Perphenazine

Perphenazine

Systematic (IUPAC) name
2-[4-[3-(2-chloro-10H-phenothiazin-10-yl) propyl]piperazin-1-yl]ethanol
Clinical data
AHFS/Drugs.com	monograph
MedlinePlus	a682165
Pregnancy cat.	C(AU) C(US)
Legal status	POM (UK) ℞-only (US)
Routes	oral and i.m.
Pharmacokinetic data
Bioavailability	40%
Metabolism	hepatic
Half-life	8-12 (up to 20) hours
Excretion	biliar
Identifiers
CAS number	58-39-9 Y
ATC code	N05AB03
PubChem	CID 4748
IUPHAR ligand	209
DrugBank	DB00850
ChemSpider	4586 Y
UNII	FTA7XXY4EZ Y
KEGG	D00503 Y
ChEBI	CHEBI:8028 N
ChEMBL	CHEMBL567 Y
Chemical data
Formula	C21H26ClN3OS
Mol. mass	403.97
SMILES	eMolecules & PubChem
InChI InChI=1S/C21H26ClN3OS/c22-17-6-7-21-19(16-17)25(18-4-1-2-5-20(18)27-21)9-3-8-23-10-12-24(13-11-23)14-15-26/h1-2,4-7,16,26H,3,8-15H2 Y Key:RGCVKNLCSQQDEP-UHFFFAOYSA-N Y
N(what is this?)  (verify)

Perphenazine is a typical antipsychotic drug. Chemically, it is classified as a piperazinyl phenothiazine. It has been in clinical use for decades.

Perphenazine is roughly five times as potent as chlorpromazine;^[1] thus perphenazine is considered a medium-potency antipsychotic.^[2][3]

Pharmacokinetics

It has an oral bioavailability of approximately 40% and a half-life of 8 to 12 hours (up to 20 hours), and is usually given in 2 or 3 divided doses each day. It is possible to give two-thirds of the daily dose at bedtime and one-third during breakfast to maximize hypnotic activity during the night and to minimize daytime sedation and hypotension without loss of therapeutic activity.

Uses

Perphenazine is used to treat psychosis (e.g. in schizophrenics) and the manic phases of bipolar disorder. Perphenazine effectively treats the positive symptoms of schizophrenia, such as hallucinations and delusions, but its effectiveness in treating the negative symptoms of schizophrenia, such as flattened affect and poverty of speech, is unclear. Earlier studies found the typical antipsychotics to be ineffective or poorly effective in the treatment of negative symptoms,^[4] but two recent, large-scale studies found no difference between perphenazine and the atypical antipsychotics.^[5]

In low doses it is used to treat agitated depression (together with an antidepressant). Fixed combinations of perphenazine and the tricyclic antidepressant amitriptyline in different proportions of weight exist (see Etrafon below). When treating depression, perphenazine is discontinued as fast as the clinical situation allows.^{[citation needed]} Perphenazine has no intrinsic antidepressive activity. Several studies show that the use of perphenazine with fluoxetine (Prozac) in patients with psychotic depression is most promising, although fluoxetine interferes with the metabolism of perphenazine, causing higher plasma levels of perphenazine and a longer half-life. In this combination the strong antiemetic action of perphenazine attenuates fluoxetine-induced nausea and vomiting (emesis), as well as the initial agitation caused by fluoxetine. Both actions can be helpful for many patients.

Perphenazine has been used in low doses as a 'normal' or 'minor' tranquilizer in patients with a known history of addiction to drugs or alcohol, a practice which is now strongly discouraged.^{[6][citation needed]}

Perphenazine has sedating and anxiolytic properties, making the drug useful for the treatment of agitated psychotic patients and, in high doses (up to 100 mg per day), for patients with life-threatening (febrile) catatonia, a state in which the patients are extremely agitated, but unable to express themselves. In this situation perphenazine may be used together with electroconvulsive therapy and correction of electrolytes and fluids in the body.

