Evidence-Based Use of Antipsychotics: A Quick “How To”

How can you apply the framework and philosophy of evidence-based medicine to the use of antipsychotic medication?Here to discuss is Leslie Citrome, MD, MPH. Dr Citrome is Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla. He is a scheduled speaker at this year's US Psychiatric and Mental Health Congress in Las Vegas.Here is a brief summary of some of the points Dr Citrome makes in his 5-minute audio presentation:
•Evidence-based medicine is not cookbook medicine. It means pairing your clinical judgment with the relevant scientific evidence and including your patients’ values and preferences into making a decision for your patient. It’s about individualizing therapy.
•Treatment effectiveness is not just efficacy; it is also the combination of efficacy plus tolerability plus adherence.
•When appraising evidence of a drug’s efficacy, number need to treat (NNT) and number needed to harm (NNH) are favorite tools. We can use these tools to indirectly compare the new antipsychotics with one another, for example. With ilopederidone, asenapine, and lurasidone, we can calculate where the data are available: how many patients does it require to be treated with any of these agents versus placebo before we can expect to encounter one additional responder? Those agents with a lower NNT would be expected to be more efficacious. We need to balance this as well with safety and tolerability outcomes. The product labels for each of these new agents list commonly encountered adverse effects. We can calculate NNH to cause (for example) sedation or akathesia or weight gain of at least 7% from baseline. By doing so, we can figure out where these drugs indirectly compare with each other. For NNH, the higher the number the better. The NNH should be double digit so that we don’t encounter that harm very often.
•Other factors to consider when looking at the new agents include how often per day these agents are taken; does the drug need to be taken with or without a meal or liquids; what are the warnings regarding prolactin, QT prolongation, and perhaps pregnancy category . . . all these factors may be influential depending on the patient you are treating.Further reading:Citrome LL. A review of the pharmacology, efficacy and tolerability of recently approved and upcoming oral antipsychotics: an evidence-based medicine approach. CNS Drugs. September 2013. http://link.springer.com/article/10.1007/s40263-013-0105-7.Citrome LL. New second-generation long-acting injectable antipsychotics for the treatment of schizophrenia. Expert Rev Neurother. 2013;13:767-83.