How to cross taper antipsychotics?

[ryerica22]

I always wonder how the preferred method is? Say I have someone on Risperdal 2 mg BID and it is not working, I am contemplating switching them to Zyprexa. I usually look at the half lives of the medications and adjust it accordingly till symptoms (i.e. psychosis/hallucinations) are better. Is there a standard way to do this? Do you guys use a dose equivalency chart or something?

One of my attendings, use to cross taper for years on his patients, which I try to avoid for many reasons.

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[wolfvgang22]

There are some good antipsychotic equivalency charts. I'm away from my desk or I would attach them here. They are easily found via google or pubmed.

 

[hamstergang]

I don't understand how you'd use a dose equivalency chart in a cross taper.

I taper down at roughly the same speed I titrate up.

 

[Merely]

My attendings wing this I’m pretty sure. They just decrease one and increase the other incrementally without much thought lol

 

[NJWxMan]

There are some guidelines that insist on avoiding any cross titration and only tapering weeks, sometimes months, later.

 

[Armadillos]

Worth remembering that in outpatient world except for patients in RCFs your patients on antipsychotics are probably missing meds like half the days of the week and if they report side effects probably already stopped the meds anyway.

Just to say you can cook up elaborate plans, but it will likely be a waste of time if you don’t have a good sense of what the patient is actually doing vs what they say they are doing.

Also if your changing meds just for lack of efficacy, I would almost always try the LAI before a different Med for the same reason as above.(Assuming outpatient where you can’t assure compliance, otherwise obviously want to see someone stable on the PO before the LAI)

 

[NickNaylor]

I will typically keep the old antipsychotic at whatever dose it's currently at while starting the new antipsychotic. I will keep dual therapy going for a bit just to make sure the patient is getting an adequate dose of antipsychotic in case they have trouble with the new one for some reason.

After that, I just kind of wing it. I will typically increase the dose of the new antipsychotic and decrease the dose of the old antipsychotic at the same time while monitoring for recurrence of symptoms. I will typically increase/decrease the dose at gradations that make sense with respect to the dosing of the individual antipsychotics. For example, olanzapine typically comes in 5 mg tablets, so I'll usually make 5 mg changes in the dose. Same with aripiprazole. I'll typically titrate quetiapine in 100 mg steps, though you could do 50 mg. And on and on. I try to avoid asking patients to cut tablets as much as possible since I figure that's a fairly large barrier to adherence.

 

[FlowRate]

Agree with Nick. I don't have much chance to do this on my own patients but worked with attendings whose caseload is 100% super resistant psychosis/MIPSB cases. They recommend (obviously) first trying an antipsychotic to a therapeutic dose. If there's no response at all you can probably stop the medication while adding a new one. If there's partial response, leave the med while starting a new one. Then, if the patient stabilizes after adding the new med, try tapering the partial response med, as those attendings felt that, in most cases, monotherapy will end up being effective.

 

[clozareal]

Try this:

Antipsychotic Dose Conversion Calculator

Antipsychotic Dose Conversion Calculator

psychopharmacopeia.com

 

[TexasPhysician]

If Risperidone 2mg BID isn’t working, it’s time for 3mg BID in my opinion. I wouldn’t cross-titrate.

Otherwise this is patient specific.

If it’s a hypomanic patient with experience on multiple neuroleptics in which Risperidone has no benefit at this dose (and side effects), I’d hard stop and transition to another option simultaneously.

If in a situation requiring true cross-titration, I’ll move as quickly or slowly as clinically indicated.

 

[ryerica22]

Wow this thread has been super helpful. I hate doing cross-titrations. lol

 

[PsyDr]

Psychiatrienet

wiki.psychiatrienet.nl

 

[clausewitz2]

Psychiatrienet

wiki.psychiatrienet.nl

Most of these entries are based on a single paper or are just the recommendations of the EU equivalent of the FDA. It's fine as suggestions but this is an area where an excessively rigid schedule derived from population means is not helpful.