Antipsychotic treatment in the maintenance phase of schizophrenia: An updated systematic review of the guidelines and algorithms

Shimomura, Yutaro; Kikuchi, Yuhei; Suzuki, Takefumi; Uchida, Hiroyuki; Mimura, Masaru; Takeuchi, Hiroyoshi

doi:10.1016/j.schres.2019.09.013

Cited by 57 publications

(51 citation statements)

References 47 publications

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“…The maintenance treatment algorithm recommends dose reduction of SGAs, which is consistent with the current evidence. Recent clinical guidelines for schizophrenia tend to shift to endorsing dose reduction of antipsychotics in the maintenance treatment (Shimomura et al., 2020 ), given the fact that SGAs are associated with dose‐dependent adverse effects (Yoshida & Takeuchi, 2021 ) and accumulating evidence from RCTs examining dose reduction of SGAs (Rouillon, Chartier, & Gasquet, 2008 ; Takeuchi et al., 2013 ; Wang et al., 2010 ; Zhou, Li, Li, Cui, & Ning, 2018 ). In addition, a recent meta‐analysis of RCTs revealed that dose reduction up to chlorpromazine equivalent 200 mg/day was not associated with a higher relapse risk but with improvement in negative symptoms, extrapyramidal symptoms, and neurocognitive impairment (Tani et al., 2020 ).…”

Section: Discussionmentioning

confidence: 99%

“…In addition, a recent meta‐analysis of RCTs revealed that dose reduction up to chlorpromazine equivalent 200 mg/day was not associated with a higher relapse risk but with improvement in negative symptoms, extrapyramidal symptoms, and neurocognitive impairment (Tani et al., 2020 ). On the other hand, several issues remain to be addressed regarding dose reduction of antipsychotics, such as the timing and speed of dose reduction (Shimomura et al., 2020 ). We recommended starting dose reduction 6 months after remission of positive symptoms and a gradual reduction by every 3 months, according to some recent clinical guidelines (note: all of them only said “gradually” in terms of the speed of dose reduction) (Shimomura et al., 2020 ).…”

Section: Discussionmentioning

confidence: 99%

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Pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first‐episode schizophrenia: Japanese Society of Clinical Neuropsychopharmacology treatment algorithms

Takeuchi

Takekita

Hori

et al. 2021

Human Psychopharmacology

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Objective: There are only a few treatment algorithms for first-episode schizophrenia. Moreover, all the algorithms apply to acute treatment, but not maintenance treatment. Therefore, we aimed to develop acute and maintenance treatment algorithms for first-episode schizophrenia. Methods:The algorithm committee of the Japanese Society of Clinical Neuropsychopharmacology developed pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first-episode schizophrenia. Results:The acute treatment algorithm focuses on drug-naïve patients with firstepisode schizophrenia who are not old or very agitated and recommends first-line treatment with aripiprazole, second-or third-line treatment with risperidone/paliperidone or olanzapine, and fourth-line treatment with clozapine. Long-acting injection of the current antipsychotic agent can be used for poor medication adherence or based on patient preference. The agitation treatment algorithm recommends first-line treatment with lorazepam and second-or third-line treatment with quetiapine or levomepromazine and clearly instructs that the medication used for agitation should be reduced and then discontinued after remission of agitation.The maintenance treatment algorithm recommends the gradual reduction of antipsychotics to the minimum effective dose after remission of positive symptoms. Conclusions:We hope that our unique algorithms will be used broadly and will contribute to minimizing patients' burden related to antipsychotic treatment.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first‐episode schizophrenia: Japanese Society of Clinical Neuropsychopharmacology treatment algorithms

Takeuchi

Takekita

Hori

et al. 2021

Human Psychopharmacology

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“…24) A recent systematic review reported that most treatment guidelines for schizophrenia recommend continuing the antipsychotic treatment for 1-2 years after the stabilization of acute symptoms in first-episode schizophrenia. 20) However, previous studies [25][26][27] have reported that a substantial proportion of patients discontinue the antipsychotic treatment earlier than the recommended time point in clinical practice. The current study also reported a higher proportion of patients discontinuing treatment within 2 years compared to those reported in previous studies.…”

Section: Discussionmentioning

confidence: 99%

“…Eight of the eleven guidelines specify the duration of maintenance treatment; seven guidelines recommend 1-2 years, while only one guideline recommends 2-5 years. 20) Current evidence on the discontinuation of antipsychotic treatment and its associated clinical outcomes in first-episode schizophrenia is largely based on the findings from RCTs. Despite the advantages of high intrinsic validity derived from random sampling and minimizing the risk of confounding bias, an RCT study design is limited by the selective study participants and a relatively short observation period.…”

