My recommended treatment plan for schizophrenia is.
1. It has been recognized worldwide that, by efficacy, of the many antipsychotics available, only amisulpride, olanzapine, clozapine, and risperidone, are better than the standard control drug haloperidol (note: risperidone is only slightly better).
Amisulpride.
1, currently only imported, 1200 mg per day (expensive, to $120) ;
2, less side effects such as drowsiness and weight gain, but often affects menstruation when applied to women (but after reducing the amount or stopping the drug, it will return to normal completely);
3, another advantage is that it does not induce compulsion. (This drug is not yet in our hospital)
Clozapine.
1, a number of side effects, often therefore can not use the full 300-600 mg of treatment;
2, there is the possibility of adverse reactions to the reduction of white blood cells;
3, often lead to drooling, related to the size of the dose;
4.There is the possibility of more serious induced compulsion;
5.Weight gain may be greater, but can be countered by diet control and the addition of metformin;
6.After long-term application, there is a certain tendency of dependence, and it is more difficult to stop the drug;
7, completely domestic, low drug prices.
Olanzapine.
1, relatively few side effects;
2, no effect on heart function;
3, although there is also the possibility of inducing compulsion, but less than clozapine;
4, weight gain may be greater, but can be dealt with by diet control and the addition of metformin;
5, there are already national products, 20 mg per day as long as 40 yuan.
Risperidone.
1, side effects are relatively large, especially for female patients such as menstruation impact;
2, no particular effect on the heart ;
3, although there is also the possibility of inducing compulsion, but less than clozapine olanzapine;
4, weight gain may be greater, but can be dealt with by diet control and the addition of metformin;
5, has all the national products, 3-6mg per day.
Therefore, I advocate the first cases or to choose olanzapine risperidone is better. No matter which of the above treatment. Must reach the original symptoms completely disappeared (note: not basic improvement) before moving to the consolidation period. After consolidation of the original amount for at least 2 months, the dosage can be gradually reduced; finally, it is replaced with pentafluoridol for maintenance. Pentoxifylline is currently the ideal maintenance drug, inexpensive ($5 per month), no side effects, no weight gain, no impact on blood glucose or lipid metabolism, and no induced compulsion. It can be combined in advance when the therapeutic drug is reduced to a smaller dose, then it is more insurance when reducing the therapeutic drug.
2, if it has been repeatedly used risperidone and so on various antipsychotics, did not solve the problem of the case, I suggest first switch or add olanzapine treatment; hope to step in place, add to 20 or 30 mg. In this case, olanzapine can be added immediately on top of the original medication. You can also start with olanzapine 10 mg the night you immediately stop using the original drug, and if there is no abnormal reaction, from the next day onwards, use olanzapine 20 mg every night. 2 weeks later, if the symptoms have not disappeared, increase the dosage to 30 mg every night. As for taking the medication once or in divided doses, it is optional. In the meantime, it is advisable to take Benadryl (1-2 tablets 2-3 times a day) to prevent side effects. If after taking the drug appears to be unable to sit still, distracted, etc., temporary take 2 capsules of insulin, usually can be relieved within 15 minutes, no need to panic.
3, if olanzapine alone, still failed to as desired. Then you can olanzapine 20-30 mg, and use the pharmacological mechanism is not exactly the same antipsychotic drugs, such as: haloperidol, sulpiride, or pentafluridol.
The therapeutic amount of pentoxifylline, 5 mg (i.e., 1/4 tablet) per day.
Sulpiride at a therapeutic dose of 1 tablet (100 mg per tablet) twice daily, increasing to 10 tablets per day over 1 week.
Haloperidol, from 1 tablet twice a day (2 mg per tablet), increasing to 10 or even 20 tablets per day within 1 week.
Of course, you can also add clozapine, from 2 times a day, each time 1 tablet (25 mg per tablet), and gradually increase to 10-20 tablets per day within 2-3 weeks; however, clozapine has many side effects, especially 0.1% of cases have the possibility of leukopenia (less than 4.0), must be checked every 1-2 weeks routine blood, the condition of the psychiatric hospital can monitor the blood concentration of clozapine, as a precaution.
