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Why and How to Switch Antipsychotic Medications – Part 1
Many people take antipsychotic medication.
In fact, Abilify (aripiprazole) was the fourth highest grossing drug in 2011 at $5.2 billion. And three antipsychotics—Abilify, Seroquel (quetiapine) and Zyprexa (olanzapine)—are in the top 20 grossing products of 2011. Taken together, this is an overall gross of about $12.7 billion. Seroquel is the 43rd most frequently prescribed drug in the U.S.
And why is this? This is because the antipsychotic market has become quite broad. While once primarily prescribed to people with schizophrenia, antipsychotics are now also commonly prescribed to people with bipolar disorder, severe depression, and other disorders as well.
So when we talk about those on antipsychotics, we’re talking about numbers of patients in the millions.
And all these medications don’t work for all people. In fact, if I had to estimate, I would say the vast majority of these people have gone through at least one antipsychotic switch during their treatment.
Why Do People Switch Antipsychotics?
There are many reasons to switch antipsychotics but the most common reason is due to side effects. This is a known problem with antipsychotics as there is a very high rate of medication non-adherence due, primarily, to side effects. In one study, 64 percent of people on olanzapine and 82 percent of people on quetiapine discontinued these drugs, in spite of clinical improvement.
According to the Psychiatric Times article Switching Antipsychotics: Why, When, and How?, other reasons for switching antipsychotics include:
- poor response (continuation of symptoms)
- request of the patient
- reduce medication cost
- simplify dosing schedule
Alternatives to an Antipsychotic Switch
Of course, most of these issues can possibly be handled without switching medication. So before a medication switch is warranted, psychiatrists typically try:
- lowing the dose (to reduce side effects)
- raising the dose (to increase efficacy)
- staying on the medication longer (to see if it will improve efficacy)
- adding an adjunct medication (to increase efficacy)
- better treatment adherence (if this had been an issue)
Those approaches are generally tried before switching antipsychotics as they pose fewer risks than an actual antipsychotic switch.
Risks of Switching Antipsychotics
As in all things, nothing comes for free, and in the case of switching antipsychotics, there are risks. According to the Psychiatric Times article switching is generally not a good idea for these types of patients:
- Those who have recently recovered from an acute psychotic episode and are taking an antipsychotic drug that was clearly beneficial during acute-phase treatment
- Those who are currently stable on long-acting injectable antipsychotics but have a history of clinical instability before using long-acting injectable agents resulting from poor adherence to oral antipsychotics
- Those who are presently stable with a clear positive response to antipsychotic treatment but have a history of violence, self-harm, severe symptoms, or profound self-neglect during acute psychotic episodes
But if you’ve determined you’re ready for a switch and you’re not in one of the high-risk groups, how should you switch antipsychotics?
In my next article I’ll discuss exactly how to go about switching antipsychotics.