COMMENTARY

The Year in Psychiatry: Studies Not to Miss From 2011

Christoph U. Correll, MD; Maren Carbon, MD

Disclosures

November 23, 2011

In This Article

Switching Antipsychotics to Reduce Metabolic Risk

Stroup TS, McEvoy JP, Ring KD, et al; Schizophrenia Trials Network. A randomized trial examining the effectiveness of switching from olanzapine, quetiapine, or risperidone to aripiprazole to reduce metabolic risk: comparison of antipsychotics for metabolic problems (CAMP). Am J Psychiatry. 2011;168:947-956.

What should be done for individuals who are adequately controlled on their current antipsychotic treatment but who have gained substantial amounts of weight? Should they continue to remain at an increased risk for cardiovascular disease or even worsen further as a price for efficient control of psychiatric symptoms? To reduce metabolic risk profiles, Stroup and colleagues assessed switching significantly overweight patients (BMI ≥ 27) with schizophrenia or schizoaffective disorder, and with increased non-HDL cholesterol above 130 mg/dL, to aripiprazole. Patients had to be on a stable dose of olanzapine, risperidone, or quetiapine for 3 months and without any other antipsychotic in the month prior to study inclusion. Study participants were randomly assigned to either switch gradually (over 4 week) to aripiprazole (n = 109) or stay on their current medication (n = 106) and were followed for up to 24 weeks. All subjects were additionally enrolled in healthy-lifestyle training classes. In order to ensure clinically proper dosing and efficient psychiatric symptom control, treating clinicians and patients were not blinded, but blinded raters obtained the PANSS and GCI scores, as well as side-effect ratings.

During the study period, non-HDL cholesterol, triglycerides, and weight reduced significantly. Non-HDL cholesterol in switchers fell from 169 mg/dL at baseline to 148 mg/dL after 6 months, which translates approximately into a 10% risk reduction for cardiovascular disease. Although stayers also showed a slight reduction of non-HDL cholesterol from 176 mg/dL at baseline to 165 mg/dL, no reduction in triglycerides was found in this group. Switching was also associated with clinically relevant cardiovascular risk factor reductions compared with staying on the same antipsychotic, including a 1.1 unit greater reduction in BMI, a 2.9-kg larger weight reduction and, important for the prevention of diabetes, a 32.7-mg/dL greater reduction in triglycerides as well as a significantly greater reduction in 2-hour insulin levels. Although protocol-defined efficacy failure did not differ between switchers and stayers (20.6% vs 17.0%), significantly more switchers discontinued treatment before 24 weeks due to any cause (43.9% vs 24.5%). However, the individual reasons for discontinuation seem poorly understood because no significant differences in side effects were reported. In conclusion, switching to a lower cardiometabolic risk medication is a viable treatment option for stable patients with cardiometabolic risk factors accrued during treatment with higher-risk antipsychotics.

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