4, really can not solve the problem, for example, the application of the above methods, although there is a significant effect, but not complete, then you can use amisulpride (it seems to be necessary to 1200 mg or more, can be completely in 1 week on this dose). If it works, consolidate for 2 months. To reduce the dose, you can first reduce olanzapine, the first 2 times as 2.5 mg every 2 weeks, and if still normal, from the 3rd time, reduce 5 mg each time until the reduction is complete. Then, reduce amisulpride by 200 mg every 2 weeks until the reduction is completed. Final maintenance with pentoxifylline. If there are no obsessive-compulsive side effects, amisulpride can also be reduced first. Of course, it is possible to reduce olanzapine and amisulpride alternately.
5. While applying the above drugs, it is recommended to check the electrocardiogram once a month in order to ensure that there are no accidents. The advantage of olanzapine is that it has no adverse effect on the heart, but it is better to review the ECG several times. If the ECG report says ‘sinus tachycardia’, it means that the heart beats faster when the ECG is done, so don’t worry about it. If it says ‘sinus arrhythmia’, this is normal and does not matter. What should be noted is: Are there more ‘premature beats’? Is there any ‘low st pressure’? Is there a prolonged QTc (normal value is ‘below 470 or 480’)? It is better to compare with the ECG before taking the medication. If the QTc exceeds the normal limit, or increases by more than 60 at once, then the medication should be reduced. As for liver function, it can be rechecked monthly or every 2 or 3 months. If transaminases are found to be elevated, there is no need to be nervous, even if you don’t take the so-called ‘liver-protective drugs’, they will often return to normal within a month on their own. Amisulpride is not metabolized in the liver, so there is no question of affecting transaminases. In cases where clozapine is applied, routine blood tests must be performed every 2-4 weeks. The normal value for white blood cells is 4.0-10.0, which means that it should not go below 4.0. The white blood cell count tends to vary up and down throughout the day, as long as it does not exceed this range. If it is a little bit low, don’t be nervous, just recheck it again in a few days. If the count falls below 4.0 several times, then you should stop taking clozapine. You can add lithium carbonate, 50 to 100 mg per day (i.e., about 1/4 tablet), to increase the release of white blood cells from the bone marrow, and the white blood cell count may rise.
Additional information on maintenance medication.
If economic factors are not taken into account and only the efficacy is considered, the maintenance medication I recommend is still pentoxifylline. The reasons are as follows.
A. Clozapine: Even with only 75 mg (practice has shown that if less dose, often not maintained; only a few cases can be maintained with 50 mg).
1, there is also a greater tendency to drowsiness.
2, there may be a more pronounced suppression of sexual desire.
3. If compulsions have been induced and are still maintained with clozapine, the compulsive symptoms are often not completely cleared.
4. There is still a mild drooling side effect.
5. There may be potential effects on cardiac function (? This is not quite certain).
B. Olanzapine: maintenance with 5 mg is more likely, but.
1, the problem of weight gain is unlikely to be completely resolved, at least not to restore the original slim body shape.
2, blood sugar problems may also persist, the
3. There is also still a mild feeling of suppressed mental activity. If it can be maintained normally with 2.5 mg, generally speaking, there are no such problems; however, not most cases can be successfully maintained with this dose.
C. Risperidone: It should be said that for males, there are few problems, mainly extrapyramidal reactions. For women, does the maintenance dose affect menstruation and ovulation? I don’t know. Just how much dose can be maintained? I have no experience. Because there is actually no theoretical study of maintenance doses of antipsychotics at all, it’s all just a lot of practical experience. So, does 4-6 mg of amisulpride affect prolactin levels? Does it affect ovulation? Does it affect sexual desire? It deserves to be studied. I’m afraid no one can answer that so far.
E. Pentoxifylline: practice has proven that there are no such problems as mentioned above.
D. In short, our ‘goal’ of drug maintenance is to ensure that there is no recurrence, no significant side effects, and that the price of the drug is affordable. Some patients have misunderstood my intention, I do not advocate that every case be maintained with pentoxifylline. Some cases are maintained well with risperidone 3mg, some cases are maintained well with olanzapine 5mg or 2.5mg, weight is appropriate, glucose metabolism is not a problem, and there is no compulsion, and the family does not have financial problems, then of course there is no need to toss and switch to pentoxifylline. Some cases have been well maintained with clozapine 75 mg without any side effects, so they are maintained that way and do not need to be replaced. Some male cases have been maintained with sulpiride 300 mg for several years without any side effects, and that is very desirable. As long as the above goal can be achieved, all other drugs can be used as maintenance medication. The key is: never casually reduce the dosage or casually stop the medication, that is even if the purpose of treating schizophrenia is achieved.