The Pharmaceutical Journal
Vol 268 No 7201 p793-795
8 June 2002

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NICE approves atypical antipsychotics as first-line treatment in schizophrenia

Atypical antipsychotic drugs should be considered as first-line therapy for patients with newly diagnosed schizophrenia, the National Institute for Clinical Excellence announced this week. NICE has also indicated in its guidance, issued to the National Health Service in England and Wales, that patients and carers should be involved in the treatment decision-making process.

Andrew Dillon, chief executive, NICE, said: "In effect there is a choice for patients between two interventions [typical versus atypical antipsychotic drugs] designed to control symptoms. But these drugs have different side effect profiles and there is a judgement that needs to be made about which drug best suits an individual patient." Mr Dillon stressed that the guidance was not recommending that patients treated successfully with typical antipsychotic drugs should have their medication changed.

He explained that the evidence presented had not allowed NICE to distinguish between the atypicals. "In general, NICE looks at the class effect. We would only recommend one drug over another if there was strong evidence to support this."

The guidance also recommends that patients with treatment-resistant schizophrenia should be treated with clozapine (Clozaril) at the earliest opportunity.

David Taylor, chief pharmacist, Maudsley Hospital, London, and an adviser to the NICE appraisal committee, welcomed the guidance. "The guidance strikes me as sensible. I am glad that NICE has recognised that atypicals are better tolerated by most people than older drugs and also that clozapine should be used sooner rather than later."

Mr Taylor thought that it was appropriate that the guidance did not differentiate between the newer atypical drugs. "Patients and prescribers are better able to make decisions on the ground, rather than being told that one atypical is better than another."

He pointed out that differences among the atypicals boiled down to adverse effect profiles. "It is important to know how the patient feels about the adverse effects." One patient might find an adverse effect such as weight gain acceptable, whereas another patient might not, he said.

NICE estimates that, following its guidance, the increase in drug costs to the NHS will be about £70m per year. However, the use of the newer atypical medicines is expected to result in a shift away from inpatient hospital care to residential or community care, which is less expensive. "There is evidence that, in the long run, using atypical antipsychotic drugs would make better use of NHS resources," Mr Dillon said.

In its guidance, NICE also recommends that drug tolerability is monitored and that a risk assessment is performed regarding concordance with medication, and that depot preparations are prescribed when appropriate. Atypical and typical antipsychotic drugs should not be prescribed concurrently except for short periods to cover changeover of medication, NICE says.

Copies of the full guidance are available on the NICE web site (www.nice.org.uk).