Current Schizophrenia by Dieter Naber & Martin Lambert

Author:Dieter Naber & Martin Lambert
Language: eng
Format: mobi
ISBN: 9781907673382
Publisher: Springer Healthcare
Published: 2012-12-01T22:00:00+00:00

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Current Schizophrenia_3rd Edn_Layout_V23.indd 103

7/23/2012 9:44:07 AM

104 • current schizophrenia

Pharmacotherapeutic algorithm for treatment-resistant schizophrenia Exclusion of psychosocial confounding factors

Possible TRS

(before exclusion assume pseudo-TRS)

• Previous psychosocial treatment adequate?

− At least 3–6 months integrated care with assured

Confirmed TRS?

compliance?

No

• Comorbid psychiatric disorder, which can reduce

response, not present or adequately treated?

Treatment of all psychosocial

− Substance use disorder?

and/or pharmacological

− Obsessive–compulsive disorder?

confounding factors

− Depression?

− Anxiety disorder?

− Personality disorder?

Response?

• Other psychososcial factors, which can reduce

Return to maintenance

response, not present or adequately treated?

treatment

• Start clozapine with test dose (12.5 mg)

Nonresponse?

• Slow dose titration up to response

• Main dose at night

• If no or poor response, increase dose up to a plasma

Start clozapine

level of 350 ng/mL (be aware that plasma levels

≤260 ng/mL are related to a greater risk of

nonresponse). Females and nonsmoker respond to

lower doses

• Optimal response can take 6–12 months (patient

education about treatment duration needed)

Maintenance treatment

Incomplete response?

Response?

and close monitoring

Clozapine-resistant schizophrenia

Treatment options according

to various resistant syndromes

Optimize clozapine treatment

Positive syndrome augmentation

• Check whether plasma level was

treatment

≥350 ng/mL for ≥6 months

• Add on antipsychotic with additive

Other additional treatment options

receptor profile (eg, amisulpride,

• Be aware that all further treatment

haloperidol, risperidone)

options are poorly studied

• Be aware of drug interactions

Figure 3.12 Pharmacotherapeutic algorithm for treatment-resistant schizophrenia.

These are general guidelines that must be adapted to the individual needs of each patient.

CPZ, chlorpromazine; EPS, extrapyramidal symptom; FGAs, first-generation antipsychotics; SGAs, second-generation antipsychotics; TRS, treatment-resistant schizophrenia. Adapted from Huber et al [11] and Lambert et al [12].

Current Schizophrenia_3rd Edn_Layout_V23.indd 104

7/23/2012 9:44:07 AM

104 • current schizophrenia

organiz at ion of c ar e and t r e atmen t • 105

Pharmacotherapeutic algorithm for t

t reatment-resistant schizophrenia

Exclusion of psychosocial confounding factors

Possible TRS

Exclusion of pharmacological confounding factors

(before exclusion assume pseudo-TRS)

(before exclusion assume pseudo-TRS)

• Previous psychosocial treatment adequate?

• Previous antipsychotic treatment adequate?

− At least 3–6 months integrated care with assured

Confirmed TRS?

− Two previous antipsychotic trials without or

compliance?

No

with poor response?

Yes

• Comorbid psychiatric disorder, which can reduce

− Duration of each antipsychotic trial at least

response, not present or adequately treated?

6–8 weeks with compliance?

Treatment of all psychosocial

TRS confirmed

− Substance use disorder?

− Each medication trial with 300–600 or more

and/or pharmacological

− Obsessive–compulsive disorder?

CPZ equivalents?

confounding factors

− Depression?

• Drug interactions or fast metabolizer excluded?

− Anxiety disorder?

• Comorbid psychiatric disorders, if present,

− Personality disorder?

Response?

medically treated?

• Other psychososcial factors, which can reduce

Return to maintenance

Treatment with clozapine

• No side effects present, which can reduce

Yes

Yes

response, not present or adequately treated?

treatment

possible?

response (such as EPS)?

No

• Start clozapine with test dose (12.5 mg)

Nonresponse?

• Detailed assessment of reasons

• Slow dose titration up to response

Start alternative treatment

• Education on clozapine and supporting

• Main dose at night

interventions

• If no or poor response, increase dose up to a plasma

Start clozapine

level of 350 ng/mL (be aware that plasma levels

≤260 ng/mL are related to a greater risk of

Optimize antipsychotic medication

nonresponse). Females and nonsmoker respond to

• Pharmacotherapy according to predominant syndrome/symptoms and optimized lower doses

treatment. Most patients fulfill several syndromes concurrently. Intensify

• Optimal response can take 6–12 months (patient

psychosocial

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