Indeed, “none of the 4 SGAs [second-generation antipsychotics] demonstrated statistically significant superiority” to the first-generation drug in CATIE, Dr. Volavka and Dr. Citrome asserted, although research generally, and a number-needed-to-treat analysis by Dr. Citrome and another of his colleagues, Dr. T. Scott Stroup, support the idea that olanzapine demonstrates a clear advantage over other drugs in terms of patient retention in therapy (Int. J. Clin. Pract. 2006;60:933-40).
Another individual atypical drug, clozapine, stood out in a Finnish population-based cohort study as conferring a 26% relative mortality advantage over perphenazine over an 11-year period (Lancet 2009;374:620-7).
If genetic testing could identify patients at low risk for agranulocytosis, a feared side effect of that drug, clozapine might edge its way upward on treatment decision trees, Dr. Citrome said.
“It may no longer be useful to draw a clear distinction between these two classes of drugs based on class alone,” said Dr. Citrome, director of the clinical research and evaluation facility at the Nathan S. Kline Institute for Psychiatric Research, a division of the New York State Office of Mental Health in Orangeburg, in an interview.
With regard to the weight gain conundrum, which he argues is of great importance in considering drug alternatives, Dr. Citrome advised individualizing therapy.
“Although some medications are associated with the possibility of gaining more weight than others, this is highly variable among individuals.
“Children, youth, and first-episode patients with schizophrenia almost always gain weight, no matter what the medicine is,” he said.
For early monitoring and ongoing assessment, Dr. Citrome said he keeps a scale in his private office, and weighs patients at every session, regardless of which medication or medications someone is receiving.
“It shows that we are serious about making an impact,” he said, noting that only one patient has ever objected to the practice.
A patient's previous response to a drug and previous weight gain are often helpful in guiding therapy, he said.
But for newly diagnosed patients with acute psychosis, the way ahead is less clear.
Efficacy might weigh more heavily in his decision about a medication choice in such a patient, whereas long-term safety issues might hold more sway in his follow-up care of the patient, he said.
Such nuanced management will require resources and continuity of care, along with the need to integrate evolving knowledge about efficacy and safety by drug and not just by class, Dr. Salimi said.
Dr. Citrome is a consultant for, has received honoraria from, or has conducted clinical research supported by Abbott Laboratories, AstraZeneca Pharmaceuticals, Avanir Pharmaceuticals Inc., Azur Pharma Inc., Barr Laboratories Inc., Bristol-Myers Squibb, Forest Laboratories Inc., GlaxoSmithKline PLC, Janssen Pharmaceuticals, Jazz Pharmaceuticals Inc., Eli Lilly & Co., Merck/Schering-Plough Pharmaceuticals, Novartis Pharmaceuticals Corp., Pfizer Inc., and Vanda Pharmaceuticals Inc.
Dr. Salimi reported no relevant financial disclosures.
By Betsy Bates. Share your thoughts and suggestions at cpnews@elsevier.com
'It may no longer be useful to draw a clear distinction between these two classes of drugs based on class alone.'
Source DR. CITROME