WO2006072732A1 - Use of cyproterone acetate for treating aggressive behaviours in patients suffering from dementia - Google Patents

Abstract

The behaviour disorders of patients suffering from a demential syndrome of degenerative origin or from acquired brain injuries constitute the main cause of exhaustion in their environment. The current medicinal resources may prove insufficient and/or induce considerable unwanted effects. Anti-andogenic, progestative cyproterone acetate has been proposed in a context of therapeutic impasse to 15 demented patients having major aggressive behavioural disorders in long term geriatric care units or at home. The clinical and behavioural assessment was based on an assessment scale of behaviour disorders in Cohen Mansfield institution, prior to treatment and following stabilization under treatment. Cyproterone acetate significantly improved the aggressive and impulsive behaviours. The efficacy with regards to aggressiveness and impulsiveness was maintained during the treatment phase and aggressiveness resurfaced when the treatment was interrupted. Cyproterone acetate is therefore an interesting alternative to sedative psychotropic drugs for patients suffering from degenerative or vascular dementia accompanied by aggressiveness and/or impulsiveness.

Description

 USE OF CYPROTERONE ACETATE FOR THE TREATMENT OF AGGRESSIVE BEHAVIORS IN PATIENTS WITH DEATH

The present invention relates to a new use of cyproterone acetate in the treatment of aggressive or impulsive behaviors induced in particular by diseases of the central nervous system with dementia.

Behavior disorders (agitation, aggression) occur during the evolution of nearly 85% of demented patients (MEGA MS, CUMMIIMGS JL,

FIORELLO T et al. 1996 777th Spectrum ofbehavioral changes in Alzheimer's disease. Neurology, 46: 130-135) and they are more common in men than in women.

Patients with degenerative dementia (Alzheimer's disease, diffuse Lewy body disease, front-temporal dementia, untington's disease) and more often those with vascular dementia frequently develop behavioral disorders. These behavioral disorders are the main cause of the exhaustion of the environment of these patients and frequently lead to the decision of institutionalization in long-term care unit.

Several types of aggressive behavior are particularly harmful for those around you, whether family or professional:

- permanent physical aggression during care in Alzheimer's disease and related dementias;

- Elastic crises often unpredictable in vascular dementia, often related to an intolerance to frustrations;

- aggression attacks, with or without sexual aggressiveness in untington's disease; - permanent impulsive behavior in frontotemporal dementia;

- Aggressive behavior disorders associated with a confusional syndrome of cerebral palsy patients.

- Aggressive behavior disorders of psychiatric pathologies

The analytical evaluation of behavioral disorders, especially in institutions, is based mainly on the Cohen-Mansfield scale (KOSS E, WEINER M, ERNESTO C and AL 1997 Assessing patterns of agitation in Aizheimers disease patients with the Cohen-Mansfield agitation inventory. The Aizheimers Disease cooperative study. Alzheimer Dis Assoc Disord, 11 (Suppl 2): S45-50).

The management of behavioral disorders in cerebral patients is usually complex.

The current drug arsenal (anxiolytics, antidepressants, atypical or conventional neuroleptics, cholinesterase inhibitors) may be insufficient and / or induce significant adverse effects.

Environmental therapies are primarily for patients with mild or moderate dementia. The use of physical restraint in agitated men often reinforces aggression or agitation and accelerates functional and cognitive decline. Psychotropic drugs have almost all important side effects: increased risk of falls (with high fracture risk), worsening of memory problems or mental confusion, decreased autonomy by Parkinson's medicated syndrome. In addition, there is no predictor of the efficacy of psychotropic drugs, regardless of their class, and it is sometimes difficult to find a proper measure between sedation (responsible for falls and swallowing disorders) and agitation. The favorable effect of cholinesterase inhibitors on behavioral disorders has recently been questioned (AD 2000 COLLABORATIVE GROUP 2004, Long-term donezepil treatment in 565 patients with Aizheimers disease (AD2000): randomized double-blind trial.The Lancet, 363: 2105-2115).

The object of the present invention is to propose a new therapy of aggressive or impulsive behavioral disorders, this new therapy making it possible to maintain and treat at home more patients suffering from degenerative dementia, vascular dementia or aggressive disorders not associated with a delusional state in a psychiatric context.

To this end, the subject of the invention is the use of cyproterone acetate for the preparation of a medicament for the treatment of aggressive or impulsive behaviors. In most cases, aggressive or impulsive behaviors are induced by diseases of the central nervous system such as vascular dementia, or degenerative dementia such as Alzheimer's disease, Lewy body disease diffuse, frontotemporal degeneration, Huntington's disease or psychiatric pathologies.

According to a second aspect, the invention relates to a pharmaceutical preparation comprising cyproterone acetate for use in the treatment of aggressive or impulsive behaviors.

Cyproterone acetate, an anti-androgenic progestin steroid, has been used for 25 years as a treatment for hirsutism in women and as an adjuvant treatment for prostate cancer in men, with good tolerance.

The invention will now be described in detail. In the case of inpatient and institutional follow-up, the effect of treatment with cyproterone acetate has been evaluated in patients with severe dementia who have major behavioral problems, who are resistant to prescribed psychotropic treatments, often in combination up to one year. at the maximum tolerated dose (anxiolytics, atypical or conventional neuroleptics, antidepressants, or even anticonvulsants at maximum tolerated doses), combined with cholinesterase inhibitors and / or the memantine in case of Alzheimer's disease. These patients were in a context of therapeutic impasse and major behavioral crisis. This is an open-label, unblinded trial.

Surprisingly, the administration of cyproterone acetate to these patients has significantly improved aggressive and impulsive behaviors.

Cyproterone acetate was chosen because of its good clinical tolerance and its lipophilic character, facilitating the passage of the blood-brain barrier. Fifteen patients, thirteen men and two women were treated with cyproterone acetate for an average of eleven months. Patients were selected for the severity of the behavioral disorders whose characteristics compromised the maintenance in hospitalization or at home. These patients were hospitalized in psychiatry because of their dangerousness to themselves or those around them. Psychotropic treatments failed to achieve a satisfactory reduction in behavioral disorders. The treatment criterion was a physical aggression repeated on a weekly or daily basis. The Non-treatment criteria were contraindications to cyproterone acetate: imbalanced diabetes, thromboembolic disease, hepatopathy and severe chronic depression. None of these patients had any pathology contraindicating cyproterone acetate. The average age was 71 (range: 45 - 92). Cognitive disorders were related to Alzheimer's disease in six cases, vascular dementia in seven cases, frontotemporal degeneration in one case, and Huntington's disease in one case. All patients had a neurological assessment with cognitive assessment and brain imaging (CT or MRI). A systematic biological assessment with liver enzymes was performed before treatment, and one month after the introduction of it. During the introduction of the treatment, the MMS was always less than 15, sometimes of difficult interpretation, because of a marked aphasia or a lack of cooperation. All the patients had frontal disinhibition, responsible for disorders of the behavior of diverse expression. Aggressiveness or agitation was not associated with perceptible anxiety or depressive disorders, with the exception of a patient with a mild depressive syndrome, related to a sequela of hemiplegia and its institutionalization. Autonomy was assessed by the measure of functional independence (MIF) before treatment and after stabilization of psychotropic treatment with cyproterone. Aggression was assessed by the Cohen-Mansfield scale (COHEN-MANSFIELD J 1996 Conceptualization of agitation: results based on the Cohen-Mansfield agitation inventory and agitation behavior mapping instrument Int Psychogeriatr, 8 (suppl 3): 309- 315) before treatment and after stabilization of the behavior under treatment. The initiation of treatment was made after stabilization of drug treatments for more than a week. The treatment decision was made after an evaluation that took into account the impact of the behavioral disorders on the family (ie other patients, the health care team and the families). Cyproterone acetate was prescribed at 50 mg / day and increased to 100 mg / day in the case of a partial response to treatment, by name prescription. The goal was to see the aggressive behavior disappear. After initiation of treatment, any clinical or behavioral event was reported daily. The main undesirable effects were sought systematically (weight change, dyspnea, headache, depression, hepatic toxicity). The possible modalities of management of behavioral disorders were discussed with the family environment, when it existed. The patient's consent could not be obtained, given the severity of cognitive impairment. The reduction of psychotropic drugs was evaluated after stabilization of the behavior under treatment. The reduction or discontinuation of neuroleptics was attempted in all cases. The agitation and aggression scores were performed before treatment and 10 days after stabilization of the associated prescriptions, ie approximately 6 weeks after initiation of treatment. The clinical and behavioral follow-up (before and after treatment) was on average 3 months (range: 1 - 10).

