Pharmacological guidelines in the treatment of schizophrenia

1. PHARMACOLOGICAL
GUIDELINES IN THE
TREATMENT OF
SCHIZOPHRENIA
BY. EHAB ELBAZ
16-12-2012

2. REFERNCES
► Thomas RE Barnes and the Schizophrenia ConsensusThomas RE Barnes and the Schizophrenia Consensus
Group of the British Association for PsychopharmacologyGroup of the British Association for Psychopharmacology
(2011)(2011) :: Evidence-based guidelines for theEvidence-based guidelines for the
pharmacological treatment of schizophrenia:pharmacological treatment of schizophrenia:
recommendations from the British Association forrecommendations from the British Association for
PsychopharmacologyPsychopharmacology . Journal of. Journal of
Psychopharmacology.25(5) 567Psychopharmacology.25(5) 567––620620
► David Taylor, Carol Paton and Shitij KapurDavid Taylor, Carol Paton and Shitij Kapur (2009)(2009) ::TheThe
South London and Maudsley NHS Foundation Trust &South London and Maudsley NHS Foundation Trust &
Oxleas NHS Foundation Trust PRESCRIBINGOxleas NHS Foundation Trust PRESCRIBING
GUIDELINESGUIDELINES . Informa healthcare . London. Informa healthcare . London

3. OBJECTIVES
1.1. Step by stepStep by step approach for drug treatmentapproach for drug treatment
of schizophrenia in different stages of theof schizophrenia in different stages of the
illness.illness.
2.2. DevelopDevelop one styleone style of prescription that isof prescription that is
evidence based.evidence based.
3.3. MinimizeMinimize faultyfaulty prescription as possible.prescription as possible.

4. Q :Q :
What are the phases of treatmentWhat are the phases of treatment
of schizophrenia as a chronicof schizophrenia as a chronic
disease ?disease ?

5. 1.1. ProdromaProdroma
2.2. First episode psychosisFirst episode psychosis
3.3. Maintenance and relapse preventionMaintenance and relapse prevention
4.4. Relapse or acute exacerbationRelapse or acute exacerbation

6. Q:Q:
Can we recognize the prodromalCan we recognize the prodromal
phase of schizophrenia ?phase of schizophrenia ?

7. ► The termThe term ‘‘At-risk Mental StateAt-risk Mental State’’ oror ‘‘Ultra High RiskUltra High Risk’’
is more appropriate thanis more appropriate than ‘‘prodromeprodrome’’, as the, as the
majority of subjects will not progress to a majormajority of subjects will not progress to a major
psychotic disorder.psychotic disorder.
► Attenuated positive symptoms, major recentAttenuated positive symptoms, major recent
decline in function in someone who has a schi-decline in function in someone who has a schi-
zotypal personality disorder, or a family history ofzotypal personality disorder, or a family history of
psychosis.psychosis.
► Subjective disturbances in thinking, language andSubjective disturbances in thinking, language and
attentionattention
► High risk (20High risk (20––40%) of progression to frank40%) of progression to frank
psychosis within 2 yearspsychosis within 2 years

8. Q:Q:
Is there any thing that can beIs there any thing that can be
done in this prodromal phase ?done in this prodromal phase ?

9. ►Encourage a therapeutic relationshipEncourage a therapeutic relationship
► Assess the nature and impact of anyAssess the nature and impact of any
substance usesubstance use
► If antipsychotic medication is consideredIf antipsychotic medication is considered
should be treated as off-label , short-term,should be treated as off-label , short-term,
Very low doses .Very low doses .
► Individual CBT can be considered.Individual CBT can be considered.

10. Q:Q:
In an established first episodeIn an established first episode
schizophrenia ,how toschizophrenia ,how to
proceed ?proceed ?

12. Q:Q:
In case of relapse or acuteIn case of relapse or acute
exacerbation , what to do ?exacerbation , what to do ?

15. Recommendations regarding
medication adherence
► Offer a choice of medication . Take into account the known adverse effect profiles ofOffer a choice of medication . Take into account the known adverse effect profiles of
individual antipsychotics, a patientindividual antipsychotics, a patient’’s past experience of adverse effects, and the risk ofs past experience of adverse effects, and the risk of
drug interactions and past medical history.drug interactions and past medical history.
► The regimen should be as simple as possible (number of tablets and the number ofThe regimen should be as simple as possible (number of tablets and the number of
times each day).times each day).
► Asking the patients at regular intervals how much of their medication they have taken inAsking the patients at regular intervals how much of their medication they have taken in
the last week, and their view regarding the efficacy of this medication.the last week, and their view regarding the efficacy of this medication.
► Using one of the rating scales or checklists to assess a patientUsing one of the rating scales or checklists to assess a patient’’s attitudes towardss attitudes towards
medication.medication.
► In patients with a history of non-adherence leading to relapse, consideration should beIn patients with a history of non-adherence leading to relapse, consideration should be
given to using more objective methods to monitor adherence to oral medication regimensgiven to using more objective methods to monitor adherence to oral medication regimens
such as pill counts or plasma drug levels.such as pill counts or plasma drug levels.
► A depot/long-acting injection formulation should be considered when this is preferred byA depot/long-acting injection formulation should be considered when this is preferred by
the patient, previous non-adherence has led to frequent relapse or the avoidance of non-the patient, previous non-adherence has led to frequent relapse or the avoidance of non-
adherence is a clinical priority.adherence is a clinical priority.

