Opinion
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Recommendations for Switching to Xanomeline/Trospium Chloride for Patients With Schizophrenia
Panelists discuss how switching patients to xanomeline/trospium chloride requires different cross-titration strategies depending on whether patients are on “done” medications versus “pines” medications, with special attention to anticholinergic effects when transitioning from sedating antipsychotics.
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The discussion addresses practical switching strategies from conventional antipsychotics to xanomeline/trospium chloride, acknowledging the absence of official prescribing guidelines for medication transitions. Linda describes her cross-titration approach, emphasizing the risks of abrupt antipsychotic discontinuation that could destabilize patients while balancing the need for improved efficacy and tolerability.
Different switching strategies are employed based on the originating antipsychotic class. For “peens” (quetiapine, olanzapine), Linda implements a modified approach due to anticholinergic concerns, moving these medications to nighttime dosing while initiating morning xanomeline/trospium chloride at 50 mg. She waits until reaching lower threshold doses (quetiapine <150 mg, olanzapine <10 mg) before adding the evening dose to minimize additive anticholinergic effects.
For “dones” (risperidone, aripiprazole), traditional cross-titration methods are employed with less concern for anticholinergic interactions. The approach involves a gradual dose reduction of the original medication while simultaneously increasing xanomeline/trospium chloride, with careful monitoring for breakthrough symptoms and adverse effect management. This individualized approach recognizes the unique challenges of transitioning from dopamine-blocking mechanisms to muscarinic activation while maintaining therapeutic stability.
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