Algorithm for the Pharmacological Treatment of Patients with Schizophrenia or Schizoaffective Disorder.
Algorithm for the Pharmacological Treatment of Patients with Schizophrenia or Schizoaffective Disorder. - Flowchart Treatment Treatment
«Flowchart»

Schizophrenia or Schizoaffective Disorder

Inform Antipsychotic choice by:


Stage of illness: Prodromal, first-episode, acute or chronic
Comorbid substance use
Suicide risk
Risk of agitation/violence
Metabolic risk (diabetes, weight gain) - especially for CLOZ, OLZCatatonia/neuroleptic malignant syndrome
Non-adherence
Motor side effects including tardive dyskinesia
Patient choice

Schizophrenia or Schizoaffective Disorder

Inform Antipsychotic choice by:


Stage of illness: Prodromal, first-episode, acute or chronic
Comorbid substance use
Suicide risk
Risk of agitation/violence
Metabolic risk (diabetes, weight gain) - especially for CLOZ, OLZCatatonia/neuroleptic malignant syndrome
Non-adherence
Motor side effects including tardive dyskinesia
Patient choice

Schizophrenia or Schizoaffective Disorder

Schizophrenia or Schizoaffective Disorder


Stage of illness: Prodromal, first-episode, acute or chronic
Comorbid substance use
Suicide risk
Risk of agitation/violence
Metabolic risk (diabetes, weight gain) - especially for CLOZ, OLZCatatonia/neuroleptic malignant syndrome
Non-adherence
Motor side effects including tardive dyskinesia
Patient choice


Stage of illness: Prodromal, first-episode, acute or chronic
Comorbid substance use
Suicide risk
Risk of agitation/violence
Metabolic risk (diabetes, weight gain) - especially for CLOZ, OLZ
Non-adherence
Motor side effects including tardive dyskinesia
Patient choice

AMI, not available in the United States), aripiprazole (ARIP), olanzapine (OLZ), quetiapine (QTP), risperidone (RISP), paliperidone (PALI), or ziprasidone (ZIP) NMS, Neuroleptic malignant syndrome.

AMI, not available in the United States), aripiprazole (ARIP), olanzapine (OLZ), quetiapine (QTP), risperidone (RISP), paliperidone (PALI), or ziprasidone (ZIP) NMS, Neuroleptic malignant syndrome.

AMI, not available in the United States), aripiprazole (ARIP), olanzapine (OLZ), quetiapine (QTP), risperidone (RISP), paliperidone (PALI), or ziprasidone (ZIP) NMS, Neuroleptic malignant syndrome.

Consider initial or emergent issues affecting management and choice of drugs (here and at each subsequent step)

Consider initial or emergent issues affecting management and choice of drugs (here and at each subsequent step)

Consider initial or emergent issues affecting management and choice of drugs (here and at each subsequent step)

CONSIDER AT EACH STAGE

Major suicide risk

Metabolic issues (especially with OLZ) and treatment related adverse effects

Severe agitation or violence

Noncompliance

Depression of mood symptoms

Substance abuse

Prodromal or first episode

Catatonia or NMS

CONSIDER AT EACH STAGE

Major suicide risk

Metabolic issues (especially with OLZ) and treatment related adverse effects

Severe agitation or violence

Noncompliance

Depression of mood symptoms

Substance abuse

Prodromal or first episode

Catatonia or NMS

CONSIDER AT EACH STAGE

Major suicide risk

Metabolic issues (especially with OLZ) and treatment related adverse effects

Severe agitation or violence

Noncompliance

Depression of mood symptoms

Substance abuse

Prodromal or first episode

Catatonia or NMS

Trial of adequate dose, duration, no intolerability?

Trial of adequate dose, duration, no intolerability?

Trial of adequate dose, duration, no intolerability?

