From a Contributing Editor
For individuals with schizophrenia who are failed by trials of single antipsychotics, what’s next?
This week, we discuss a paper that addresses a treatment controversy. Antipsychotic polypharmacy (the use of more than one antipsychotic) is generally discouraged because the efficacy evidence is weak, and there is risk of increasing adverse events and effects with the addition of a second antipsychotic. Choosing Wisely is an initiative that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures; among their psychiatric recommendations is to avoid the use of multiple antipsychotics. The American Psychiatric Association contributed this to the Choosing Wisely initiative:
Research shows that use of two or more antipsychotic medications occurs in 4 to 35% of outpatients and 30 to 50% of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased. Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of Clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy.
This is where this week’s selection comes in. The study, “Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia,” is from Finland by Karolinska Institutet’s Jari Tiihonen and his colleagues. This paper uses Finnish population-based health administrative data to evaluate the association between antipsychotic polypharmacy and psychiatric hospitalization. They conclude: “These results indicate that rational antipsychotic polypharmacy seems to be feasible by using 2 particular antipsychotics with different types of receptor profiles.”
Finland: home to big Northern Lights (and big databases)
In this Reading, we consider this paper and wonder if it should change our prescribing choices.
Paul Kurdyak, MD, PhD, FRCPC