1
|
Galuba V, Cordes J, Feyerabend S, Riesbeck M, Meisenzahl-Lechner E, Correll CU, Kluge M, Neff A, Zink M, Langguth B, Reske D, Gründer G, Hasan A, Brockhaus-Dumke A, Jäger M, Baumgärtner J, Leucht S, Schmidt-Kraepelin C. Identifying differential predictors for treatment response to amisulpride and olanzapine combination treatment versus each monotherapy in acutely ill patients with schizophrenia: Results of the COMBINE-study. Schizophr Res 2024; 270:383-391. [PMID: 38986385 DOI: 10.1016/j.schres.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 06/19/2024] [Accepted: 06/22/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Extensive research has been undertaken to predict treatment response (TR) to antipsychotics. Most studies address TR to antipsychotics in general and as monotherapy, however, it is unknown whether patients might respond favourably to a combination of antipsychotics. AIMS This study aimed to identify differential predictors for TR to monotherapy with amisulpride or olanzapine compared to a combination of antipsychotics. METHODS Post-hoc analysis was conducted of data collected from the COMBINE-study, a double-blind, randomized, controlled trial. Demographic and disease-related measures were gathered at baseline to predict TR after eight weeks defined by the Positive and Negative Syndrome Scale. Missing values were accounted for by a random replacement procedure. Attrition effects and multicollinearity were analysed and sets of logistic regression models were calculated for different treatment groups. RESULTS Of the 321 randomized patients, 201 completed procedures until week eight and 197 were included in the analyses. For all treatment groups, early TR after two weeks and high subjective well-being under antipsychotics at baseline were robust predictors for TR. The propensity for early side effects also indicated a higher risk of later non-response. Specific parameter estimates were rather similar between treatment groups. CONCLUSION Early TR, drug-related subjective well-being, and early side effect propensity evolved as predictors for later TR whether to monotherapy or combination strategy. Accordingly, due to a lack of differential predictors, early and close monitoring of targeted and unwanted effects is indicated to guide respective treatment decisions.
Collapse
Affiliation(s)
- Viktoria Galuba
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Faculty of Medicine, Heinrich-Heine-University, Germany.
| | - Joachim Cordes
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Faculty of Medicine, Heinrich-Heine-University, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Germany
| | - Sandra Feyerabend
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Faculty of Medicine, Heinrich-Heine-University, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Germany
| | - Mathias Riesbeck
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Faculty of Medicine, Heinrich-Heine-University, Germany
| | - Eva Meisenzahl-Lechner
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Heinrich-Heine-University, LVR Düsseldorf, Germany
| | - Christoph U Correll
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Charité- Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt- Universität zu Berlin, and Berlin Institute of Health, Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Berlin, Germany
| | - Michael Kluge
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany; Department of Psychiatry, Rudolf-Virchow-Klinikum Glauchau, Glauchau, Germany
| | - Andrea Neff
- LVR-Klinikum Langenfeld, Langenfeld, Germany
| | - Mathias Zink
- Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; District Hospital Mittelfranken, Ansbach, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | | | - Gerhard Gründer
- Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany; German Center for Mental Health (DZPG), Partner Site Mannheim - Heidelberg - Ulm, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, Ludwig- Maximilians-University, Munich, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany; German Center for Mental Health (DZPG), Partner Site Munich - Augsburg, Germany
| | - Anke Brockhaus-Dumke
- Department of Psychiatry and Psychotherapy 1 and 2, Rheinhessen-Fachklinik Alzey, Academic Hospital of the University of Mainz, Alzey, Germany; LVR-Klinikum Bonn, Bonn, Germany
| | - Markus Jäger
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany; BKH Kempten, Kempten, Germany
| | - Jessica Baumgärtner
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Stefan Leucht
- German Center for Mental Health (DZPG), Partner Site Munich - Augsburg, Germany; Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Schmidt-Kraepelin
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Faculty of Medicine, Heinrich-Heine-University, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Germany
| |
Collapse
|
2
|