A valuable off-label indication is the short-time treatment of hyperemesis gravidarum, in which pregnant women experience violent nausea and vomiting. This problem can become severe enough to endanger the life of the unborn. As perphenazine has not been shown to be teratogenic and works very well, it is sometimes given orally in the smallest possible dose.

Side effects

As a member of the phenothiazine type of antipsychotics, perphenazine shares in general all allergic and toxic side-effects of chlorpromazine. A 2005 systematic review of the data on perphenazine conducted by the Cochrane Collaboration concluded that "there were no convincing differences between perphenazine and other antipsychotics" in the incidence of adverse effects.^[7] Perphenazine causes early and late extrapyramidal side effects more often than placebo, and at a similar rate to other medium-potency antipsychotics^[8] and the atypical antipsychotic risperidone.^[9][10]

When used for its strong antiemetic or antivertignosic effects in cases with associated brain injuries, it may obscure the clinical course and interferes with the diagnosis. High doses of perphenazine can cause temporary dyskinesia. As with other typical antipsychotics, permanent or lasting tardive dyskinesia is a risk.

Similarly to other potent antipsychotics, long-term use has been associated with cognitive decline and permanent brain damage.^[11]

Formulations

It is sold under the brand names Trilafon (single drug) and Etrafon/Triavail (contains fixed dosages of amitriptyline). A brand name in Europe is Decentan pointing to the fact that perphenazine is approximately 5-times more potent than chlorpromazine. Usual oral forms are tablets (2, 4, 8, 16 mg) and liquid concentrate (4 mg/ml).

The 'Perphenazine injectable USP' solution is intended for deep intramuscular (i.m.) injection, for patients who are not willing to take oral medication or if the patient is unable to swallow. Due to a better bioavailability of the injection, two-thirds of the original oral dose is sufficient. The incidence of hypotension, sedation and extrapyramidal side-effects may be higher compared to oral treatment. The i.m.-injections are appropriate for a few days, but oral treatment should start as soon as possible.

In many countries, depot forms of perphenazine exist (as perphenazine enanthate). One injection works for 1 to 4 weeks depending on the dose of the depot-injection. Depot-forms of perphenazine should not be used during the initial phase of treatment as the rare neuroleptic malignant syndrome may become more severe and uncontrollable with this form. Extrapyramidal side-effects may be somewhat reduced due to constant plasma-levels during depot-therapy. Also, patient compliance is sure, as many patients do not take their oral mediaction, particularly if feeling better once improvement in psychosis is achieved.

Interactions

Fluoxetine causes higher plasma-levels and a longer half-life of perphenazine, therefore a dose reduction of perphenazine might be necessary.

Perphenazine intensifies the central depressive action of drugs with such activity (tranquilizers, hypnotics, narcotics, antihistaminics, OTC-antiemetics etc.). A dose reduction of perphenazine or the other drug may be necessary.

The antihelmintic drug piperazine may intensify extrapyramidal side-effects. Avoid the concomitant use. Also, neurotoxic side-effects of the antibiotic streptomycin as well as of other aminoglycosids on the VIII. Brain nerve may be masked due to the strong antivertignosic effect of perphenazine. Avoid the concomitant use, too.

In general, all neuroleptics may lead to seizures in combination with the opioid tramadol (Ultram).

Perphenazine may increase the insulin needs of diabetic patients. Monitor blood glucose levels of insulin-dependent patients regularly during long-term treatment.

