Schizophrenia past clozapine: what works?

Clozapine is superior to other antipsychotic drugs for treatment of refractory schizophrenia. However, its use has been limited by its potentially serious adverse effects. There is little guidance on the management of patients who discontinue clozapine for reasons such as lack of response, intolerance, or noncompliance. The literature was searched for studies on the efficacy of antipsychotics that replaced clozapine in such patients. The search revealed 15 papers, which were evaluated in this article. Olanzapine was the most tested alternative to clozapine with most of the studies reporting positive outcome, especially in patients with less severe illness and those who stop clozapine for reasons other than poor response. Other antipsychotics were not adequately tested in this manner. We concluded that in patients who discontinue clozapine, considering a trial of olanzapine would be worthwhile.