ANTIPSICOTICOS

Conference Report From the 2009 American Psychiatric Association Annual Meeting: "A Real-World Comparison of Second-Generation Antipsychotics

Johnsen E, Kroken RA, Wentzel-Larsen T, Jorgensen HA. A practical, randomized comparison of the effectiveness of risperidone, olanzapine, quetiapine, and ziprasidone. Proceedings and abstracts of the 162nd Annual Meeting of the American Psychiatric Association; May 16-21, 2009; San Francisco, California. New research poster NR6-048.
Summary

The goal of this Norwegian trial, which received no industry funding, was to compare 4 leading second-generation antipsychotics for tolerability and symptom reduction in a naturalistic setting. The inclusion criteria for patients, who were admitted to a university hospital, included presence of psychosis and age of at least 18 years. Of the 213 subjects, 68% were male, 42% had a diagnosis of schizophrenia-spectrum illness, and the remainder had drug-induced or another psychotic illness.

Investigators randomly assigned patients to receive olanzapine, quetiapine, risperidone, or ziprasidone with flexible dosing. Switching medication was permitted. Treating physicians and patients were aware of the assigned medication, but raters were masked. Baseline ratings included PANSS, Calgary Depression Scale for Schizophrenia, Clinical Global Impression (CGI) scale, Global Assessment of Functioning (GAF), and side effect scales; periodic ratings took place for as long as 2 years. Investigators also monitored weight, and glucose and lipid levels.

Mean daily doses were 14.3 mg for olanzapine, 357 mg for quetiapine, 3.3 mg for risperidone, and 101 mg for ziprasidone. Time to discontinuation of allocated medication did not differ among the 4 treatments. Symptom relief as determined by reduction in PANSS total and positive scores was significantly greater in patients treated with quetiapine than in those treated with risperidone or olanzapine (P < .05). PANSS positive score was reduced significantly more in patients treated with ziprasidone than in those treated with risperidone (P = .026). Improvements in CGI and GAF scores tended to follow the same trends. Compared with other medications, olanzapine caused greater mean increase in hip circumference, and risperidone was more likely to cause galactorrhea.
Comment

This study did not single out any 1 psychotic disorder and was not double-blinded; each medication group contained only about 50 patients. These could be interpreted as major design liabilities. Nonetheless, the investigators succeeded in a naturalistic study with a good duration of follow-up. The findings are at odds with a recent meta-analysis of second-generation antipsychotic comparisons, which found olanzapine more efficacious than quetiapine and risperidone.[2] The second-generation antipsychotic doses were modest in this study, perhaps attributable to the fact that 44% of patients were naive to antipsychotics."