failure to respond to treatment
Last reviewed 01/2018
30% of patients will fail to respond to adequate dopamine D2 receptor blockade with conventional antipsychotics such as haloperidol.
NICE suggest that (1):
- if symptoms have not responded adequately to treatment:
- review the diagnosis
- check that there has been adherence to antipsychotic medication, prescribed at an adequate dose and for the correct duration
- check that psychological treatments have been offered and review engagement
with these
- offer CBT if family intervention has been undertaken; if CBT has been undertaken, suggest family intervention for those in close contact with their family
- consider other causes of non-response, for example comorbid substance or alcohol misuse, concurrent use of other prescribed medication, or physical illness
- clozapine should be offered if symptoms have not responded adequately despite sequential use of at least two different antipsychotics, one of which should be a non-clozapine second-generation antipsychotic
- if symptoms have not responded adequately to an optimised dose
of clozapine, review the diagnosis, adherence to treatment, engagement
with and use of psychological treatments, other possible causes of
non-response and measure therapeutic drug levels before offering a
second antipsychotic to augment clozapine
- second drug should not compound the common side effects of clozapine. An adequate trial of augmentation may need to be up to 8-10 weeks
Notes:
- clozapine:
- the first of the new generation antipsychotics
- thought to block a range of dopamine receptors (D1, D2 and D4) and the serotonin receptor
- there is a 1% risk of agranulocytosis
- fewer extra-pyramidal side-effects
- reduces hospitalisation in resistant schizophrenia
Reference: