氯氮平联合治疗与增效策略在精神分裂症患者中的应用——精神病治疗反应和抵抗（TRRIP）工作组的国际专家调查建议。
Clozapine Combination and Augmentation Strategies in Patients With Schizophrenia -Recommendations From an International Expert Survey Among the Treatment Response and Resistance in Psychosis (TRRIP) Working Group.
机构信息
Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY.
出版信息
Schizophr Bull. 2020 Dec 1;46(6):1459-1470. doi: 10.1093/schbul/sbaa060.
BACKGROUND
Evidence for the management of inadequate clinical response to clozapine in treatment-resistant schizophrenia is sparse. Accordingly, an international initiative was undertaken with the aim of developing consensus recommendations for treatment strategies for clozapine-refractory patients with schizophrenia.
METHODS
We conducted an online survey among members of the Treatment Response and Resistance in Psychosis (TRRIP) working group. An agreement threshold of ≥75% (responses "agree" + "strongly agree") was set to define a first-round consensus. Questions achieving agreement or disagreement proportions of >50% in the first round, were re-presented to develop second-round final consensus recommendations.
RESULTS
Forty-four (first round) and 49 (second round) of 63 TRRIP members participated. Expert recommendations at ≥75% agreement included raising clozapine plasma levels to ≥350 ng/ml for refractory positive, negative, and mixed symptoms. Where plasma level-guided dose escalation was ineffective for persistent positive symptoms, waiting for a delayed response was recommended. For clozapine-refractory positive symptoms, combination with a second antipsychotic (amisulpride and oral aripiprazole) and augmentation with ECT achieved consensus. For negative symptoms, waiting for a delayed response was recommended, and as an intervention for clozapine-refractory negative symptoms, clozapine augmentation with an antidepressant reached consensus. For clozapine-refractory suicidality, augmentation with antidepressants or mood-stabilizers, and ECT met consensus criteria. For clozapine-refractory aggression, augmentation with a mood-stabilizer or antipsychotic medication achieved consensus. Generally, cognitive-behavioral therapy and psychosocial interventions reached consensus.
CONCLUSIONS
Given the limited evidence from randomized trials of treatment strategies for clozapine-resistant schizophrenia (CRS), this consensus-based series of recommendations provides a framework for decision making to manage this challenging clinical situation.
背景
氯氮平治疗抵抗性精神分裂症患者临床疗效不佳的治疗方法证据有限。因此，开展了一项国际性的倡议，旨在为氯氮平难治性精神分裂症患者的治疗策略制定共识推荐。
方法
我们对治疗反应和精神分裂症抵抗性（TRRIP）工作组的成员进行了在线调查。设定了≥75%（“同意”+“强烈同意”的回答）的一致性阈值来定义第一轮共识。对第一轮中达成≥50%的一致性或不一致性比例的问题进行重新呈现，以制定第二轮最终共识推荐。
结果
63 名 TRRIP 成员中的 44 名（第一轮）和 49 名（第二轮）参与了研究。≥75%一致性的专家建议包括将氯氮平的血浆水平提高到难治性阳性、阴性和混合症状≥350ng/ml。当基于血浆水平的剂量递增对持续性阳性症状无效时，建议等待延迟反应。对于氯氮平难治性阳性症状，建议联合第二种抗精神病药（氨磺必利和口服阿立哌唑）和电休克治疗。对于阴性症状，建议等待延迟反应，作为氯氮平难治性阴性症状的干预措施，氯氮平联合抗抑郁药也达成了共识。对于氯氮平难治性自杀倾向，抗抑郁药或情绪稳定剂的增效治疗以及电休克治疗符合共识标准。对于氯氮平难治性攻击性行为，情绪稳定剂或抗精神病药物的增效治疗也达成了共识。一般来说，认知行为疗法和心理社会干预也达成了共识。
结论
鉴于氯氮平抵抗性精神分裂症（CRS）治疗策略的随机试验证据有限，本共识推荐系列为管理这一具有挑战性的临床情况提供了决策框架。
Zotero 插件