Schizophrenia Division, Complex Care & Recovery Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.
Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
Schizophr Bull. 2017 Jul 1;43(4):862-871. doi: 10.1093/schbul/sbw171.
Antipsychotic switching is routine in clinical practice, although it remains unclear which is the preferable switching method: immediate discontinuation of the current antipsychotic or a gradual tapering approach. The first strategy has been implicated in rebound/withdrawal symptoms and emergence/exacerbation of symptoms, whereas the gradual approach is thought to pose a risk of additive or synergistic side effects if employed in the context of a crossover approach.
MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were systematically searched. Randomized controlled trials examining immediate vs gradual antipsychotic discontinuation in antipsychotic switching in patients with schizophrenia and/or schizoaffective disorder were selected. Data on clinical outcomes, including study discontinuation, psychopathology, extrapyramidal symptoms, and treatment-emergent adverse events, were extracted.
A total of 9 studies involving 1416 patients that met eligibility criteria were included in the meta-analysis. No significant differences in any clinical outcomes were found between the 2 approaches (all Ps > .05). Sensitivity analyses revealed that the findings remained unchanged in the studies where switching to aripiprazole was performed or where immediate initiation of the next antipsychotic was adopted, while some significant differences were observed in switching to olanzapine or ziprasidone.
These findings indicate that either immediate or gradual discontinuation of the current antipsychotic medication represents a viable treatment option. Clinicians are advised to choose an antipsychotic switching strategy according to individual patient needs. This said, immediate discontinuation may be advantageous both for simplicity and because a stalled cross-titration process in antipsychotic switching could end up in antipsychotic polypharmacy.
抗精神病药的转换在临床实践中很常见，尽管目前尚不清楚哪种转换方法更为可取：是立即停止当前的抗精神病药物治疗，还是逐渐减量。第一种策略与反弹/戒断症状以及症状的出现/加重有关，而逐渐减量的方法如果在交叉转换的情况下使用，则被认为会增加或协同出现副作用的风险。
系统检索了 MEDLINE、Embase 和 Cochrane 对照试验中心注册库。选择了比较精神分裂症和/或分裂情感障碍患者抗精神病药转换时立即与逐渐停止抗精神病药治疗的随机对照试验。提取了包括研究中止、精神病理学、锥体外系症状和治疗中出现的不良事件等临床结局的数据。
共有 9 项符合纳入标准的研究，共纳入 1416 例患者，进行了荟萃分析。两种方法在任何临床结局上均无显著差异（所有 P 值均＞0.05）。敏感性分析显示，在转换为阿立哌唑或立即开始使用下一种抗精神病药的研究中，研究结果保持不变，而在转换为奥氮平和齐拉西酮的研究中则观察到了一些显著差异。
这些发现表明，立即或逐渐停止当前的抗精神病药物治疗都是可行的治疗选择。临床医生应根据患者的个体需求选择抗精神病药转换策略。尽管如此，立即停止治疗可能具有优势，既简单又因为抗精神病药转换过程中的交叉滴定停滞最终可能导致抗精神病药的联合用药。
