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Terms used to differentiate old and new antipsychotics are redundant

The term “second-generation antipsychotic” should be abandoned, say the authors of a study published online on 5 December 2008

The term “second-generation antipsychotic” should be abandoned, say the authors of a study published online on 5 December 2008 (The Lancet).

The study, a meta-analysis of randomised controlled trials, compared nine second-generation antipsychotic drugs with a range of first-generation drugs for overall efficacy, effect on positive, negative and depressive symptoms, relapse, quality of life, extrapyramidal side effects, weight gain and sedation. The study analysed 150 double-blind studies with a combined 21,533 participants.

Four second-generation antipsychotic drugs (amisulpride, clozapine, olanzapine and  risperidone)were more efficacious, for overall symptoms, than first generation drugs.

Aripiprazole, quetiapine, sertindole, ziprasidone and zotepine were not significantly different from first-generation antipsychotic drugs in terms of their effects on overall symptoms. These five drugs were also not more efficacious than first generation drugs for the treatment of either positive or negative symptoms. Quetiapine was less efficacious for positive symptoms.

For depressive symptoms, amisulpride, clozapine, olanzapine, aripiprazole and quetiapine were significantly better than first-generation drugs, but risperidone was not.

All second-generation antipsychotic drugs had fewer extrapyramidal side effects than haloperidol but, apart from clozapine, olanzapine and risperidone, none was found to have fewer extrapyramidal side effects than low-potency first generation antipsychotic drugs.

Commenting on the study, Stephen Bazire, chief pharmacist, Norfolk and Waveney Mental Health NHS Foundation Trust, said “Many of us have been saying [what the results of the paper suggest] for years.” He added that “there really is not a clear definition of atypical or second generation and the group is clearly heterogeneous”.

Sulpiride is defined as a typical antipsychotic in England but an atypical antipsychotic drug in France, he pointed out.

Ian Maidment, chairman of the UK Psychiatric Pharmacy Group and senior pharmacist, Kent and Medway NHS and Social Care Partnership Trust, told The Journal that the results should be viewed in context of the recently published CATIE and CUtLASS studies.

CATIE, he said, showed that clozapine was more effective than other atypicals. CUtLASS found that atypicals and typicals were equally effective.

Professor Bazire said that prescribers should not return to using haloperidol routinely. He said that health professionals should be looking at antipsychotic drugs more openly when helping service users to choose which drug they might prefer to have prescribed, since they all have different effects and side effects. It should not be considered wrong or right to prescribe an old antipsychotic, he added.

Citation: The Pharmaceutical Journal URI: 10043398

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