Pres 3 col

it time to ditch this fixation?
Martin Livingston MD, FRCPsych
Professor Cunningham Owens, in his paper com- cacy. The differences between drugs usually lie in side- paring older and newer antipsychotics in this issue effect profiles, often the key factor in drug selection. (Antipsychotics: is it time to end the generation game?, see pages 48–50), has drawn several important conclu- Wonderland may, however, be tilting at windmills in his sions that should influence our prescribing. Classifying recommendation for thorough dose-ranging studies of antipsychotics as ‘atypical’ or ‘typical’ is unhelpful.
the older drugs to be carried out so that we are better The evidence supporting such a dichotomy is lacking, informed on what is the minimum effective dose. There despite the fact that the BNF sets out these drugs in is little commercial benefit for the pharmaceutical com- panies in re-examining older patent-expired drugs where The term ‘atypical’ does not define a group of there is unlikely to be a new prescribing indication.
antipsychotics that are more effective in any symptom domain in schizophrenia than a previous generation Using the whole range
of such drugs. All antipsychotics, with the notable This iconoclastic paper does carr y a positive message, exception of clozapine, have approximately equal effi- which is that we should feel free to use the whole range Editorial
of antipsychotics, targeting the drug therapy to the done – quetiapine (Seroquel) or aripiprazole are use- patient’s clinical needs and tolerance. ful choices, the latter drug also being an appropriate The malnourished schizophrenic may benefit from choice in Parkinson’s disorder where there are psy- some weight gain, so olanzapine and chlorpromazine would be good choices here. If obesity is a problem, For the poor responder with schizophrenia who has or the metabolic syndrome is developing, then arip- failed to improve significantly on two consecutive iprazole (Abilify) and haloperidol would be helpful. antipsychotics, a trial of clozapine is indicated. This is a If poor adherence is evident in an outpatient with drug to be avoided – at least in higher doses – in patients psychosis, super vised administration of an oral drug with epilepsy but trifluoperazine, haloperidol or becomes feasible when prescribing pimozide (Orap), sulpiride are antipsychotics less likely to provoke seizures.
which can be given as infrequently as three times per Similarly, the revival of interest in long-acting week due to its long half-life. Is a once-daily regimen injectable antipsychotics need not be confined to sought? Choose aripiprazole, haloperidol or olanzapine. newer compounds. Older drugs such as flupentixol If the patient has hyperprolactinaemia and com- (Depixol), zuclopenthixol (Clopixol), fluphenazine plains of galactorrhoea or amenorrhoea, avoid risperi- and haloperidol (Haldol Decanoate) in their respec- Editorial
tive ‘depot’ formulations are as effective as the newer While we await the emergence of new antipsy- formulations and may be well tolerated, especially if chotics that do not rely on the dopamine model of psy- chosis, the lack of which Cunningham Owens laments, The depots are, however, not good choices in renal we should take advantage of all the available options or hepatic impairment. Aripiprazole and trifluoper- azine are appropriate drugs in the former, and haloperi- dol is the leading choice in hepatic impairment. Declaration of interests
Dr Livingston has ser ved on an advisor y board for
paliperidone on behalf of Janssen-Cilag and he has Early inter vention in psychosis ser vices, which tend to also received speaker fees for chairing meetings spon- use the newer drugs as first choice, may wish to take a fresh look at the array of compounds that become available once the fixation with atypicality is aban- Dr Livingston is consultant psychiatrist and honorar y doned. Again, care with dosage, usually involving slow senior clinical lecturer, Southern General Hospital, upward titration, is the key to tolerability.


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