Pimavanserin: Potential Treatment For Dementia-Related Psychosis

Abstract

Psychosis is common across dementia types with a prevalence of 20% to 70%. Currently, no pharmacologic treatment is approved for dementia-related psychosis. Atypical antipsychotics are frequently used to treat these disorders, despite significant safety concerns. Pimavanserin, a selective 5-HT2A inverse agonist/antagonist, was approved in the U.S. for treating hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Patients in the pimavanserin group experienced a significant (p=0.001) improvement in Scale for the Assessment of Positive Symptoms - Parkinson's disease (SAPS-PD) scores vs. placebo. In a subgroup analysis of patients with cognitive impairment (MMSE score ≥21 but ≤24), the observed improvement on the SAPS-PD with pimavanserin (N=50) was also significant (p=0.002) and larger than in the overall study population without an adverse effect on cognition. In a Phase 2 study with pimavanserin in Alzheimer's disease psychosis, pimavanserin significantly (p=0.045) improved psychosis at Week 6 vs. placebo on the NPI-NH Psychosis Score (PS). In a prespecified subgroup of patients with a baseline NPI-NH PS ≥12, a substantively larger treatment effect (p=0.011) was observed vs. participants with NPI-NH PS <12. The results of these studies in cognitively impaired patients with PDP provided the scientific foundation for an ongoing study of pimavanserin for treating patients with dementia-related psychosis associated with the most common neurodegenerative disorders. The study uses a relapse-prevention design with the endpoint of time-to-relapse of psychosis to evaluate the long-term efficacy and safety of pimavanserin as a potential treatment for hallucinations and delusions of dementia-related psychosis.

Keywords: Alzheimer’s disease; Dementia; Parkinson’s disease; dementia with Lewy bodies; frontotemporal dementia; psychosis.

Figure 1

LS mean change in the SAPS-PD score to Week 6 for pimavanserin and placebo in the overall population and by baseline MMSE score (46)

Figure 2

LS mean change from baseline to Week 6 for the NPI-NH psychosis score among the overall population from a randomized, placebo-controlled study (30) and in subgroups by severity of psychosis (47)

Figure 3

Response rate at Week 6 for the NPI-NH psychosis score among the overall population from a randomized, placebo-controlled study (30) and in subgroups by severity of psychosis (47)