Selecting an atypical antipsychotic by combining clinical experience with guidelines from clinical trials

Three atypical antipsychotics are currently considered to be first-line therapies for schizophrenia, namely risperidone, olanzapine, and quetiapine. Deciding which one of these agents to choose for any given patient can be a daunting task because head-to-head comparisons of these 3 agents are just beginning, and most published trials are comparisons with typical antipsychotics, not with another atypical antipsychotic. Furthermore, results from clinical trials often do not match findings from clinical practice. Thus, guidelines for selection and use of the atypical antipsychotics are evolving from controlled studies as well as from clinical judgment based on the practical use of these agents once they have entered clinical practice. The atypical properties of first-line atypical antipsychotics as well as clozapine are reviewed here, with clinical pearls and dosing tips for each based upon a consensus of information from both clinical trials and clinical practice. The conventional antipsychotic loxapine is also reviewed and proposed as a potentially valuable agent to augment atypical antipsychotics when patients do not experience an acceptable treatment response from monotherapy with an atypical antipsychotic. By integrating information from clinical trials and clinical practice, the prescriber can be in a better position to choose which atypical antipsychotic to select for any given patient.