Schmidt-Kraepelin C, Feyerabend S, Engelke C, Riesbeck M, Meisenzahl-Lechner E, Verde PE, Correll CU, Kluge M, Makiol C, Neff A, Lange C, Englisch S, Zink M, Langguth B, Poeppl TB, Reske D, Gouzoulis-Mayfrank E, Gründer G, Hasan A, Brockhaus-Dumke A, Jäger M, Baumgärtner J, Leucht S, Cordes J, Cordes J, Feyerabend S, Engelke C, Riesbeck M, Meisenzahl-Lechner E, Gaebel W, Deiß M, Sofie N, Galuba V, Wiechmann F, Janssen B, Kluge M, Makiol C, Kertzscher L, Neff A, Lange C, Englisch S, Zink M, Becker A, Muszinski S, Gründer G, Langguth B, Poeppl T, Frank E, Kreuzer P, Reske D, Gouzoulis-Mayfrank E, Veselinovic T, Hasan A, Falkai P, Wagner E, Brockhaus-Dumke A, Klos B, Jäger M, Lang F, Kling-Lourenço P, Baumgärtner J, Hasan A, Dreimüller N, Hiemke C, Leucht S, Heres S, Leucht C, Assion HJ, Kis B, Zilles-Wegner D, Kahl K, Correll C, Verde PE, Kolbe H, Rottmann A. Amisulpride and olanzapine combination treatment versus each monotherapy in acutely ill patients with schizophrenia in Germany (COMBINE): a double-blind randomised controlled trial. Lancet Psychiatry 2022; 9:291-306. [PMID: 35276079 DOI: 10.1016/s2215-0366(22)00032-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/03/2022] [Accepted: 01/19/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Combining antipsychotics is common in schizophrenia treatment, despite evidence-based guidelines generally not recommending such practice. Otherwise, evidence remains inconclusive, especially regarding specific combinations. The trial aimed to test whether a combination of amisulpride plus olanzapine is more effective than either intervention as a monotherapy. METHODS A multicentre, 16-week, randomised, double-blind, controlled trial was done at 16 psychiatric in-patient centres throughout Germany. Inclusion criteria were adults aged 18-65 years with non-first episode schizophrenia or schizoaffective disorder and with a Positive and Negative Syndrome Scale (PANSS) total score of at least 70 and at least two items of the positive symptoms subscale rated at least 4. Patients were randomly assigned to receive 16 weeks of treatment with either amisulpride plus olanzapine, amisulpride plus placebo, or olanzapine plus placebo (1:1:1), and block randomisation was stratified by study site. To keep patients and investigators masked throughout the duration of the trial, amisulpride, olanzapine, and placebo were administered as identical capsules. Flexibly dosed monotherapy of oral amisulpride (amisulpride plus placebo, 200-800 mg per day) or olanzapine (olanzapine plus placebo, 5-20 mg per day) was compared with a combination of amisulpride plus olanzapine. The primary outcome was symptom reduction measured by the PANSS total score after 8 weeks, in the modified intention-to-treat population (all patients randomly assigned to an intervention and receiving at least one study drug dose). As determined a priori, group differences were examined by t tests (Bonferroni-Holm-adjustment) followed by pre-planned Bayesian analyses as well as imputation methods based on mixed models to account for missing values and post-hoc ANCOVA adjusting for PANSS baseline scores. The study was registered on ClinicalTrials.gov, NCT01609153; the German Clinical Trials Register, DRKS00003603; and the European Union Drug Regulating Authorities Clinical Trials Database, EudraCT-No. 2011-002463-20. FINDINGS Between June 15, 2012, and Dec 15, 2018, 13 692 patients were assessed for eligibility. 13 364 patients were excluded (including for not meeting inclusion criteria, declining to participate, or inappropriate reasons for changing pharmacological treatment), and 328 were then randomly assigned to an intervention group. 112 patients were randomly assigned to receive amisulpride plus olanzapine, 109 were randomly assigned to receive amisulpride plus placebo, and 107 were randomly assigned to receive olanzapine plus placebo. 321 patients were analysed for the primary outcome in the modified intention-to-treat population after exclusion of screening failures and patients who did not receive the intervention (110 for amisulpride plus olanzapine, 109 for amisulpride plus placebo, and 102 for olanzapine plus placebo). Among the 321 patients who were randomly assigned to intervention groups and analysed for the primary outcome, 229 (71%) were male, 92 (29%) were female; the mean age was 40·2 years (SD 11·7); and 296 (92%) were White and 25 (8%) were classified as other ethnicity. PANSS total score improved significantly more at 8 weeks in the amisulpride plus olanzapine group (-29·6 [SD 14·5]) than in the olanzapine plus placebo group (-24·1 [13·4], p=0·049, Cohen's d=0·396). A significant difference was not observed in reduction of PANSS total score between the amisulpride and olanzapine group compared with the amisulpride and placebo group (-25·2 [SD 15·9], p=0·095, Cohen's d=0·29). After 8 weeks and 16 weeks, sexual dysfunction, weight, and waist circumference increase were significantly higher for patients receiving amisulpride plus olanzapine than for those receiving amisulpride plus placebo, with no differences in serious adverse events. Two patients died during study participation; one randomly assigned to the amisulpride plus olanzapine group, and one assigned to the olanzapine plus placebo group (both assessed with no relation to treatment). INTERPRETATION The advantages of amisulpride plus olanzapine have to be weighed against a higher propensity for side-effects. The use of this specific combination therapy could be an alternative to monotherapy in certain clinical situations, but side-effects should be considered. FUNDING German Federal Ministry of Education and Research.
