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

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

Individual patients have their own preferences and values regarding efficacy and tolerability goals. These may differ from what the clinician has in mind. Thus, although the practitioner may want to prioritize the diminution of hallucinations and delusions, the patient may desire mainly to feel less anxious and less dysphoric. Similarly, different patients may find different adverse effects of medications distressing—some may abhor tremors but others may not mind them.

Pragmatic clinical trials (such as CATIE) provide generalizable data that can be incorporated into medical decision making. In the different phases of CATIE, advantages were evident for each of the atypical antipsychotics and for the representative typical antipsychotic perphenazine, but all in different contexts.

Olanzapine had advantages in terms of all-cause discontinuation and efficacy, particularly in phase 1. It appears that the efficacy advantage of olanzapine drove its overall lower all-cause discontinuation rate. The disadvantage of olanzapine was discontinuation because of weight gain or metabolic effects; although this disadvantage was statistically significant, it did not reach the same level of magnitude as the number needed to treat advantage for efficacy.8

Risperidone and perphenazine had advantages over quetiapine in phase 1 in terms of number needed to treat for all-cause discontinuation. Quetiapine (and olanzapine) had advantages in terms of all-cause discontinuation in phase 1B where perphenazine had failed. Clozapine was superior to risperidone and quetiapine for patients who discontinued an antipsychotic in phase 1 (or 1B) because of poor efficacy. Risperidone had advantages in terms of overall tolerability in phases 1, 2E, and 2T. Ziprasidone had the most benign metabolic profile, and in phase 2T it was associated with a higher likelihood of weight loss for patients who gained more than 7% of their initial body weight in phase 1.

Conclusion

CATIE can be viewed as a switch study. Switches offer both opportunity and risk. Data from CATIE demonstrate differences in overall effectiveness, but these differences depend on the individual patient context. Questions to ask include:

• Did therapy with a “tight” D2 binding agent fail?

• Did therapy fail because of lack of efficacy or tolerability?

• Is weight gain greater than 7% the predominant concern?

• Is the risk of hospitalization the predominant concern?

It will be necessary to match the expectations and requirements of the individual patient to a specific medication—one size does NOT fit all. Treating clinicians need access to all these medications to optimize treatment for each patient.

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References

References

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