When do you switch antipsychotics in the inpatient setting?

[uhmocksuhsillen]

Curious how long you guys trial a patient on an antipsychotic before switching course and changing meds? We are under the gun to move people of course, so I often find myself 7-8 days in and scared to change meds because we'll be starting from square one all over again. I also know that we may not get peak efficacy for 6-20 weeks out.

I find myself often going to olanzapine or risperdal, then changing to the other. Occasionally abilify if there's documented positive response in the history. Will at times augment with VPA, lithium. Will at times start clozapine after a failure but there is very poor follow up available and many patients will refuse labs their entire time throughout the hospital stay.

I do deal with a very sick population in a county facility. Just curious what your approach is in this type of environment with patients are not improving much with that first antipsychotic.

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[comp1]

Sounds about right. I typically start new antipsychotic trials with new admissions. I'm guessing the vast majority of your patients will be back. Definitely concur that starting all over is going to lead to longer lengths of stays. Shouldn't most of your people be on LAIs? That really limits the options for switching. Remember, there's not a lot of evidence for difference amongst the antipsychotics in terms of efficacy. Most of what you see during a 2 week inpatient admission is going to be related to sedation. It's honestly in discharge planning, mostly location, that you're going to get a lot more bang for your buck in terms of effort than switching around antispychotics.

 

[uhmocksuhsillen]

Sounds about right. I typically start new antipsychotic trials with new admissions. I'm guessing the vast majority of your patients will be back. Definitely concur that starting all over is going to lead to longer lengths of stays. Shouldn't most of your people be on LAIs? That really limits the options for switching. Remember, there's not a lot of evidence for difference amongst the antipsychotics in terms of efficacy. Most of what you see during a 2 week inpatient admission is going to be related to sedation. It's honestly in discharge planning, mostly location, that you're going to get a lot more bang for your buck in terms of effort than switching around antispychotics.

The issue I run into is I have someone who is still acutely psychotic, gravely disabled at day 7 or 8 and there's not been much improvement. I also don't see too many patients on LAIs. Most people I see have been completely non-compliant with medication. I'll pour through discharge summaries, etc to try and find if anything was beneficial in the past, but many times I'm just starting over from scratch.

My understanding that efficacy trials was essentially (clozapine not included) zyprexa>risperdal>>everything else. I guess my main issue is once you hit day 7 or 8 and there is no benefit and they are still gravely disabled, what do you do? Do you give them more time or make a change?

 

[Stagg737]

The issue I run into is I have someone who is still acutely psychotic, gravely disabled at day 7 or 8 and there's not been much improvement. I also don't see too many patients on LAIs. Most people I see have been completely non-compliant with medication. I'll pour through discharge summaries, etc to try and find if anything was beneficial in the past, but many times I'm just starting over from scratch.

My understanding that efficacy trials was essentially (clozapine not included) zyprexa>risperdal>>everything else. I guess my main issue is once you hit day 7 or 8 and there is no benefit and they are still gravely disabled, what do you do? Do you give them more time or make a change?

That depends on the situation. Literature says that while it can take weeks to months to reach full efficacy, you should see some improvements in the first 2 weeks (and probably some effect in the first week). If you notice no improvements at all, you're either at a sub-therapeutic dose or the med may not work at all. I think a week at a solid dose should be enough time to see some kind of change in most patients, but if you're seeing people who have been on multiple antipsychotics at moderate to high doses, it could take longer. If you're seeing some benefit in week 1, even if mild, I'd probably stick with that med and continue titration. If you're at a moderate dose for 7 days without any improvement, you should be able to justify a switch.

Also depends on what symptoms you're trying to treat. Obvious positive symptoms like hallucinations, severe and bizarre 'delusions', and to a lesser extent significant disorganization typically improve quicker than chronic fixed delusions and or significant negative symptoms which may not respond at all.

 

[comp1]

Most patients you see were completely non-adherent and you don't see many people on LAIs? There might be a connection there...

 

[psycho-matic]

Curious how long you guys trial a patient on an antipsychotic before switching course and changing meds? We are under the gun to move people of course, so I often find myself 7-8 days in and scared to change meds because we'll be starting from square one all over again. I also know that we may not get peak efficacy for 6-20 weeks out.

I find myself often going to olanzapine or risperdal, then changing to the other. Occasionally abilify if there's documented positive response in the history. Will at times augment with VPA, lithium. Will at times start clozapine after a failure but there is very poor follow up available and many patients will refuse labs their entire time throughout the hospital stay.

I do deal with a very sick population in a county facility. Just curious what your approach is in this type of environment with patients are not improving much with that first antipsychotic.

LAIs are your friend here.

 

[psycho-matic]

LAIs are your friend here.

Curious how long you guys trial a patient on an antipsychotic before switching course and changing meds? We are under the gun to move people of course, so I often find myself 7-8 days in and scared to change meds because we'll be starting from square one all over again. I also know that we may not get peak efficacy for 6-20 weeks out.

I find myself often going to olanzapine or risperdal, then changing to the other. Occasionally abilify if there's documented positive response in the history. Will at times augment with VPA, lithium. Will at times start clozapine after a failure but there is very poor follow up available and many patients will refuse labs their entire time throughout the hospital stay.

