OPTiMiSE validated the clinical utility of a simple treatment algorithm, as 56% of patients achieved remission using stringent criteria by week 4 on amisulpride, and an additional 7% reached that endpoint by week 10, with the switch to olanzapine offering no added value over continued amisulpride. Switching week-10 nonresponders to clozapine enabled 28% of them to achieve remission (Lancet Psychiatry. 2018 Oct 1;5[10]:797-807).
A key take-home message of the trial, Dr. Weiser said, is that a switch to clozapine is justified after 10 weeks of unsuccessful treatment with a first-line antipsychotic; there’s no need to wait until patients have failed on two consecutive antipsychotics, as guidelines now recommend.
He observed that it can be a lot more challenging to keep patients in remission after a first psychotic episode than it is to get them to respond in the first place. For this reason, he found particularly instructive a recent study by psychiatrists at the University of Hong Kong that shined a light on the understudied long-term adverse consequences of stopping antipsychotic therapy after 1 year in patients successfully treated for a first-episode psychosis. At the 1-year point in this randomized trial, the successfully remitted patients were given maintenance therapy or their antipsychotic therapy was discontinued for 12 months. Ten years later, the investigators reported, the rate of a composite endpoint comprising persistent psychotic symptoms, requirement for clozapine, or completed suicide was 21% in the maintenance therapy group and significantly worse at 39% in those who had stopped treatment at 1 year (Lancet Psychiatry. 2018 May 1;5[5]:432-42).
“It’s probably a good idea to keep patients who are stable on maintenance therapy for longer than a year. A lot of first-episode patients don’t want to hear this. A lot of family members don’t want to hear this. And a lot of patients, of course, decide for themselves and stop treatment, although I tell them they should not.
Asked how low his low-dose long-term maintenance therapy is, he replied: “Negotiate with your patient about the lowest dose he or she is willing to take. In my opinion, 1 mg of risperidone is a lot better than 0 mg of risperidone, although that’s not an opinion supported by data.”
Dr. Weiser reported having no financial conflicts regarding his presentation.