EVALUATION OF ACETATE TREATMENT OF CYPROTERONE

Before treatment, eight patients (five with vascular dementia, three with Alzheimer's disease) had physical and verbal aggression, one patient had physical aggression, verbal abuse and violent seizures (vascular dementia), three patients were aggressive physical and sexual (two with Alzheimer's disease and one patient with Huntington's disease), one patient had permanent agitation with major impulsivity (fronto- temporal dementia) and two patients had physical aggression and aberrant motor behaviors incessant ambulation (Alzheimer's disease).

Aggressive and impulsive behaviors were improved with cyproterone in the 15 treated patients; this improvement was all the more spectacular because the initial aggressiveness was severe.

The results are shown in Tables 1 and 2 below. Table 1 gives a description of the patients enlisted in the study. Table 2 presents a description of the patients and the results of the behavioral and functional assessment. The following abbreviations were used: AGR = aggression, P = physical, V = verbal, S ≈ sexual, C = elastic seizures, IMP = impulsivity, DEAMBUL = ambulation; M.1.F. is the measure of functional independence before and after treatment with cyproterone acetate; NA means not applicable (neuroleptics or anxiolytics interrupted as ineffective or poorly tolerated). Two patients (Nos. 1 and 10 of the tables) had a major aggression, considerably hampering care. The overall shake score was 150 and 131 out of 203. The caregivers of each of these patients were victims of kicking, punching, spitting, biting or splashing objects on a no somatic and environmental cause was identified at the origin of the disorders. Hygiene care required the presence of 4 to 5 caregivers. These patients also developed physical aggression towards other residents or their families, and would have justified hospitalization in psychiatry at the request of a third party, if the dementia syndrome had been less severe. The behavioral improvement was dramatic, 12 to 72 hours after the prescription of 100 mg of cyproterone acetate. This change in treatment led to a significant reduction in the care burden, as basic care was only provided by one or two caregivers, instead of five. The regression of aggression restored a relational life and a social interaction, not only with the care teams (who were no longer afraid of the patient), but also with the family environment. This effect on social interaction reflects the improvement of the MiFID (Table 2). The neuroleptics were interrupted and the anxiolytics reduced in the first patient, without altering the benefits obtained by cyproterone acetate. Patient # 4 had vascular dementia with multi-week episodes of elastic seizures, occurring unpredictably or in response to frustration (due to irregular family visits, limitation of smoking or any type of stress). ). These attacks involved very violent acts, threatening remarks about staff or other patients, and repeated insults. For example, he could overturn a computer, or whatever was in his way. He could grab a caregiver's arm and hurt him. Under cyproterone (100 mg / day), the elastic seizures disappeared. His ability to tolerate what he perceived as frustration has improved considerably. In particular, the delay (deliberate) to give him a cigarette he claimed no longer led to a crisis of aggression. The patient also seemed to have a better acceptance of institutional life and his sequential hemiplegia. For all patients, the cohen-Mansfield scale of aggression and agitation scores averaged 90 before treatment and 55 after treatment. The variation, evaluated by the Wilcoxon test, was very significant (W = 5177, p <0.001). The partial score, evaluating only physical and verbal aggression, improved on average by 74% under treatment (Table 2). The improvement achieved remained unchanged after discontinuation of neuroleptics in seven patients, and its reduction in one patient. In two patients, reduction of neuroleptic increased behavioral disorders. Anxiolytics were reduced in six patients. In contrast, the non-aggressive agitation was little or no change, except in the impulsive patient. The aberrant motor behaviors observed more particularly in an old psychotic patient (N ° 8) were not improved.

