Comparative effects of intramuscular thiothixene and trifluoperazine in psychotic patients

Antipsychotic medication for elderly people with schizophrenia

BACKGROUND

A large and growing number of older people across the world suffer from schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. In addition most manufacturers of such medications recommend prescription of reduced doses to the elderly. The evidence base for these assumptions is unclear and raises obvious questions regarding the appropriateness of such prescribing practice.

OBJECTIVES

To find and assimilate good evidence of the effects of antipsychotic medication for treatment of schizophrenia in people over 65 years of age.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (May 2003). We inspected references of all included studies for further trials and contacted relevant pharmaceutical companies.

SELECTION CRITERIA

All clinical randomised trials evaluating antipsychotic drugs for schizophrenia and schizophrenia-like psychoses in older people.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data, the random effects, relative risk (RR), and 95% confidence interval (CI) and, where appropriate, the numbers needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

Two hundred and fifty two elderly people with schizophrenia participated in three relevant randomised controlled studies. We were unable to extract usable data on quality of life, satisfaction, service use, or economic outcomes. One small study (n=18) compared thioridazine with remoxipride (RR leaving the study early 1.0 CI 0.07 to 13.6). A second study (n=175) compared risperidone with olanzapine. Global state 'not improved/worse' was not significantly different between treatments (n= 171, RR 1.26 CI 0.8 to 1.9); mental state PANSS total endpoint scores were also equivocal (n=171, RR 0.98 CI 0.76 to 1.26) as were all cognitive function tests. The third study (subset n=59) compared olanzapine with haloperidol and mental state change scores (BPRS WMD -3.60 CI -10.8 to 3.6; PANSS WMD -6.00 CI -18.3 to 6.3) were equivocal.

AUTHORS' CONCLUSIONS

Antipsychotics may be widely used in the treatment of elderly people with schizophrenia, however, based on this systematic review, there are little robust data available to guide the clinician with respect to the most appropriate drug to prescribe. Clearly reported large short, medium and long-term randomised controlled trials with participants, interventions and primary outcomes that are familiar to those wishing to help elderly people with schizophrenia are long overdue.

Trifluoperazine for schizophrenia

BACKGROUND

Trifluoperazine is an inexpensive accessible 'high potency' antipsychotic drug, widely used to treat schizophrenia or related psychoses.

OBJECTIVES

To estimate the effects of trifluoperazine compared with placebo and other drugs.

SEARCH STRATEGY

Searches of the Cochrane Schizophrenia Group's register of trials (March 2002), supplemented with hand searching, reference searching, personal communication and contact with industry.

SELECTION CRITERIA

All clinical randomised trials involving people with schizophrenia and comparing trifluoperazine with any other treatment.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected and quality rated and data was extracted. For dichotomous data, relative risks (RR) were estimated, with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, the number needed to treat (NNT) was calculated. We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

1162 people from 13 studies were randomised to trifluoperazine or placebo. For global improvement, small short-term studies favoured trifluoperazine (n=95, 3 RCTs, RR 0.62 CI 0.49 to 0.78 NNT 3 CI 2 to 4). Loss to follow up was about 12% in both groups (n=280, 7 RCTs, RR 0.99 CI 0.62 to 1.57) and more people allocated trifluoperazine used antiparkinson drugs to alleviate movements disorders compared with placebo (n=195, 4 RCTs, RR 5.06 CI 2.49 to 10.27, NNH 4 CI 2 to 9). 2230 people from 49 studies were randomised to trifluoperazine or another older generation antipsychotic. Trifluoperazine was not clearly different in terms of 'no substantial improvement' (n=1016, 27 RCTs, RR 1.06 CI 0.98 to 1.14) or leaving the study early (n=930, 22 RCTs, RR 1.15 CI 0.83 to 1.58). Almost identical numbers of people reported at least one adverse event (60%) in each group (n=585, 14 RCTs, RR 0.99 CI 0.87 to 1.13), although trifluoperazine was more likely to cause extrapyramidal adverse effects overall when compared to low potency antipsychotics such as chlorpromazine (n=130, 3 RCTs, RR 1.66 CI 1.03 to 2.67, NNH 6 CI 3 to 121). One small study (n=38) found no clear differences between trifluoperazine and the atypical drug, sulpiride.

REVIEWER'S CONCLUSIONS

Although there are shortcomings and gaps in the data, there appears to be enough consistency over different outcomes and periods to confirm that trifluoperazine is an antipsychotic of similar efficacy to other commonly used neuroleptics for people with schizophrenia. Its adverse events profile is similar to that of other drugs. It has been claimed that trifluoperazine is effective at low doses for patients with schizophrenia but this does not appear to be based on good quality trial based evidence.

Trifluoperazine for schizophrenia

BACKGROUND

Trifluoperazine is an inexpensive accessible 'high potency' antipsychotic drug, widely used to treat schizophrenia or related psychoses.

OBJECTIVES

To estimate the effects of trifluoperazine compared with placebo and other drugs.

SEARCH STRATEGY

Searches of the Cochrane Schizophrenia Group's register of trials (March 2002), supplemented with hand searching, reference searching, personal communication and contact with industry.

SELECTION CRITERIA

All clinical randomised trials involving people with schizophrenia and comparing trifluoperazine with any other treatment.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected and quality rated and data was extracted. For dichotomous data, relative risks (RR) were estimated, with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, the number needed to treat (NNT) was calculated. We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

1162 people from 13 studies were randomised to trifluoperazine or placebo. For global improvement, small short-term studies favoured trifluoperazine (n=95, 3 RCTs, RR 0.62 CI 0.49 to 0.78 NNT 3 CI 2 to 4). Loss to follow up was about 12% in both groups (n=280, 7 RCTs, RR 0.99 CI 0.62 to 1.57) and more people allocated trifluoperazine used antiparkinson drugs to alleviate movements disorders compared with placebo (n=195, 4 RCTs, RR 5.06 CI 2.49 to 10.27, NNH 4 CI 2 to 9). 2230 people from 49 studies were randomised to trifluoperazine or another older generation antipsychotic. Trifluoperazine was not clearly different in terms of 'no substantial improvement' (n=1016, 27 RCTs, RR 1.06 CI 0.98 to 1.14) or leaving the study early (n=930, 22 RCTs, RR 1.15 CI 0.83 to 1.58). Almost identical numbers of people reported at least one adverse event (60%) in each group (n=585, 14 RCTs, RR 0.99 CI 0.87 to 1.13), although trifluoperazine was more likely to cause extrapyramidal adverse effects overall when compared to low potency antipsychotics such as chlorpromazine (n=130, 3 RCTs, RR 1.66 CI 1.03 to 2.67, NNH 6 CI 3 to 121). One small study (n=38) found no clear differences between trifluoperazine and the atypical drug, sulpiride.

REVIEWER'S CONCLUSIONS

Although there are shortcomings and gaps in the data, there appears to be enough consistency over different outcomes and periods to confirm that trifluoperazine is an antipsychotic of similar efficacy to other commonly used neuroleptics for people with schizophrenia. Its adverse events profile is similar to that of other drugs. It has been claimed that trifluoperazine is effective at low doses for patients with schizophrenia but this does not appear to be based on good quality trial based evidence.