
- Psychiatric Times Vol 36, Issue 2
- Volume 36
- Issue 2
Understanding the Risks and Benefits of Antipsychotic Polypharmacy
Antipsychotic drugs are the cornerstone in the management of psychotic disorders, but most patients fail to have a “good” response in short-term trials. Alternative strategies are presented here.
Antipsychotic drugs are the cornerstone in the management of psychotic disorders, but most patients fail to have a “good” response in short-term trials. Therefore, alternative strategies including dose escalation, switching to another antipsychotic, or co-treatment with polypharmacy are often necessary. At any given time, more than 20% of the patients receive antipsychotic polypharmacy in an attempt to manage suboptimal response to monotherapy (
Surveys reveal that most of the patients treated with antipsychotic polypharmacy were in fact inherited from other prescribers, yet most clinicians are reluctant to convert these patients to antipsychotic monotherapy (
Beyond adding a second antipsychotic, adjunctive treatment with other types of drugs is also common. A
The common use of polypharmacy contrasts with the relatively limited attention that is paid to usual drivers of insufficient treatment response. As with any chronic condition that involves taking drugs on a daily basis, psychotic disorders are associated with high rates of treatment non-adherence. However, this is often challenging for clinicians to recognize and may result in changes in the treatment plan. For example, about one-third of patients deemed to be poor responders and in need of a management strategy change may not have therapeutic antipsychotic serum levels.
Another likely driver of poor response is treatment-resistant schizophrenia (TRS). A diagnosis of TRS and a trial with clozapine are indicated for patients who have had 2 antipsychotic monotherapy trials fail; however, both are often delayed.5 Data show that patients with TRS may undergo more than 5 antipsychotic trials before they receive clozapine, and that it may take a median of 5 years between meeting criteria for TRS and the onset of a clozapine trial. Some clinicians prefer to use polypharmacy over clozapine, and many patients may never have a clozapine trial. The utilization rate of this drug in the US is about 5% of antipsychotic initiations among patients with TRS, which indicates that this drug is largely underutilized.6
The benefits of polypharmacy
To date, no combination strategy has been approved for the management of psychosis. In fact, proving that a combination of 2 drugs in polypharmacy works better than either of those drugs in monotherapy is particularly challenging. The combination needs to be tested independently against each individual drug in monotherapy, to confirm that the combination, and not the augmenting drug only, is superior to the augmented drug-this trial design is rarely done. Instead, most of the data come from studies that only compare the augmented drug to the combination, or directly compare co-treatment to monotherapy without confirming that monotherapy is not efficacious in a particular population.
With these caveats, hundreds of randomized controlled trials have been conducted to test the efficacy of the multiple forms of polypharmacy in various symptom domains of psychoses. These trials are often meta-analyzed as a way of obtaining unique pooled effects, which are often considered more reliable than those obtained from individual studies.
In a
Our team concluded that none of the recommended combinations had a meaningful benefit compared with their monotherapy counterparts. Those that showed benefit, had important risk of bias that did not justify the recommendation of drug combination for any of the symptom domains in schizophrenia. This is particularly disappointing for cognitive or negative symptoms that show limited benefit from antipsychotics monotherapy, yet are very burdensome. Our findings suggest that large high-quality trials are still necessary to address this issue.
Neurobiological research is also looking at the effects of augmenting antipsychotics with other drugs. For example, in
Similarly, when the effects of fatty acids augmentation have been studied,
The implications of the described neurobiological effects in the pathophysiology of psychotic symptoms is unknown. Furthermore, this type of research is challenged by the simultaneous action of more than one drug intervention at once, which makes it difficult to disentangle the neurobiological effects of each one. There are insufficient data from clinical or biological research that indicate the benefits of polypharmacy compared with antipsychotic monotherapy.
