Antipsychotic Polypharmacy in Time Course: Evidence for a Cross-titration Trap

Area of Science:

• Psychiatry
• Pharmacology
• Clinical Medicine

Background:

• Antipsychotic polypharmacy (APP) is a common but controversial practice, used in approximately 20% of patients with psychotic disorders.
• Investigating the reasons for initiating and continuing APP is crucial for optimizing patient care and reducing inappropriate medication use.

Purpose of the Study:

• To determine the primary indications for initiating and continuing antipsychotic polypharmacy (APP) in inpatients.
• To assess the contribution of unfinished cross-titration to the persistence of APP.

Main Methods:

• A prospective 2-month study involving 55 inpatients diagnosed with psychotic disorders, primarily schizophrenia.
• Prescribers were surveyed at the initiation of APP and at 30 and 60 days to ascertain indications (e.g., switching, sedation, treatment refractoriness) and track APP continuation.
• The secondary outcome measured was the occurrence of unfinished cross-titration at 60 days.

Main Results:

• Switching antipsychotics was the most common initial indication for APP (56%), followed by sedation (22%) and treatment refractoriness (18%).
• APP was discontinued in 45% of patients by 30 days and 51% by 60 days.
• At 60 days, APP initiated for switching antipsychotics was ongoing in 29% of cases, sedation in 66%, and treatment refractoriness in 90%. Unfinished cross-titration occurred in 29% of patients whose APP was initiated for switching.

Conclusions:

• Antipsychotic polypharmacy (APP) is frequently initiated for the purpose of switching antipsychotics, with a significant proportion (29%) resulting in unfinished cross-titration.
• The initial indication for APP tended to be maintained over the 60-day study period, particularly when the reason was treatment refractoriness.
• This study highlights the need to carefully manage antipsychotic switching to avoid prolonged or inappropriate APP.