Combination Antipsychotic Therapy in Clinical Practice

Tapp, André; Wood, Annette; Secrest, Lori; Erdmann, Jaime; Cubberley, Lindy; Kilzieh, Nael

doi:10.1176/appi.ps.54.1.55

Cited by 160 publications

(93 citation statements)

References 17 publications

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“…However, in Table 2 Comparison of characteristics between patients on one antipsychotic (NP) and patients on more than one antipsychotic (P) this study the rates of antipsychotic polypharmacy in Taiwan and Hong Kong were considerably lower compared with the other countries despite their patients being recruited from psychiatric hospitals, suggesting that other factors also are likely to be important, including local prescribing traditions and cultural factors. Polypharmacy may indicate a slow cross-tapering from one antipsychotic to another, or that patients were stuck in the combination during the process of cross titration of polypharmacy [5,22]. The association of antipsychotic polypharmacy with male gender may also reflect the biases and perception of clinicians in expecting male inpatients to present with a greater severity of illness, agitation, aggression, or that they are physically better able to tolerate combination antipsychotic therapy despite the lack of evidence to support such assumptions [23][24][25].…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies of the prescription patterns of antipsychotic drugs in patients with psychotic disorders including schizophrenia have revealed widely variable rates (13-90%) of antipsychotic polypharmacy, defined as the use of more than one antipsychotic [1][2][3][4][5]. The wide variation in the rates of combination antipsychotic therapy between countries has been attributed to differences in healthcare systems affecting availability and economic cost of antipsychotics [6], local prescription traditions and culture as well as personal experience and choice [7].…”

Section: Introductionmentioning

confidence: 99%

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Antipsychotic polypharmacy in patients with schizophrenia: a multicentre comparative study in East Asia

Sim

Fujii

et al. 2004

Brit J Clinical Pharma

132

107

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AimsPrevious studies of the prescription patterns of psychotropic medications in patients with schizophrenia have highlighted a high rate of antipsychotic polypharmacy, but data in Asia are sparse. This study seeks to examine the prevalence of antipsychotic polypharmacy in patients with schizophrenia and compare the differences between patients receiving one vs. those receiving more than one antipsychotic. MethodsAntipsychotic prescription for a sample of 2399 patients with schizophrenia from six countries and territories was evaluated. Daily doses of antipsychotic medications were converted to standard chlorpromazine equivalents (CPZ). ResultsAntipsychotic polypharmacy was found in 45.7% ( n = 1097) of the patients with wide intercountry variations. Polypharmacy was associated with male gender [odds ratio (OR) 1.24, 95% confidence interval (CI) 1.06, 1.46, P < 0.01], advanced age ( t = -7.81, d.f. = 2396, P < 0.001), psychiatric hospital setting (OR 1.34, 95% CI 1.11, 1.62) as well as higher daily CPZeq doses (411.47 vs. 983.10 CPZeq day -1 , z = -25.94, P < 0.001), anticholinergic use (OR 3.17, 95% CI 2.65, 3.79, P < 0.001) and less use of an atypical antipsychotic drug (OR 0.83, 95% CI 0.71, 0.98, P < 0.05). On multivariate analysis, country, age and duration of illness were significantly associated with antipsychotic polypharmacy. ConclusionThis study highlighted the wide intercountry variations of antipsychotic polypharmacy which are likely to be influenced by a complex combination of clinical, setting, cultural and personal practice factors, requiring more research.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Antipsychotic polypharmacy in patients with schizophrenia: a multicentre comparative study in East Asia

Sim

Fujii

et al. 2004

Brit J Clinical Pharma

132

107

View full text Add to dashboard Cite

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“…22 The aetiological basis of this is poorly understood and is not explained by increased suicide rates. Individuals with a diagnosis of schizophrenia are at higher risk of cardiovascular morbidity and mortality than those in the general population.…”

