Comparing Antipsychotics for Schizophrenia.
Huhn, M., Nikolakopoulou, A., Schneider-Thoma, J., Krause, M., Samara, M., Peter, N., Arndt, T., Bäckers, L., Rothe, P., Cipriani, A., Davis, J., Salanti, G., & Leucht, S. (2019). Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet (London, England), 394(10202), 939–951. https://doi.org/10.1016/S0140-6736(19)31135-3
This article by Huhn et. al is one of my favorites, and that’s not because it's easy! Published in the Lancet (yes, very fancy, highly reputable) despite being published in 2019 I find it incredibly useful academically and clinically. It's also quite collaborative, and funded by the Ministry of Education and Research in Germany (aka not big pharma).
Why I like this article so much because it’s like the Olympics of medication, basically like a competition, between different antipsychotics. Which ones are the best and worst at certain things like subtypes of symptoms and side effects? Through some really detailed investigative work and statistical prowess, they have been able to show efficacy and tolerability differences between medications. The take-home is that some medications are a bit better than others (though in a more gradual sense), whereas we know that there is more of a difference in certain side effects of certain antipsychotics.
How did these clever researchers come up with this? Well, they looked at 402 studies, with a total of over 50,000 patients. They only looked at studies that compare placebo (fake medication) with the medication itself, or studies that compare one medication with another. And this was exclusively for schizophrenia (so we can’t generalise the results of this study in other illnesses which might use the same agent too much). They then use some complex mathematics to work out the differences between the studies and medications.
One of the factors when looking at articles like this, is that some medications just have more research published than others. Regardless of whether it was drug companies who published the original studies, some medications are older, and more researched and therefore will have more robust comparisons. Some new medications might not have too much data, so we can’t be too sure about how well they “compete” with others.
Overall, clozapine is king in my head. Closely followed by sulpride/amisulpride and olanzapine. There are some interesting medications here such as thiotixene and thioridazine that we don’t use much here in Australia. It makes me wonder if Australia is missing out on something, or conversely, we are more strategic and streamlined with our prescribing. Unfortunately, the side effect profile of some of the most effective medications is also undesirable and can be quite serious. But, there are a few that do have not the best efficacy, yet some really serious side effects that are important to note.
At the end of the day, we use this data with a small grain of salt. The article reminds me that not all medications are created equally. It also reminds me that side effects happen, and these medications need to be taken seriously. If patients are trying to lose weight, or perhaps their negative symptoms of schizophrenia are the worst, this can help them choose a medication that might have a better chance of working. It is still difficult to predict which medication will work best for each person, and every brain/mind is different – something we have to remember. Though this article isn’t a bible of prescribing, it helps us personalise our treatment to the patient and ensure the healthiest version of themselves.