- Engage in shared decision making
- Work with patients and their caregivers to identify treatment goals, values, and tolerability concerns
- Identify patient preferences for pace and method of switching and align the switch plan with patient comfort and safety (e.g., some patients want a slower taper to avoid side effects; others prefer a faster transition)
- Establish realistic expecations: no medication is perfect; balance "good enough" efficacy and tolerability and avoid unrealistic hopes (e.g., complete cure)
- Assess clinical context before switching
- Consider history of response, nature and acuity of psychiatric condition, target signs and symptoms, history of adherence, need for special monitoring, and patient preference
- Weigh potential benefits of switching against risks of destabilization (e.g., are other interventions available to address tolerability)
- Monitor and manage tolerability issues
- Switching can trigger withdrawal, rebound, or new side effects
- Consider supportive strategies (e.g., rescue sleep medications, tapering anticholinergics slowly)
|
- Assess potential for rebound phenomena
- Can occur when a previously-blocked receptor is no longer blocked, leading to increased stimulation by the endogenous neurotransmitter
- Dopaminergic rebound: potential worsening of psychosis, mania, or agitation; potential hyperkinetic motor side effects
- Histaminergic and cholinergic rebound: risk for agitation, insomnia, akathisia, dyskinesia, or Parkinsonism
- Higher risk
- Switching from an agent with more antagonism to one with less antagonism/partial agonism (PD)
- Switching from an agent with a shorter half-life to one with a longer half-life (PK)
- Lower risk/protective
- Switching from an agent with less antagonism to one with more antagonism (PD)
- Switching from an agent with a longer half-life to one with a shorter half-life (PK)
- Take steps to mitigate risk
- Delay or slow discontinuation of the previous medication
- Consider short-term use of sedating co-medications during cross-titration
|