Section: Mortality and Morbiditymentioning

confidence: 99%

Antipsychotic polypharmacy: review of mechanisms, mortality and management

Langan

Shajahan

2010

Psychiatrist

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Polypharmacy was first described in the psychiatric literature in 1969.1 Studies reported variable rates of concurrent antipsychotic prescription depending on the population considered. A study in Australia, examining people receiving out-patient treatment for schizophrenia, showed a 13% rate of multiple antipsychotic prescription use.2 One Japanese study indicated that the rate of antipsychotic polypharmacy exceeded 90%.3 A recent study in the UK showed an intermediate rate of 30%. 4 Despite its common occurrence, the evidence base behind antipsychotic polypharmacy is widely recognised as limited and its use has been considered both a 'therapeutic option' and a 'dirty little secret'. 5 Routes to polypharmacyWhen considering the prescription of more than one antipsychotic, perceived potential clinical benefit rather than receptor theory often leads to the chosen combination. It is increasingly evident that various non-dopaminergic receptors have an important role in the clinical profile of schizophrenia -with adrenergic, glutamatergic and serotonergic receptors (in particular 5-HT 2A receptors) involved in the pathogenesis of positive and negative symptoms. It is postulated that combined therapy might help to diversify the range of receptors affected by drug treatment and thereby improve symptoms of disease and reduce recurrence rates. 6The National Institute for Health and Clinical Excellence (NICE) has produced algorithms for the use of antipsychotics in schizophrenia. 7 The guidance states that in a first presentation, concurrent antipsychotics should not be prescribed except to cover short change-over periods (i.e. cross-tapering) and recommends that a second antipsychotic could be 'cautiously' trialled in combination with clozapine in patients whose disorder is truly 'treatment resistant', following an inadequate response to adequate trials of initial antipsychotics and also clozapine. It is only in these specific clinical settings that NICE suggests dual antipsychotic prescription should occur. However, antipsychotic polypharmacy prescription may occur in other clinical scenarios. When clinicians aim to switch their patients from one antipsychotic to another by cross-tapering, the switch may never be fully completed as symptoms stabilise or improve. This leads to reluctance on the part of clinician or patient to complete the switch and may postpone the completion of the switch indefinitely, leading to long-term antipsychotic polypharmacy.Clinicians sometimes prescribe antipsychotic doses close to or beyond that defined as maximum by the UK British National Formulary (BNF).8 When this occurs, highdose monitoring protocols are recommended. 9 Good clinical practice suggests that we avoid high-dose prescribing in order to minimise side-effects. For this reason, clinicians may trial more than one antipsychotic at lower doses, leading once again to long-term antipsychotic polypharmacy. However, polypharmacy may in itself unwittingly result in high total dose prescribing. An audit carried out by the Prescrib...

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“…There is a guideline for using polypharmacy in chronic schizophrenia, the "Texas Medical Algorithm Project Guideline". This guideline emphasizes an initial five steps for "monopharmacy" use and s u p p o r t s a dd i n g a n o t h e r a n t i p s y c h o t i c medication only if the prior 5 steps have not been effective [21][22][23] . Discrepancies exist in different reports for the dosing of antipsychotics in chronic schizophrenic patients, but all agree to start polypharmacy at a low dose [24][25][26][27] .…”

Section: Introductionmentioning

confidence: 99%

Antipsychotic Polypharmacy Versus Monotherapy in Elderly Patients with Chronic Schizophrenia: A Clinical Trial

Mirabzadeh

Shemshadi

Khodaei

et al. 2014

Klinik Psikofarmakoloji Bülteni-Bulletin of Clinical Psychophar

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Objective: Antipsychotic polypharmacy in the elderly usually results in higher rates of interactions, side effects and increased cost. This research was designed to observe the benefits of replacing polypharmacy with a single medication in elderly patients with chronic schizophrenia. Methods: This was a quasi-experimental, prospective, descriptive and analytical clinical trial. A survey was performed at the long stay public and academic Tehran Razi Mental Hospital. From the initial 157 conveniently access patients, 59 cases were selected based on inclusion and exclusion criteria. Before intervention, 7 patients did not participate in the study due to the recent diagnosis of new medical conditions. Fifty-two (52) cases (males=13 and females= 39) entered and completed the 36 week research time period. At baseline 40 patients were receiving two types of antipsychotics, whereas, 11 patients were receiving three types and only 1 patient was receiving four types of antipsychotic drugs. In the pre-intervention period, the approval of the University`s ethics committee and the informed consents of the patients' relatives were obtained. Systematically, the patients` multiple antipsychotics were switched to a single medication, risperidone. After determining the equivalent dose of risperidone, it was started at 1 mg/day for all patients. After a 3-6 week cross-titration period, the patients reached the previously determined equivalent risperidone doses and completed 36 weeks until the end of the study. Clinical assessments including the Brief Psychotic Rating Scale (BPRS), Global Assessment of Functioning (GAF), and Extra-Pyramidal Syndrome (EPS) Scale were applied on a weekly basis for a 36 week period. Results: The mean BPRS scores of the participants showed statistically significant improvement after the 9 th week of intervention. Improvements were observed in all symptom dimensions of the BPRS (positive, negative and general schizophrenic symptoms). At the end of 36 weeks of risperidone use, 90.1% of the patients achieved at least a 50% reduction in their symptoms. Additionally, functional improvement and a lower incidence of extrapyramidal side effects were also achieved after 36 weeks of risperidone use in the study population. Conclusion: Risperidone may be considered safe as a monotherapy alternative for elderly patients with chronic schizophrenia who are being treated with multiple concomitant antipsychotics. This replacement may result in some clinical benefits and fewer side effects.

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Combination Antipsychotic Therapy in Clinical Practice

Cited by 160 publications

References 17 publications

Antipsychotic polypharmacy in patients with schizophrenia: a multicentre comparative study in East Asia

Antipsychotic polypharmacy in patients with schizophrenia: a multicentre comparative study in East Asia

Antipsychotic polypharmacy: review of mechanisms, mortality and management

Antipsychotic Polypharmacy Versus Monotherapy in Elderly Patients with Chronic Schizophrenia: A Clinical Trial

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