46 - Relapse or acute exacerbation of schizophreni

Relapse or acute exacerbation of schizophrenia

46 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Investigate social or psychological precipitants Provide appropriate support and/or therapy Continue usual drug treatment Add short-term sedative or Switch to a different, more acceptable antipsychotic medication if appropriate Discuss medication choice with patient and/or carer Assess over 6–8 weeks Switch to clozapine Acute drug treatment required Treatment algorithm Treatment ineffective Notes ■ ■First-­generation drugs may be slightly less efficacious than some SGAs.14,15 FGAs should probably be reserved for second-­ or third-­line use (or not used at all) because of the possibility of poorer outcome compared with SGAs and the higher risk of movement disorder, particularly TD.16,17 ■ ■Choice should be based largely on comparative adverse-­effect profile and relative toxicity. Patients seem able to make informed choices based on these factors,18,19 although in practice they are rarely involved in drug choice.20 Allowing patients informed choice seems to improve outcomes.1 ■ ■Where there is prior treatment failure (but not confirmed treatment refractoriness), olanzapine or risperidone may be better options than quetiapine.21 Olanzapine, because of the wealth of evidence suggesting slight superiority over other antipsychotics, should probably be tried before clozapine unless contraindicated.22–25 However, one RCT6 found that continuing with amisulpride was as effective as switching to olanzapine. ■ ■Before considering clozapine, ensure adherence to prior therapy using depot/LAI formulation or plasma drug level monitoring of oral treatment. Most non-­adherence is undetected in practice,21,26 and apparent treatment resistance may simply be a result of inadequate treatment.27 ■ ■Time to response is increased and total response decreased in exacerbations of multi-­episode schizophrenia.28 ■ ■Where there is confirmed treatment resistance (failure to respond to adequate trials of at least two antipsychotic medications), evidence supporting the use of clozapine (and only clozapine) is overwhelming.29,30

• In patients taking oral antipsychotics, non-­compliance often goes undetected.26 Absolute non-­compliance (blood levels of zero) is surprisingly common.27 Relapse or acute exacerbation of schizophrenia (full adherence to medication confirmed)*