Collapse
Affiliation(s)
- Christian Schmidt-Kraepelin
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Düsseldorf, Germany.
| | - Sandra Feyerabend
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Düsseldorf, Germany
| | - Christina Engelke
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Mathias Riesbeck
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Eva Meisenzahl-Lechner
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Pablo-Emilio Verde
- Coordination Centre for Clinical Trials, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christoph U Correll
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Berlin, Germany
| | - Michael Kluge
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Christian Makiol
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Andrea Neff
- LVR-Klinikum Langenfeld, Langenfeld, Germany
| | | | - Susanne Englisch
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Mainz, Germany
| | - Mathias Zink
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; District Hospital Mittelfranken, Ansbach, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Timm B Poeppl
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
| | | | | | - Gerhard Gründer
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
| | - Anke Brockhaus-Dumke
- Department of Psychiatry and Psychotherapy 1 and 2, Rheinhessen-Fachklinik Alzey, Academic Hospital of the University of Mainz; Alzey, Germany
| | - Markus Jäger
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Jessica Baumgärtner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - Joachim Cordes
- LVR-Clinic Düsseldorf, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; Kaiserswerther Diakonie, Florence Nightingale Hospital, Department of Psychiatry and Psychotherapy, Düsseldorf, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Schmidt-Kraepelin C, Meisenzahl-Lechner E, Kujovic M, Cordes J, Engelke C, Riesbeck M, Zielasek J, Engemann S, Vrinssen J, Lehmann I, Tönnesen-Schlack A, Banger M, Grümmer M, Scherbaum N, Muysers J, Rinckens S, Marggraf R, Gouzoulis-Mayfrank E. [Antipsychotic Polypharmacy in the Treatment of Patients with Schizophrenia in Nine Psychiatric Hospitals of the Landschaftsverband Rheinland, Germany]. PSYCHIATRISCHE PRAXIS 2021; 48:250-257. [PMID: 33472267 DOI: 10.1055/a-1321-7866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Antipsychotics are the cornerstone in the treatment of schizophrenia and are primarily recommended as monotherapy by evidence-based guidelines. Nevertheless, antipsychotic polypharmacy (APP) is prevalent in routine practice and APP is also used as a quality indicator since 2016 in quality management programs. OBJECTIVE Based on routine data of nine psychiatric hospitals of the Landschaftsverband Rheinland (LVR)/Germany the prevalence of APP was determined and correlated with factors of routine healthcare in order to monitor the adoption of APP and to discuss its feasibility as a quality indicator. MATERIALS AND METHODS All cases with schizophrenia (ICD-10 F20.x; ≥ 18 years) discharged between June 1st, 2016, and June 1st, 2017, (in-patient and day clinic) were extracted from an established research database shared by all nine hospitals and analyzed regarding APP prevalence at the time of discharge. RESULTS Based on 6,788 cases, the prevalence of APP was 55.5 % with an average of 2.4 antipsychotics (SD = 0.6) administered simultaneously. In multivariate analyses, significant predictors for APP were: gender (male > female), the number of days in hospital (long > short), involuntary treatment (no > yes) and the location of the hospital. CONCLUSIONS We found a high proportion of polypharmacy in inpatient schizophrenia patients and significant differences between hospitals. The use of the results as a quality indicator (criteria ≥ 2 antipsychotics) remains dependent on the background of the individual treatment courses, which cannot be adequately represented by the existing routine data. The LVR has been using the quality indicator of ≥ 3 antipsychotics since 2018, which is discussed as a more appropriate approach for future evaluations.
Collapse
Affiliation(s)
| | - Eva Meisenzahl-Lechner
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf.,LVR-Institut für Versorgungsforschung, Köln
| | - Milenko Kujovic
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf
| | - Joachim Cordes
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf.,Kaiserswerther Diakonie, Florence-Nightingale-Krankenhaus, Düsseldorf
| | - Christina Engelke
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf
| | - Mathias Riesbeck
- LVR-Klinikum Düsseldorf, Kliniken der Heinrich-Heine-Universität Düsseldorf
| | | | | | | | | | | | | | | | - Norbert Scherbaum
- LVR-Klinikum Essen, Kliniken und Institut der Universität Duisburg-Essen
| | | | | | | | | |
Collapse
|