Switching and augmentation strategies for antipsychotic medications in acute-phase schizophrenia: latest evidence and place in therapy

Abstract

In terms of effectiveness of antipsychotics in schizophrenia, discrepancy often exists between results from double-blind randomized controlled trials and observations in emergency or acute-phase clinical practice. For instance, the antipsychotic switching strategy is not always applicable in emergency or acute-phase situations, and augmentation of another antipsychotic is occasionally done instead. In this review, we discuss strategies for early nonresponse to an antipsychotic drug such as switching and augmentation from the perspective of emergency and acute-phase treatment. We searched PubMed for the latest evidence on switching and augmentation strategies of antipsychotics for an emergency or acute-phase period. For risperidone and olanzapine, there is some evidence on switching and augmentation strategies in the management of acute-phase schizophrenia. There may be responders to olanzapine alone among early nonresponders to risperidone, whereas there may be few responders to risperidone alone among early nonresponders to olanzapine. However, there is still insufficient evidence at this time for application of these findings to routine clinical practice. For other antipsychotics, there is little evidence for their augmentation in acute-phase practice. We should be wary of polypharmacy, as multiple agents are too often prescribed by clinicians when not warranted. Considering current evidence, we propose how to switch antipsychotics in the acute phase of schizophrenia in routine practice.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

“…It remains uncertain whether the particular antipsychotic medications involved in a switch are relevant to the response, even though studies have hinted that a switch to amisulpride or quetiapine, or from risperidone to olanzapine (compared with olanzapine to risperidone), may achieve some clinical benefit (Hashimoto et al, 2015; Hatta et al, 2018; Kim et al, 2016). However, the antipsychotic formulation may have an influence; while switching from an oral antipsychotic to a depot/LAI may be beneficial (Schreiner et al, 2017), poorer outcomes have been reported for patients switching from a depot/LAI antipsychotic to oral antipsychotic medication (Barnes et al, 2013; Mustafa, 2017; Voss et al, 2015), which presumably partly reflects the opportunities for covert non-adherence with the latter as well as possibly the pharmacokinetic differences between oral and depot/LAI preparations.…”