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PSYCHOPHARMACOLOGY
Highlights From the 2022 NEI Synapse: Optimizing Treatment for Patients With Schizophrenia
April 22, 2022   

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      Austin, TX & Virtual   |   Session Highlights
At the 2022 NEI Synapse, Dr. Leslie Citrome delivered multiple clinically relevant presentations that provided key practical takeaways for any clinician who is striving to optimize functioning for their patients with schizophrenia. Highlighted here are his presentations on selecting and switching between antipsychotic medications.

Titration Negotiation: Switching Antipsychotics in People with Schizophrenia
Optimizing treatment plans for patients with schizophrenia often involves switching medications to reduce side effects, reduce symptoms, and improve adherence. The first step in the process is asking the question, “Should I switch or should I stay?” As Dr. Citrome puts it, “Switches offer both opportunity and risk [and] a medication does not have to be perfect.” Dr. Citrome emphasizes that one should engage in shared decision-making with the patient, and ultimately make the choice based on a combination of clinical judgment, relevant scientific evidence, and patient values and preferences.

In the event that switching medications is appropriate, the next questions is, “How?” A major challenge is the lack of evidence-based research to guide the process of switching between medications. According to Dr. Citrome, “Switch strategies vary, and although randomized studies of switch strategies have not been helpful in guiding practice, common sense does, as well as consideration of pharmacodynamic and pharmacokinetic profiles.” In his presentation, Dr. Citrome offered many pragmatic tips for minimizing risks, such as:

Switching Situation What Are the Risks What to Do
From high D2 affinity agent to low D2 affinity agent Risk of withdrawal dyskinesia (due to high-affinity agent) Slower down-titration reduces risk; warn patients of potential for withdrawal dyskinesia and that it should abate with time
From high cholinergic activity agent to low cholinergic activity agent Anticholinergic drug withdrawal syndrome—cholinergic rebound Slow down-titration; for adjunct anticholinergic agents, continue for a few weeks after cross-titration, then taper; make sure patient understands that cognitive deficits may resolve once the anticholinergic is discontinued
From sedating agent to non-sedating agent Short-term augmentation with a benzodiazepine may be beneficial Short-term augmentation with a benzodiazepine may be beneficial
From shorter half-life agent (all D2 antagonists) to longer half-life agent (all D2 partial agonists) Potential for rebound phenomena (anxiety, insomnia, psychosis, restlessness, akathisia) Avoid abrupt switching

Make New Friends, but Keep the Old: Optimizing Antipsychotic Treatments for Schizophrenia
Although the phrase, “With every relapse, patients are at risk of irreversible lifetime functional impairment,” seemed like a grim opening to Dr. Citrome’s presentation on treatment selection, what followed was an encouraging examination of the approaches clinicians can take to optimize functioning and minimize acute relapse for patients with schizophrenia. As Dr. Citrome explained, antipsychotic medications do not clearly differentiate from each other in terms of efficacy for controlling acute symptoms (with the exception of clozapine and possibly olanzapine). Instead, the differences lie in their side effect/tolerability profiles, and those differences can be substantial. In his presentation, Dr. Citrome demonstrated the potential association between receptor binding properties and clinical outcomes (both desirable and undesirable), compared the binding profiles and relative side-effect risks for different agents, and described the role that formulation can play in treatment decisions, providing clinicians the tools necessary to make informed prescribing decisions.

Of course, identifying the side effects that may be most problematic or distressing for a particular patient is key to medication selection. Often, what is considered intolerable is not only unique to the individual patient, but can also be perceived differently by the patient vs. the treating clinician. Dr. Citrome advises the use of motivational interviewing:

  • Use open-ended questions and reflective listening
  • Remember RULE
    • Resist making too many suggestions
    • Understand the patient’s motivation
    • Listen with a patient-centered empathic approach
    • Empower the patient

Ultimately, Dr. Citrome emphasized that "individuals have different values and preferences regarding tolerability concerns, and having a variety of choices in terms of molecule and formulation is key to providing evidence-based care that promotes better outcomes."

Source:
Leslie Citrome, MD, MPH. Make New Friends, but Keep the Old: Optimizing Antipsychotic Treatments for Schizophrenia. Presented April 23 at 2022 NEI Synapse, Austin, TX.
Leslie Citrome, MD, MPH. Titration Negotiation: Switching Antipsychotics in People With Schizophrenia. Presented April 23 at 2022 NEI Synapse, Austin, TX.

To Learn More: The recordings of these presentations by Dr. Citrome, as well as all of the other presentations from the 2022 NEI Synapse, will be available as Encore Presentations for NEI Members.

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