Switching stable schizophrenia patients to a different antipsychotic as a maintenance strategy (for example, to reduce side effects) does not increase the risk of relapse, according to a meta-analysis in Lancet Psychiatry. However, keeping patients on a low-dose antipsychotic during maintenance is associated with a greater relapse risk, though it is still superior to stopping medication entirely.
“Although antipsychotic maintenance treatment is widely recommended to prevent relapse in chronic psychoses, evidence-based guidelines do not provide clear indications on different maintenance treatment strategies,” wrote Giovanni Ostuzzi, M.D., Ph.D., of the University of Verona, Italy, and colleagues. “[Our] results are of pragmatic relevance for clinicians and should support the update of evidence-based guidelines.”
Ostuzzi and colleagues pooled data from 98 clinical trials that compared at least two of four maintenance treatment strategies for schizophrenia: keeping patients on the antipsychotic dose used during acute treatment, maintaining patients on a low dose of the antipsychotic (50% of or less than the regular dose), switching to a different antipsychotic, and stopping the antipsychotic altogether and replacing it with placebo. The combined data encompassed nearly 14,000 patients (62% male) with an average age of 39.
Compared with discontinuation, continuing at the regular dose, switching to a different antipsychotic, and continuing at low dose were associated with a 63%, 56%, and 32% reduced risk of relapse, respectively. Contrary to the investigators’ expectations based on current literature, antipsychotic switching was similarly effective at preventing relapse as continuing medication at regular doses. Both strategies were superior at preventing relapse to reducing the dose during maintenance treatment.
“Guidelines should highlight the need to routinely implement a shared decision-making framework that both considers these data and emphasizes subjective, recovery-oriented outcomes and ultimately tailor the choice to patients’ needs and perspectives,” Ostuzzi and colleagues concluded.
To read more on this topic, see the Psychiatric News article “To Minimize Medication Withdrawal, Taper Slowly.”
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