16. Q :Q :
My patient can not tolerate theMy patient can not tolerate the
antipsychotic because of its sideantipsychotic because of its side
effect , and I want to change it ,effect , and I want to change it ,
what drug do I choose?what drug do I choose?

18. Q:Q:
How to prevent relapse ofHow to prevent relapse of
schizophrenia ?schizophrenia ?

19. Recommendations for maintaining response
and
relapse prevention
► continued maintenance with doses of antipsychotic medication withincontinued maintenance with doses of antipsychotic medication within
the recommended range for 1-2 years in first episode and inthe recommended range for 1-2 years in first episode and in
subsequent episodes the treatment is indefinite .subsequent episodes the treatment is indefinite .
► Before undertaking a switch in antipsychotic medication, an adequateBefore undertaking a switch in antipsychotic medication, an adequate
trial is to be conducted in terms of dosage, duration and adherence.trial is to be conducted in terms of dosage, duration and adherence.
► The care plan should address reversible risk factors for relapse, suchThe care plan should address reversible risk factors for relapse, such
as comorbid substance use, poor adherence and a criticalas comorbid substance use, poor adherence and a critical
environment.environment.
► Depot formulations should be considered when adherence is a priorityDepot formulations should be considered when adherence is a priority
and where a patient expresses a preference for such a formulation.and where a patient expresses a preference for such a formulation.

20. Q:Q:
Patients with predominantlyPatients with predominantly
negative symptoms donnegative symptoms don’’tt
respond well , is there any thingrespond well , is there any thing
more that can be done ?more that can be done ?

21. ► Negative symptoms may be 1ry or 2ry.Negative symptoms may be 1ry or 2ry.
► 1ry _______ predict poor outcome.1ry _______ predict poor outcome.
► 2ry _______ ( depression , bradykinesia,2ry _______ ( depression , bradykinesia,
social withdrawal )social withdrawal )

22. Recommendations for the pharmacologicalRecommendations for the pharmacological
management of negative symptomsmanagement of negative symptoms
► Early identification and treatment of psychosis .Early identification and treatment of psychosis .
► Chose antipsychotic that give balance betweenChose antipsychotic that give balance between
efficacy and side effect.efficacy and side effect.
► Ensure EPS and depression are detected andEnsure EPS and depression are detected and
treated if present.treated if present.
► Consider augmentation of antipsychotic with anConsider augmentation of antipsychotic with an
antidepressant .antidepressant .
► If clozapine is prescribed, consider augmentingIf clozapine is prescribed, consider augmenting
with lamotrigine or a suitable secondwith lamotrigine or a suitable second
antipsychotic.antipsychotic.

23. Q :Q :
What about combinedWhat about combined
antipsychotics ?antipsychotics ?

24. ► Antipsychotic polypharmacy is a widespreadAntipsychotic polypharmacy is a widespread
practice.practice.
► Substantial evidence suggest that polypharmacy isSubstantial evidence suggest that polypharmacy is
harmful.harmful.
► Very limited evidence supports the efficacy ofVery limited evidence supports the efficacy of
combined antipsychotics.combined antipsychotics.

25. ► Q:Q:
My patient has treatment resistantMy patient has treatment resistant
schizophrenia and I started clozapineschizophrenia and I started clozapine
therapy but the outcome is unsatisfactory ,therapy but the outcome is unsatisfactory ,
what is the next move ?what is the next move ?

27. Q:Q:
What to do if clozapine is not anWhat to do if clozapine is not an
option ?option ?

30. Q :Q :
What is the role of ECT inWhat is the role of ECT in
schizophrenia ?schizophrenia ?

31. ► Reviewing the literature by Haskett and LooReviewing the literature by Haskett and Loo
(2010) : the combination of ECT and antipsychotic(2010) : the combination of ECT and antipsychotic
medication may be a useful option for patients withmedication may be a useful option for patients with
schizophrenia that has proved unresponsive toschizophrenia that has proved unresponsive to
pharmacological interventions.pharmacological interventions.
► ECT combined with antipsychotic medicationsECT combined with antipsychotic medications
was an option to be considered when thewas an option to be considered when the
treatment aim was rapid global improvement andtreatment aim was rapid global improvement and
symptomatic reduction, and for patients whosesymptomatic reduction, and for patients whose
illnesses had shown only a limited response toillnesses had shown only a limited response to
medication alone.medication alone.

32. IN BRIEFIN BRIEF
Schizophrenia + pregnancy ______Schizophrenia + pregnancy ______
►ChloropromazineChloropromazine
►HalpridoleHalpridole

33. IN BRIEFIN BRIEF
Schizophrenia + breast feeding ________Schizophrenia + breast feeding ________
►SulpirideSulpiride
►OlanzapineOlanzapine

34. IN BRIEFIN BRIEF
Antipsychotics in renal impairmentAntipsychotics in renal impairment ::
►first-generation antipsychoticfirst-generation antipsychotic –– suggestsuggest
haloperidol 2haloperidol 2––6 mg a day6 mg a day
►second-generation antipsychoticsecond-generation antipsychotic –– suggestsuggest
olanzapine 5 mg a dayolanzapine 5 mg a day

35. IN BRIEFIN BRIEF
Antipsychotics in hepatic impairment :Antipsychotics in hepatic impairment :
► Haloperidol : low doseHaloperidol : low dose
► Sulpiride/amisulpride :Sulpiride/amisulpride : no dosage reductionno dosage reduction
required if renal function is normalrequired if renal function is normal