Yes

Yes

Yes

No

No

No

Maintenance phase

Maintenance phase

Maintenance phase

MONOTHERAPY

4-6 week trial of an atypical (AMI, ARIP, OLZ, QTP, RISP, PALI, or ZIP) or, if not available, a trial of typical neuroleptic

MONOTHERAPY

4-6 week trial of an atypical (AMI, ARIP, OLZ, QTP, RISP, PALI, or ZIP) or, if not available, a trial of typical neuroleptic

MONOTHERAPY

4-6 week trial of an atypical (AMI, ARIP, OLZ, QTP, RISP, PALI, or ZIP) or, if not available, a trial of typical neuroleptic

Psychosis persists after adjusting dose?

Psychosis persists after adjusting dose?

Psychosis persists after adjusting dose?

Yes

Yes

Yes

No

No

No

End

End

End

Adequate trial?

Adequate trial?

Adequate trial?

Yes

Yes

Yes

No

No

No

6-month trial of CLOZ up to 900 mg/day

6-month trial of CLOZ up to 900 mg/day

6-month trial of CLOZ up to 900 mg/day

Psychosis persists or moderate to severe TD after adjusting dose?

Psychosis persists or moderate to severe TD after adjusting dose?

Psychosis persists or moderate to severe TD after adjusting dose?

Yes

Yes

Yes

No

No

No

Optimize CLOZ and/or augment with ECT or adjuvant medication, alternate strategies

Optimize CLOZ and/or augment with ECT or adjuvant medication, alternate strategies

Optimize CLOZ and/or augment with ECT or adjuvant medication, alternate strategies

Psychosis persists after adjusting dose?

Psychosis persists after adjusting dose?

Psychosis persists after adjusting dose?

Yes

Yes

Yes

No

No

No

Response


Continue treatment until remission and return to adequate functioning
Consider LAI antipsychotic (LAIA)

Response


Continue treatment until remission and return to adequate functioning
Consider LAI antipsychotic (LAIA)

Response

Response

Response Response


Continue treatment until remission and return to adequate functioning
Consider LAI antipsychotic (LAIA)


Continue treatment until remission and return to adequate functioning
Consider LAI antipsychotic (LAIA)

END

END

END

Response


Continue treatment until remission and return to adequate functioning
Consider LAIA

 Response


Continue treatment until remission and return to adequate functioning
Consider LAIA

 Response Response


Continue treatment until remission and return to adequate functioning
Consider LAIA


Continue treatment until remission and return to adequate functioning
Consider LAIA NO response


Consider CLOZ
For non-adherence - consider LAIA
Address comorbidities

 NO response


Consider CLOZ
For non-adherence - consider LAIA
Address comorbidities

 NO response


Consider CLOZ
For non-adherence - consider LAIA
Address comorbidities


Consider CLOZ
For non-adherence - consider LAIA
Address comorbidities NO response


Add antipsychotic to CLOZ
For non-adherence - consider LAIA
Address comorbidities
Electroconvulsive treatment
Combinations of antipsychotics

 NO response


Add antipsychotic to CLOZ
For non-adherence - consider LAIA
Address comorbidities
Electroconvulsive treatment
Combinations of antipsychotics

 NO response


Add antipsychotic to CLOZ
For non-adherence - consider LAIA
Address comorbidities
Electroconvulsive treatment
Combinations of antipsychotics


Add antipsychotic to CLOZ
For non-adherence - consider LAIA
Address comorbidities
Electroconvulsive treatment
Combinations of antipsychotics NO response


Consider 2nd trial of antipsychotic monotherapy
For non-adherence - consider LAIA
Address comorbidities: e.g., substance use disorder

 NO response


Consider 2nd trial of antipsychotic monotherapy
For non-adherence - consider LAIA
Address comorbidities: e.g., substance use disorder

 NO response


Consider 2nd trial of antipsychotic monotherapy
For non-adherence - consider LAIA
Address comorbidities: e.g., substance use disorder


Consider 2nd trial of antipsychotic monotherapy nd
For non-adherence - consider LAIA
Address comorbidities: e.g., substance use disorder

Response

Response

Response Response Response

NO respnse

NO respnse

NO respnse NO response

MONOTHERAPY


6 week trial of any antipsychotic

MONOTHERAPY


6 week trial of any antipsychotic

MONOTHERAPY


Responce

Responce

Responce Responce Response

NO response

NO response

NO response NO response