Magazine article Clinical Psychiatry News

Side Effects Guide Antipsychotic Drug Choices: Atypicals vs. Typicals

Magazine article Clinical Psychiatry News

Side Effects Guide Antipsychotic Drug Choices: Atypicals vs. Typicals

Article excerpt

SAN FRANCISCO -- Atypical antipsychotics may or may not be more effective in treating schizophrenia than their first-generation cousins. That means clinicians choose antipsychotics largely based on side effects and patient preferences.

Experts on either side of the efficacy debate picked apart several metaanalyses comparing the two generations of the drugs and argued the fine points of methodology in a panel at the annual meeting of the American Psychiatric Association. The session was not sponsored by any pharmaceutical company.

The authors of two major metaanalyses said that they had collected virtually the same raw data but that their interpretations had led to opposite conclusions about the presumed superiority of atypical antipsychotics. "I don't think any of us can prove who's getting it wrong. It's very hard to disentangle side effects from efficacy," said Dr. John M. Davis, professor of psychiatry at the University of Illinois at Chicago.

After all was said and done, one baffled clinician asked a question on the minds of many in the audience: "I'm in the trenches. How do the data help me to decide what to do for my patients?"

The panelists generally agreed that first-generation antipsychotics, compared with one another, seem to be equally effective. The atypical antipsychotics cause fewer neurologic side effects, such as extrapyramidal symptoms, compared with the first-generation drugs but may cause more metabolic effects such as weight gain, high cholesterol, or diabetes, depending on the drug.

Dr. John Geddes, whose metaanalysis found no difference in efficacy between the two generations of antipsychotics, said, "I give a description of side effects to patients. If patients clearly state a preference for an atypical, I go with that because getting them on a medication is the priority."

The question isn't whether atypical antipsychotics should be used, but whether they should be used in all cases, said Dr. Geddes, professor of epidemiological Psychiatry at the University of Oxford (England).

Patients have voted with their feet and physicians with their prescription pads. In the United States, 90% of prescriptions for antipsychotics are for atypicals, while nations like Japan rely mainly on the first-generation drugs, noted Dr. Ira D. Glick, professor of psychiatry at Stanford (Calif.) University. Dr. Glick is a paid adviser and a speaker for nearly all the pharmaceutical companies that make atypical antipsychotics.

Studies comparing the two generations of antipsychotics are having difficulty enrolling patients in randomized trials because so many patients and clinicians already favor atypical antipsychotics, several panelists said. They are hoping that a large study underway by the National Institute of Mental Health--the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)--will answer some of the questions about the benefits of various antipsychotics in real-world settings when the results come out next year.

Regardless of the results, "There's not going to be a shift back to first-generation antipsychotics because patients don't feel well on them. Patients feel better on the newer drugs," said Dr. Stephen R. Marder, the panel's discussant. Dr. Marder has financial affiliations with five companies that make atypical antipsychotics.

Data suggesting that, among atypicals, some are more effective than others may be due to different populations being treated, with more recent atypicals studied in more treatment-resistant patients, he said. …

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