I do deal with a very sick population in a county facility. Just curious what your approach is in this type of environment with patients are not improving much with that first antipsychotic.

I will also add that, anecdotally, I've had good success with Vraylar and Caplyta. I work in outpatient, so I don't know if this would translate well to inpatient. For active psychosis, I will often use risperidone, soemtimes zyprexa, but I've seen caplyta stabilize patients pretty quickly. Once daily dosing and no titration is an advantage plus it helps with sleep and anxiety, no metabolic effects (same as placebo).

 

[brainmedicine]

LAIs should be the top choice.

What do you all think of Abilify in severe psychosis?

 

[psycho-matic]

Y Jj] yyyyyyyyrr Jr 90 NN

LAIs should be the top choice.

What do you all think of Abilify in severe psychosis?

It wouldn't be my first or 2nd or 3rd choice... Because of it's partial agonism I think it's less effective.

 

[uhmocksuhsillen]

Most patients you see were completely non-adherent and you don't see many people on LAIs? There might be a connection there...

It's not like LAI are more effective than PO (or if they are I believe its very marginal at best when controlling for compliance). A lot of these people have never found an effective medication.

 

[comp1]

LAIs are the standard of care in psychotic disorders for a reason. There are hundreds, if not thousands, of studies demonstrating not only improved treatment adherence (how could there not be?), but also improved long term functioning over oral. Here's just one random recent study: Treatment adherence in forensic patients with schizophrenia spectrum disorders discharged on long-acting injectable antipsychotics: a comparative 3-year mirror-image study - PubMed Basically, if patients aren't treatment adherent for a longer period of time than you're going to see them inpatient, you have no idea if a medication is effective or not. And in terms of Abilify, yeah, it's not great, but Maintena or Aristada beat an unopened oral Zyprexa bottle thrown in the trash.

 

[Stagg737]

Y Jj] yyyyyyyyrr Jr 90 NN

It wouldn't be my first or 2nd or 3rd choice... Because of it's partial agonism I think it's less effective.

It's got it's place. I definitely prefer other medications over Abilify for severe psychosis, but have had a handful of patients where it's just "the right med". It's also one of the first options when clozapine needs an augmenting agent.

 

[claypigeon]

LAIs are the standard of care in psychotic disorders for a reason. There are hundreds, if not thousands, of studies demonstrating not only improved treatment adherence (how could there not be?), but also improved long term functioning over oral. Here's just one random recent study: Treatment adherence in forensic patients with schizophrenia spectrum disorders discharged on long-acting injectable antipsychotics: a comparative 3-year mirror-image study - PubMed Basically, if patients aren't treatment adherent for a longer period of time than you're going to see them inpatient, you have no idea if a medication is effective or not. And in terms of Abilify, yeah, it's not great, but Maintena or Aristada beat an unopened oral Zyprexa bottle thrown in the trash.

There's a lot of studies showing LAI's don't offer improvement over oral antipsychotics. I'm sure a huge confound is adherence and whether family or someone is able to help get these patients to take the LAI (hence why a study in forensic patients might be positive), with another huge confound being if one has the resources to track when your patients misses their injection and to intervene early, but it's not black and white. In the long term, a month on maintena isn't any better than that unopened oral zyprexa bottle.

https://www.nejm.org/doi/full/10.1056/nejmoa1005987

Treatment of Schizophrenia With Long-Acting Fluphenazine, Haloperidol, or Risperidone

Abstract. Objective: This study compares 3 cohorts of patients with schizophrenia before, during, and after initiating treatment with fluphenazine decanoat

academic.oup.com

Psychosis breakthrough on antipsychotic maintenance: results from a nationwide study - PubMed

BAMM was relatively common even when adherence was confirmed with LAIs. Illness instability at treatment onset accounted for most cases, but relapse after years of continuous treatment was still prevalent. There was insufficient evidence to support causality between cumulative antipsychotic...

pubmed.ncbi.nlm.nih.gov

 

[comp1]

I recognize that one can find a study to support any belief...but it's just not accurate to say that the most literature finds no evidence of difference between oral and LAI. Impact of schizophrenia relapse definition on the comparative effectiveness of oral versus injectable antipsychotics: A systematic review and meta-analysis of observational studies - PubMed

 

[ClosetCentrist]

If you don't see significant improvement in 2 weeks, you should be switching your agent. The literature indicates that the vast majority of improvement on antipsychotics occurs in the first 4 weeks of treatment, and the majority of that improvement happens in the first 2 weeks

The “delayed onset” of antipsychotic action — an idea whose time has come and gone

For years, it has been known that the “onset” of the antipsychotic response is “delayed,” and this notion is expressed in many major textbooks, informs clinical decisions and has even led to the search for biological markers ...

www.ncbi.nlm.nih.gov

 

[clozareal]

If you don't see significant improvement in 2 weeks, you should be switching your agent. The literature indicates that the vast majority of improvement on antipsychotics occurs in the first 4 weeks of treatment, and the majority of that improvement happens in the first 2 weeks

The “delayed onset” of antipsychotic action — an idea whose time has come and gone

For years, it has been known that the “onset” of the antipsychotic response is “delayed,” and this notion is expressed in many major textbooks, informs clinical decisions and has even led to the search for biological markers ...

www.ncbi.nlm.nih.gov

There's lots of studies like this that are really interesting. Nonresponse at 2 weeks predicts nonresponse at 8 weeks with about 80-90% accuracy.

