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What to Make of CATIE: Are We Better Off With Atypical Antipsychotics?: Page 3 of 6

What to Make of CATIE: Are We Better Off With Atypical Antipsychotics?: Page 3 of 6

CASE VIGNETTE cont’d

In view of the relative rankings of the different antipsychotics in CATIE phase 1, generic risperidone was not an unreasonable choice, especially given Simone’s past history of response. Moreover, should adherence become an issue, the availability of a depot formulation of risperidone is a definite plus. Unfortunately, 2 months after being placed on treatment with 4 mg of risperidone per day, Simone complained of feeling restless. Her clinician was of the opinion that the patient’s restlessness was due to akathisia. Simone was no longer willing to take risperidone. She did not want to wait to see if a reduction in dosage would decrease her subjective restlessness, nor did she want to take pro-pranolol to see if that would relieve her symptoms. Given Simone’s strong family history for type 2 diabetes mellitus and Simone’s elevated weight, as well as her unhealthy lifestyle, her clinician decided to treat her with ziprasidone. CATIE supports this decision as well.

CATIE phase 2T: tolerability

The so-called ziprasidone pathway for phase 2, known as phase 2T, was designed to test whether ziprasidone had advantages over the other atypical antipsychotics for patients who discontinued phase 1 early because of poor tolerability. In reality, phase 2T is challenging to interpret because approximately equal numbers of patients who discontinued phase 1 because of poor efficacy entered phase 2T as those who discontinued phase 1 because of poor tolerability. The number needed to treat and the 95% CI for all-cause discontinuation are summarized in Table 5.

For all-cause discontinuation in phase 2T, the only 2 statistically significant results for number needed to treat were the comparisons of olanzapine or risperidone versus quetiapine. For every 6 patients randomized to olanzapine, or every 5 patients randomized to risperidone, instead of quetiapine, there was 1 additional patient taking olanzapine or risperidone who did not discontinue therapy prematurely. Ziprasidone did not demonstrate superiority on the global outcome of all-cause discontinuation. However, phase 2T did confirm the benign metabolic profile for ziprasidone and there were fewer discontinuations because of weight or metabolic concerns (Table 6).

 
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