References

1. ^ Rees L (August 1960). "Chlorpromazine and allied phenothiazine derivatives". British Medical Journal 2 (5197): 522–5. doi:10.1136/bmj.2.5197.522. PMC 2097091. PMID 14436902. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2097091. Retrieved 2009-06-22. 
2. ^ Ascher-Svanum H, Zhu B, Faries D, Landbloom R, Swartz M, Swanson J (2006). "Time to discontinuation of atypical versus typical antipsychotics in the naturalistic treatment of schizophrenia". BMC Psychiatry 6: 8. doi:10.1186/1471-244X-6-8. PMC 1402287. PMID 16504026. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1402287. Retrieved 2009-06-22. 
3. ^ Freudenreich, Oliver (2007). "Treatment of psychotic disorders". Psychotic disorders. Practical Guides in Psychiatry. Lippincott Williams & Wilkins. p. 88. ISBN 978-0-7817-8543-3. http://books.google.co.uk/books?id=Y58hbZN-lZYC&pg=PA88&lpg=PA88&dq=perphenazine+eps+medium+potency&source=bl&ots=XCuOf1Zymn&sig=bZt_mF9cTFQn3U5-li2mCKloiOY&hl=en&ei=YN4_SrapC4S5jAer0rwH&sa=X&oi=book_result&ct=result&resnum=4. Retrieved 2009-06-22. 
4. ^ King DJ (February 1998). "Drug treatment of the negative symptoms of schizophrenia". European Neuropsychopharmacology : the Journal of the European College of Neuropsychopharmacology 8 (1): 33–42. doi:10.1016/S0924-977X(97)00041-2. PMID 9452938. 
5. ^ Lieberman JA (October 2006). "Comparative effectiveness of antipsychotic drugs. A commentary on: Cost Utility Of The Latest Antipsychotic Drugs In Schizophrenia Study (CUtLASS 1) and Clinical Antipsychotic Trials Of Intervention Effectiveness (CATIE)". Archives of General Psychiatry 63 (10): 1069–72. doi:10.1001/archpsyc.63.10.1069. PMID 17015808. 
6. ^ "Perphenazine, Warnings mentalhealth.com", Retrieved 2010-1-24.
7. ^ Hartung B, Wada M, Laux G, Leucht S (2005). Hartung, Benno. ed. "Perphenazine for schizophrenia". Cochrane Database of Systematic Reviews (Online) (1): CD003443. doi:10.1002/14651858.CD003443.pub2. PMID 15674907. 
8. ^ Kelsey, Jeffrey E; Newport, D Jeffrey; Nemeroff, Charles B (2006). "Schizophrenia". Principles of psychopharmacology for mental health professionals (illustrated ed.). John Wiley and Sons. p. 114. ISBN 978-0-471-25401-0. http://books.google.co.uk/books?id=FxaBz-ufvN0C&pg=PA114&lpg=PA114&dq=perphenazine+as+other+medium-potency+antipsychotics&source=bl&ots=fUBfxM2H-y&sig=AFb4g4aMDxS0OF028f-Oe8WT82s&hl=en&ei=2t4_SqPDC93LjAfSzakV&sa=X&oi=book_result&ct=result&resnum=2. Retrieved 2009-06-22. 
9. ^ Schillevoort I, de Boer A, Herings RM, Roos RA, Jansen PA, Leufkens HG (July 2001). "Antipsychotic-induced extrapyramidal syndromes. Risperidone compared with low- and high-potency conventional antipsychotic drugs". European Journal of Clinical Pharmacology 57 (4): 327–31. doi:10.1007/s002280100302. PMID 11549212. 
10. ^ Høyberg OJ, Fensbo C, Remvig J, Lingjaerde O, Sloth-Nielsen M, Salvesen I (December 1993). "Risperidone versus perphenazine in the treatment of chronic schizophrenic patients with acute exacerbations". Acta Psychiatrica Scandinavica 88 (6): 395–402. doi:10.1016/S0149-2918(98)80046-5. PMID 7508675. 
11. ^ Breggin, P (2007). Brain disabling treatments in psychiatry. Springer Publishing Company. pp. 320. ISBN 082612934X. http://books.google.fi/books?id=hBd0V7Ex8PUC&lpg=PR11&dq=neuroleptics%20withdrawal%20death&pg=PA85#v=onepage&q=neuroleptics%20withdrawal%20death&f=false.