The risks of polypharmacy
In general, the use of antipsychotic polypharmacy has been associated with a greater burden of adverse effects, although some of these effects seem to be specific to the combination of antipsychotics.10 For example, when the effects of transition from various types of antipsychotic combinations to monotherapy were studied, individuals randomized to monotherapy lost weight compared with individuals who continued in polypharmacy.3
Specific drug combinations, particularly those that include aripiprazole may have particular adverse effect profiles. For example, in randomized studies that added aripirazole to clozapine or olanzapine polypharmacy was associated with weight loss.10-12 Similarly, for metabolic status, augmentation with aripiprazole has been found to be beneficial for various parameters, mostly in patients treated with clozapine.10,11 This was also the case for the addition of aripiprazole to haloperidol, which was associated with reductions in prolactinemia.13 Some of the beneficial effects found for polypharmacy including aripiprazole may not apply to other drug combinations, where in fact the adverse effect burden may be greater than with monotherapy.
Notably, most of the randomized studies on antipsychotic polypharmacy have been done using aripiprazole as an augmenting agent, which may have a different adverse effect profile than most other antipsychotics.
Altogether, the adverse effect burden of antipsychotic polypharmacy seems to be specific to the type of combination, with aripiprazole having some possible advantages in selected domains. However, in general findings suggest that most combinations of antipsychotics may have greater adverse effect profile than monotherapy. Most importantly, this practice may result in patients being labelled “poor responders” unnecessarily by preventing the utilization of more effective treatments, such as long-acting injectable or clozapine.
Evidence-based recommendations
The risk-to-benefit ratio seems to favor the use of antipsychotic monotherapy over polypharmacy in general terms, given the at best inconsistent results that favor combination treatment and the possibility of adverse effects associated with polypharmacy. Most importantly, polypharmacy may divert evidence-based treatments for patients with poor response to antipsychotic monotherapy such as clozapine or long-acting injectable antipsychotics.
The first recommendation for the management of patients with poor treatment response is to construct a clear psychopharmacological history to assure that monotherapy treatment trials reached the maximum recommended dose, and that they were of sufficient duration. This addresses the clinical response to the positive, the negative, and the cognitive domains. Although somewhat controversial, the lack of response (defined as <20% of change in a rating scale) within 2 weeks may be sufficient to recommend a change in the treatment strategy.15 Monitoring the response to a clinical trial using rating scale such as the PANSS-6 for at least 2 weeks is recommended.
Long-acting injectable formulations have substantial advantage over oral formulations because they minimize interruptions to the continuity of treatment. As a next step, consider a diagnosis of TRS. If a diagnosis of TRS is warranted, clozapine is the only approved treatment for these patients.
Conclusion
Clinicians and patients should keep in mind the risk-to-benefit ratio considerations before initiating polypharmacy, especially if they have patients with polypharmacy prescriptions inherited from other providers. Special consideration should be given to the use of long-acting injectables and clozapine for patients with poor response to antipsychotics.
Disclosures:
Dr Rubio is Assistant Professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Feinstein Institute for Biomedical Research, Northwell Health; and Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY. Dr Rubio has received honoraria from Lundbeck.
References:
1. Gallego JA, Bonetti J, Zhang J, et al.
2. Correll CU, Shaikh L, Gallego JA, et al.
3. Essock SM, Schooler NR, Stroup TS, et al.
4. Correll CU, Rubio JM, Inczedy-Farkas G, et al.
5. Hasan A, Falkai P, Wobrock T, et al.
6. Stroup TS, Gerhard T, Crystal S, et al.
7. Klauser P, Xin L, Fournier M, et al.
8. McQueen G, Lally J, Collier T, et al.
9. Pawelczyk T, Piatkowska-Janko E, Bogorodzki P, et al.
10. Fleischhacker WW, Heikkinen ME, Olie JP, et al.
11. Chang JS, Ahn YM, Park HJ, et al.
12. Henderson DC, Fan X, Copeland PM, et al.
13. Shim JC, Shin JG, Kelly DL, et al.
14. Gallego JA, Nielsen J, De Hert M, et al.
15. Tiihonen J, Mittendorfer-Rutz E, Majak M, et al.
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