Selection of atypical antipsychotics for the management of schizophrenia.
OBJECTIVE
To review the evidence for selecting one atypical antipsychotic agent over another for management of schizophrenia.


METHODS
A literature search of MEDLINE (1966-June 2003), EMBASE (1998-June 2003), and the Cochrane Library was conducted using the following terms: schizophrenia, quetiapine, ziprasidone, olanzapine, aripiprazole, and risperidone. Bibliographies of relevant articles were hand-searched for additional references.


METHODS
Prospective, randomized, blinded trials and meta-analyses that directly or indirectly compared > or =2 atypical antipsychotic agents in the management of schizophrenia are included in this review. Studies comparing an atypical agent with clozapine are not included.


RESULTS
A small number of prospective, randomized, blinded trials that compare efficacy and tolerability of olanzapine and risperidone have been published. These trials did not reveal clinically meaningful differences in efficacy but did confirm that their adverse effect profiles are slightly different (more weight gain with olanzapine and more extrapyramidal reactions with risperidone). Direct comparisons between other atypical antipsychotics are not available. Systematic reviews (indirect comparisons) of placebo-controlled or traditional antipsychotic-controlled trials suggest similar efficacy for quetiapine, olanzapine, and risperidone when placebo is the comparator and inferior efficacy of quetiapine compared to olanzapine and risperidone when haloperidol is the comparator. The few available economic analyses are difficult to interpret in light of current practice.


CONCLUSIONS
Additional randomized, blinded clinical trials directly comparing efficacy, tolerability, and cost-effectiveness are needed to confirm the proposed differences among atypical antipsychotic agents before recommendations can be made with confidence.
Sprague
Denise A
DA
Pharmaceutical Sciences Clinical Service Unit, Vancouver Hospital & Health Sciences Centre, Vancouver, British Columbia, Canada. dsprague@vanhosp.bc.ca
Loewen
Peter S
PS
Raymond
Colette B
CB
D000328:Adult; D000368:Aged; D014150:Antipsychotic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D015201:Meta-Analysis as Topic; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012559:Schizophrenia / Q000188:drug therapy*
D014150:Antipsychotic Agents