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Ostuzzi G, Bertolini F, Tedeschi F, Vita G, Brambilla P, del Fabro L, Gastaldon C, Papola D, Purgato M, Nosari G, Del Giovane C, Correll C, Barbui C. Oral and long-acting antipsychotics for relapse prevention in schizophrenia-spectrum disorders: a network meta-analysis of 92 randomized trials including 22,645 participants. World Psychiatry 2022; 21:295-307. [PMID: 35524620 PMCID: PMC9077618 DOI: 10.1002/wps.20972] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
According to current evidence and guidelines, continued antipsychotic treatment is key for preventing relapse in people with schizophrenia-spectrum disorders, but evidence-based recommendations for the choice of the individual antipsychotic for maintenance treatment are lacking. Although oral antipsychotics are often prescribed first line for practical reasons, long-acting injectable antipsychotics (LAIs) are a valuable resource to tackle adherence issues since the earliest phase of disease. Medline, EMBASE, PsycINFO, CENTRAL and CINAHL databases and online registers were searched to identify randomized controlled trials comparing LAIs or oral antipsychotics head-to-head or against placebo, published until June 2021. Relative risks and standardized mean differences were pooled using random-effects pairwise and network meta-analysis. The primary outcomes were relapse and dropout due to adverse events. We used the Cochrane Risk of Bias tool to assess study quality, and the CINeMA approach to assess the confidence of pooled estimates. Of 100 eligible trials, 92 (N=22,645) provided usable data for meta-analyses. Regarding relapse prevention, the vast majority of the 31 included treatments outperformed placebo. Compared to placebo, "high" confidence in the results was found for (in descending order of effect magnitude) amisulpride-oral (OS), olanzapine-OS, aripiprazole-LAI, olanzapine-LAI, aripiprazole-OS, paliperidone-OS, and ziprasidone-OS. "Moderate" confidence in the results was found for paliperidone-LAI 1-monthly, iloperidone-OS, fluphenazine-OS, brexpiprazole-OS, paliperidone-LAI 1-monthly, asenapine-OS, haloperidol-OS, quetiapine-OS, cariprazine-OS, and lurasidone-OS. Regarding tolerability, none of the antipsychotics was significantly worse than placebo, but confidence was poor, with only aripiprazole (both LAI and OS) showing "moderate" confidence levels. Based on these findings, olanzapine, aripiprazole and paliperidone are the best choices for the maintenance treatment of schizophrenia-spectrum disorders, considering that both LAI and oral formulations of these antipsychotics are among the best-performing treatments and have the highest confidence of evidence for relapse prevention. This finding is of particular relevance for low- and middle-income countries and constrained-resource settings, where few medications may be selected. Results from this network meta-analysis can inform clinical guidelines and national and international drug regulation policies.
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Affiliation(s)
- Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Federico Bertolini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Giovanni Vita
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Paolo Brambilla
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Department of Neurosciences and Mental HealthFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Lorenzo del Fabro
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Department of Neurosciences and Mental HealthFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Davide Papola
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Guido Nosari
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Department of Neurosciences and Mental HealthFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Cinzia Del Giovane
- Institute of Primary Health CareUniversity of BernBernSwitzerland,Population Health LaboratoryUniversity of FribourgFribourgSwitzerland
| | - Christoph U. Correll
- Department of PsychiatryZucker Hillside HospitalGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineZucker School of Medicine at Hofstra/NorthwellHempsteadNYUSA,Department of Child and Adolescent PsychiatryCharité Universitätsmedizin BerlinBerlinGermany
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
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Ostuzzi G, Bertolini F, Del Giovane C, Tedeschi F, Bovo C, Gastaldon C, Nosé M, Ogheri F, Papola D, Purgato M, Turrini G, Correll CU, Barbui C. Maintenance Treatment With Long-Acting Injectable Antipsychotics for People With Nonaffective Psychoses: A Network Meta-Analysis. Am J Psychiatry 2021; 178:424-436. [PMID: 33596679 DOI: 10.1176/appi.ajp.2020.20071120] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study compared relapse prevention and acceptability of long-acting injectable (LAI) antipsychotics in the maintenance treatment of adults with nonaffective psychoses. METHODS The authors searched MEDLINE, Embase, PsycINFO, CINAHL, CENTRAL, and online registers for randomized controlled trials published until June 2020. Relative risks and standardized mean differences were pooled using random-effects pairwise and network meta-analysis. The primary outcomes were relapse rate and all-cause discontinuation ("acceptability"). The quality of included studies was rated with the Cochrane Risk of Bias tool, and the certainty of pooled estimates was measured with GRADE (Grading of Recommendations Assessment, Development, and Evaluation). RESULTS Of 86 eligible trials, 78 (N=11,505) were included in the meta-analysis. Regarding relapse prevention, most of the 12 LAIs included outperformed placebo. The largest point estimates and best rankings of LAIs compared with placebo were found for paliperidone (3-month formulation) and aripiprazole. Moderate to high GRADE certainty for superior relapse prevention compared with placebo was also found for (in descending ranking order) risperidone, pipothiazine, olanzapine, and paliperidone (1-month formulation). In head-to-head comparisons of LAIs, only haloperidol was inferior to aripiprazole, fluphenazine, and paliperidone. For acceptability, most LAIs outperformed placebo, with moderate to high GRADE certainty for (in descending ranking order) zuclopenthixol, aripiprazole, paliperidone (3-month formulation), olanzapine, flupenthixol, fluphenazine, and paliperidone (1-month formulation). In head-to-head comparisons, only LAI aripiprazole had superior acceptability to other LAIs (bromperidol, fluphenazine, paliperidone [1-month formulation], pipothiazine, and risperidone). CONCLUSIONS LAI formulations of paliperidone (3-month formulation), aripiprazole, olanzapine, and paliperidone (1-month formulation) showed the highest effect sizes and certainty of evidence for both relapse prevention and acceptability. Results from this network meta-analysis should inform frontline clinicians and guidelines.
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Affiliation(s)
- Giovanni Ostuzzi
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Federico Bertolini
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Cinzia Del Giovane
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Federico Tedeschi
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Chiara Bovo
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Chiara Gastaldon
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Michela Nosé
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Filippo Ogheri
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Davide Papola
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Marianna Purgato
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Giulia Turrini
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Christoph U Correll
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
| | - Corrado Barbui
- World Health Organization Collaborating Centre for Research and Training in Mental Health and Service Evaluation, and Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (Ostuzzi, Bertolini, Tedeschi, Gastaldon, Nosé, Ogheri, Papola, Purgato, Turrini, Barbui); Institute of Primary Health Care, University of Bern, Bern, Switzerland (Del Giovane); University Hospital of Verona, Verona, Italy (Bovo); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, N.Y., Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., and Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin (Correll)
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