Antipsychotics for maintenance treatment should be determined mostly by tolerability: Lancet

Germany: There was no indication of apparent differences between antipsychotics for relapse prevention, the choice of antipsychotic for maintenance treatment should be determined mostly by tolerability, says an article published in The Lancet.

Schizophrenia is a widespread, severe, and typically persistent mental illness. Maintenance therapy with antipsychotic medicines can help avoid recurrence, but it can potentially have negative side effects. As a result, Johannes Schneider-Thoma and colleagues set out to assess the effectiveness and tolerability of antipsychotics as maintenance therapy for non-treatment-resistant schizophrenic patients.

Without regard for language, database inception between PubMed from April 1, 2020, to January 15, 2021, and lists of included studies from related systematic reviews were searched in this systematic review and network meta-analysis. This investigation comprised 12 weeks of follow-up randomized controlled trials (RCTs) that enrolled adult individuals with schizophrenia or schizoaffective disorder who had stable symptoms and were treated with placebo or antipsychotics (monotherapy; long-acting injectable or oral). RCTs with patients who had specified comorbidities or treatment resistance were excluded. Two authors independently identified eligible RCTs and extracted aggregate data in duplicate. The key outcome was the number of relapsed individuals, which was examined using random-effects Bayesian network meta-analyses.

The findings of this study were as follow:

1. The search yielded 4157 references, of which 501 references on 127 RCTs of 32 antipsychotics (comprising 18 152 people) were included.

2. The network meta-analysis of the primary outcome included 100 trials with 16 812 individuals and 30 antipsychotics.

3. When compared to placebo, all antipsychotics had risk ratios less than 100, and virtually all had 95% credible intervals (CrIs) eliminating no effect.

4. The RRs for paliperidone oral varied from 020 to 065 (016–114) for cariprazine oral.

5. In general, there was no strong evidence for the superiority of individual antipsychotics in terms of relapse prevention since most antipsychotic comparisons considered the possibility of no change.

In conclusion, from the findings of this study, there is no agreement on which antipsychotic is the most beneficial, its usage should be primarily directed by patient tolerance to adverse effects.

Reference:  

Schneider-Thoma, J., Chalkou, K., Dörries, C., Bighelli, I., Ceraso, A., Huhn, M., Siafis, S., Davis, J. M., Cipriani, A., Furukawa, T. A., Salanti, G., & Leucht, S. (2022). Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysis. In The Lancet (Vol. 399, Issue 10327, pp. 824–836). Elsevier BV. https://doi.org/10.1016/s0140-6736(21)01997-8

Keywords: Lancet, antipsychotics, schizophrenia, paliperidone, relapse, adverse effects, affective disorder, mental health, injectable, long-acting, injectable, oral, tolerance, relapse, Johannes Schneider-Thoma