Section: Introductionmentioning

confidence: 99%

Association of the First Antipsychotic Treatment Duration With the Re-Initiation of Treatment in Schizophrenia: A National Health Insurance Data-Based Study

Song

Lee

Kim

et al. 2021

Korean J Schizophr Res

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Objectives:The optimal duration of maintenance treatment for patients with first-episode schizophrenia (FES) remains unclear. We examined the first antipsychotic treatment duration and its association with re-initiation of treatment using a nationwide claim database. Methods: Data from the Health Insurance Review and Assessment Service database in South Korea for 2007-2016 were used. Linear regression analysis and Cox proportional hazard models were used to evaluate the associations between the duration of the first antipsychotic treatment, time to re-initiation of treatment, and occurrence of treatment re-initiation. Results: Of 30,143 patients with FES, 80.4% (n=24,231) received <2 years of the first antipsychotic treatment. In patients who discontinued treatment (n=23,030), the rate of treatment re-initiation was 74.2% (n=17,086). As the duration of the first antipsychotic treatment increased, the time to re-initiation of treatment decreased (β=-0.146, p<0.001); however, the rate of treatment reinitiation was relatively constant (hazard ratio=1.001, p<0.001). Conclusion:Long-term antipsychotic treatment was not significantly associated with the rate of treatment re-initiation but showed a negative association with the time to re-initiation of treatment. Further research is needed to better understand the optimal treatment duration for FES.

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“…The major reason behind the difficulty of reducing psychotropic drugs is that withdrawal or dose reduction of psychotropic drugs may lead to relapse or recurrence of the disease being treated or withdrawal syndromes [18][19][20][21][22][23]. In addition, several guidelines do not specify when and how to reduce drugs for patients who are already prescribed more than the standard number of drugs, especially for long-time users [4][5][6][7][8][9][24][25][26]. Thus, owing to the difficulty in reducing the prescribed number of psychotropic drugs, a decrease in the proportion of patients prescribed more than the standard number of drugs might essentially be, because healthcare providers avoided starting to prescribe more than the standard number of drugs.…”

Section: Introductionmentioning

confidence: 99%

Effects of medical service fee revision on reducing irrational psychotropic polypharmacy in Japan: an interrupted time-series analysis

Okada

Akazawa

2021

Soc Psychiatry Psychiatr Epidemiol

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Purpose According to the revised Japanese medical service fees aimed at reducing irrational psychotropic polypharmacy, medical service fees are reduced if the number of simultaneously prescribed psychotropic drugs exceeds the standard. This study primarily aims to examine the effect of the 2018 revision. Methods Using a large Japanese administrative claims database, we retrospectively identified five groups (April 2013–September 2018) prescribed at least one drug from the following drug groups: anxiolytics, hypnotics, sum of anxiolytics and hypnotics, antipsychotics, and antidepressants (study population in each group: 547,511, 406,524, 759,137, 112,929, and 201,046, respectively). We used an interrupted time-series design to evaluate changes in the proportion of patients prescribed more than the standard number of drugs. Results After the 2018 revision, the proportion of patients prescribed more than the standard number of drugs significantly decreased only for the sum of anxiolytics and hypnotics; estimated changes in level and trend were − 0.60% [− 0.69%, − 0.52%] and − 0.04% [− 0.06%, − 0.02%] per month, respectively. The proportion of patients exhibiting a decrease in the number of prescribed drugs from more than the standard to within the standard increased when the revision was enforced (April 2018); this proportion in April 2018 was 36.3%, while all other proportions were in the range of 12.1–22.3%. Conclusion The 2018 revision promoted a reduction in the number of prescribed drugs, which served as an important factor in the decrease in the proportion of patients prescribed more than the standard number of drugs for the sum of anxiolytics and hypnotics.

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Antipsychotic treatment in the maintenance phase of schizophrenia: An updated systematic review of the guidelines and algorithms

Cited by 57 publications

References 47 publications

Pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first‐episode schizophrenia: Japanese Society of Clinical Neuropsychopharmacology treatment algorithms

Pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first‐episode schizophrenia: Japanese Society of Clinical Neuropsychopharmacology treatment algorithms

Association of the First Antipsychotic Treatment Duration With the Re-Initiation of Treatment in Schizophrenia: A National Health Insurance Data-Based Study

Effects of medical service fee revision on reducing irrational psychotropic polypharmacy in Japan: an interrupted time-series analysis

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