Early non-response as a predictor of later non-response to antipsychotics in schizophrenia: a randomized trial

It remains a challenge to predict the long-term response to antipsychotics in patients with schizophrenia who do not respond at an early stage. This study aimed to investigate the optimal predictive cut-off value for early non-response that would better ...

www.ncbi.nlm.nih.gov

It might be a bit longer for the antipsychotics with longer half lives though like aripiprazole. Maybe 4 weeks.

 

[claypigeon]

I recognize that one can find a study to support any belief...but it's just not accurate to say that the most literature finds no evidence of difference between oral and LAI. Impact of schizophrenia relapse definition on the comparative effectiveness of oral versus injectable antipsychotics: A systematic review and meta-analysis of observational studies - PubMed

We can agree to disagree. I’m saying it’s not black and white. You’re saying LAIs>PO and writing off my citations without arguing anything but an ad hominem against them. Heck, one of my citations is an RCT from NEJM, not some random journals. But LAIs can’t work if we don’t have the infrastructure to support their use.

In the long term, a month on maintena isn't any better than that unopened oral zyprexa bottle.

 

[jbomba]

Are we saying lai work better because they are somehow more effective if compliance is controlled for?

 

[smalltownpsych]

There's a lot of studies showing LAI's don't offer improvement over oral antipsychotics. I'm sure a huge confound is adherence and whether family or someone is able to help get these patients to take the LAI (hence why a study in forensic patients might be positive), with another huge confound being if one has the resources to track when your patients misses their injection and to intervene early, but it's not black and white. In the long term, a month on maintena isn't any better than that unopened oral zyprexa bottle.

https://www.nejm.org/doi/full/10.1056/nejmoa1005987

Treatment of Schizophrenia With Long-Acting Fluphenazine, Haloperidol, or Risperidone

Abstract. Objective: This study compares 3 cohorts of patients with schizophrenia before, during, and after initiating treatment with fluphenazine decanoat

academic.oup.com

Psychosis breakthrough on antipsychotic maintenance: results from a nationwide study - PubMed

BAMM was relatively common even when adherence was confirmed with LAIs. Illness instability at treatment onset accounted for most cases, but relapse after years of continuous treatment was still prevalent. There was insufficient evidence to support causality between cumulative antipsychotic...

pubmed.ncbi.nlm.nih.gov

This. In my experience working with chronic and difficult to treat psychosis, the psychosocial factors typically appear to be a bigger factor than the medication choice. Especially when you include substance use as one of those factors. When my patients stabilize a bit and we discuss the pros and cons of medications and why they are taking them they typically agree with the plan. It takes quite a while to build that level of trust and understanding and usually people don’t have time for that so they just tell the patient what to do and why and then talk about how the patient is non-compliant and we need to exert more control over them. After all, “if they just took their medication, then everything would be fine”. That is a lie and it even spreads past the Bipolar and Schizophrenia patients where at least it has some foundation in reality albeit misguided to the Borderline patients where it is an expression of a pathological object relations enactment more than anything else.

edit to add: it’s typically not the psychiatrists that I have worked with promoting the misconceptions, they tend to get the bigger picture better, especially these days it seems.

 

[Styrene]

Y Jj] yyyyyyyyrr Jr 90 NN

It wouldn't be my first or 2nd or 3rd choice... Because of it's partial agonism I think it's less effective.

Good point. Dopamine supersensitivity psychosis can be induced/worsened by 1) starting Abilify in the context of active DSP and 2) abrupt switching to Abilify from full D2 antagonists. In my experience, Abilify has little if any usefulness, and the potential for substantial harm, in the acute inpatient unit setting in patients with schizophrenia exacerbations and previous full D2 antagonist exposure. Abilify is great for first episode for a few different reasons.

 

[comp1]

I get the pharmacokinetic argument...but is there any literature demonstrating harm from switching to Abilify from other atypicals? That seems like it would be pretty important, possibly important enough to put on a prescriber information sheet. Fortunately most inpatients haven't exactly been medication adherent prior to admission, so switching isn't always super relevant.

 

[Cath Up]

We can agree to disagree. I’m saying it’s not black and white. You’re saying LAIs>PO and writing off my citations without arguing anything but an ad hominem against them. Heck, one of my citations is an RCT from NEJM, not some random journals. But LAIs can’t work if we don’t have the infrastructure to support their use.

In the long term, a month on maintena isn't any better than that unopened oral zyprexa bottle.

Basically the whole thing is adherence. All patients and especially psychiatric patients have horrible adherence. LAIs ensure complete adherence for 30 day intervals.

I think there's a reasonable argument to be made that a month on maintena is better than an unopened Zyprexa bottle in that it confers protection from psychosis (and therefore some degree of brain degeneration) for >=1 month vs no protection while not taking medication.