Choice of drug

There has been a great change in prescribing over recent years in the UK. Newer drugs, the so-called atypicals, have largely supplanted the original drugs such as chlorpromazine and haloperidol. There has been great enthusiasm for atypicals, which have been heavily promoted as having fewer side-effects, and therefore being more acceptable to patients and promoting better quality of life. They have undoubtedly been a success in commercial terms. However, as with any new drug, the adverse effects have taken a little time to come out, and we are now seeing the balance of risks and benefits of the new drugs, as against the older drugs, becoming clearer.

The National Institute for Health and Clinical Excellence (NICE) (5) recommends that in 'a person who has been newly diagnosed with schizophrenia, doctors should consider prescribing one of the following atypical (newer) oral antipsychotic drugs: amisulipride, olanzepine, quetiapine, risperidone or zotepine.' This has become accepted practice, and many patients do recover on such a regime. However, there is less agreement as to what should be done if the patient does not respond to, say, risperidone or olanzepine.

Experience indicates that the most severely psychotic patients often do not respond, or do not respond fully, to the newer drugs. It should be borne in mind that, in modern randomized, controlled trials of medication, the most severely affected patients are often excluded. This will be, for example, on the grounds that if a person is dangerously unwell, it would be wrong that they should be exposed to the risk of a placebo treatment.

The older drugs seem more powerful in such cases. Hence, if the patient is severely unwell, and has not responded to an atypical, one of the older drugs should be considered. The prescriber would then face a choice between either stopping the atypical, and starting one of the 'classic' medications, or adding the second drug and continuing with the atypical. In my practice, a typical example would be a patient who has been started on olanzepine, and has benefited from the sedative and hypnotic properties of that drug, but still has troublesome delusions and hallucinations. In such patients, I often see good results from adding a small dose of haloperidol, say, 1.5-5 mg daily.

In this connection, it should be remembered that medications such as haloperidol gained their poor reputation for side-effects from having been used in excessively high doses over the years. Haloperidol 1.5 mg is a powerful antipsy-chotic regime in itself, and may be sufficient, for example, in elderly patients. If high doses of haloperidol are given, however, side-effects will increase, whereas antipsychotic effects may not.

Trials of atypical agents, compared with haloperidol or other older antipsy-chotics, have of course generally taken the opportunity to use large doses of the old drug, thereby helping to demonstrate greater acceptability to patients of the new agents.

Many patients do very well on small doses of haloperidol or trifluoperazine, and do not experience side-effects from them; NICE does not recommend changing patients who are well maintained on such regimes.

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