EVOLUTION OF DISORDERS AFTER ARREST OF ACETATE OF CYPROTERONE

Stopping treatment, which was attempted in eight patients after two months of treatment, led to the reappearance of physical and verbal aggression in patients with vascular dementia, and verbal aggression in patients with Alzheimer's disease. The most striking consequence was observed in patient N ° 4, whose elastic seizures reappeared upon cessation of cyproterone leading to his hospitalization in a psychiatric environment. There was no rebound effect but the disorders noted before treatment reappeared.

These results show that cyproterone acetate, prescribed to patients with severe dementia and / or brain lesions of various origins, significantly improves their aggressive or impulsive behavior. In addition, the administration of cyproterone acetate has no effect on the aberrant motor behaviors observed in these patients. These results therefore suggest the potential interest of cyproterone acetate in the treatment of the aggressiveness of the demented or cerebrovascular patient, in case of resistance to treatment. psychotropic and environmental classics, or in case of adverse effects of psychotropic drugs.

The mechanisms of action of sex hormones and anti-androgens in the central nervous system are unknown. Androgen-specific receptors have been detected mainly in the hypothalamus, tonsillar nucleus, hippocampus and temporal cortex, in animals and humans.

However, the effect of stimulating or blocking these receptors is not known.

In particular, the consequences on the most common neuromediators

(dopamine, gaba, acetylcholine, serotonin ...) are unknown. It is possible that stimulation of the cerebral androgenic receptors increases the adrenaline production, creating a stress response.

In this study, treatment with cyproterone acetate had few adverse effects. During the 48 to 72 hours following the introduction of cyproterone acetate, sedation was observed in three patients, sedation that began when the psychotropic drugs were decreased or stopped. This sedative effect could be related to the progestational effect of cyproterone acetate. Finally, the cognitive effect of antiandrogens is probably minor compared to those induced by psychotropic drugs, especially neuroleptics.

The optimal duration of treatment remains to be defined. The constant recurrence of aggressiveness after stopping treatment in all patients (although it was less severe than before treatment in Alzheimer's disease, probably due to an adaptation to the living environment) suggests that a long-term prescription is necessary.

Preferably, the pharmaceutical preparation based on cyproterone acetate is administered orally. The dosage, depending in particular on the weight of the person, is between 25 and 200 mg per day.

Advantageously, the pharmaceutical preparation based on cyproterone acetate may be in the form of tablets. Preferably, the tablets comprise two doses of cyproterone acetate: 75 mg and 125 mg.

TABLE 1

TABLE 2

(abbreviations: AGR P = physical aggression, AGR V = verbal aggression, AGR S = sexual aggressiveness, IMP = impulsivity)

Claims

1. Use of cyproterone acetate for the preparation of a medicament for the treatment of aggressive or impulsive behavior in central nervous system diseases selected from neurodegenerative diseases with dementia and neuro-vascular diseases with dementia. 2. Use according to claim 2, in which the diseases of the central nervous system are part of the group: vascular dementia, degenerative dementia such as Alzheimer's disease, diffuse Lewy body disease, frontotemporal degeneration, disease dΗuntington. The preparation of claim 6 wherein the cyproterone acetate is administered orally. The preparation of claim 7 wherein the dosage of cyproterone acetate is from 25 to 200 mg per day. 5. Preparation according to any one of claims 7 and 8 being in the form of tablets. The preparation of claim 9 wherein the tablets are 75 or 125 mg.