makes Austedo a no-go.




They can be hit or miss, but when they work the results can be dramatic. I don't prescribe them in patients with mild TD, but if they have significant symptoms and are really distressed about them, imo they're worth a try. Biggest responses I've had were a couple of people through the VA whose AIMS went from ~20 to low single digits on tetra/deutetrabenazine. I've also had a bunch of patients who saw no benefit at all.

For newer medications, its better that the patient doesnt have any insurance, rather than crappy commerical or medicaid. If you have no insurance/low income/no income ingrezza, trintellix, vraylar, etc all have patient support programs. You fill out the form, put in proof of income, and they delivery monthly supplies right to the patient door. Never had issues with vraylar or ingrezza but trintellix patient support program gave me headaches more than a few times. I usually just give 30 day supply of samples in meantime, but once theyre on the support program they get it for free indefinitely and its actual prescriptions. You just have to ensure you send it to the right specialty pharmacy (which is where the drug rep comes in handy).

Now if you dont have nurse support or other staff, filling out these forms isnt exactly fun, lol. Luckily I have a LPN who assists me with this.

Lybalvi ive had zero luck with them. Caplyta I only have person on it, somehow shes getting it for free delivered, and she has commercial. Not sure how we pulled that off, maybe due to her income.

But yeah its very interesting because like you said, the studies would make someone think they're of minor benefit. In reality they work wonders for some people.