[Pharmacological Treatment for Adult Diagnosed With Schizophrenia With Agitation or Violent Behavior]

OBJECTIVES

To determine the most effective pharmacological intervention and to bring recommendations for decision-making in the management of adults with schizophrenia with violent behavior or agitation.

METHODS

A clinical practice guideline was elaborated under the parameters of the Methodological Guide of the Ministerio de Salud y Protección Social to identify, synthesize and evaluate the evidence and make recommendations about the treatment and follow-up of adult patients with schizophrenia. The evidence of NICE guide 82 was adopted and updated. The evidence was presented to the Guideline Developing Group and recommendations, employing the GRADE system, were produced.

RESULTS

It is recommended the use of parenteral drugs in all agitated patient who does not respond to the measures of persuasion. The drugs with better evidence on effectiveness (control of violent behavior) are haloperidol and benzodiazepines, administered jointly or individually. Olanzapine is also an option considering that should only be used in institutions where a psychiatrist is available 24hours. Ziprasidone can be considered as a second-line drug. The information about the side effects associated with these drugs is insufficient and has low quality.

CONCLUSION

Violent behavior in adults with schizophrenia represents a risk for themselves and for those around them, so the opportune implementation of interventions aimed to calm the patient, in order to prevent potential negative outcomes is necessary. It is recommended to initiate these interventions with measures of verbal persuasion, and if these measures are not effective, appropriate use of parenteral drugs: haloperidol and benzodiazepines as first-line and olanzapine and ziprasidone as second choices.

[Clinical Practice Guidelines for Management of Schizophrenia: Evaluation Using AGREE II]

INTRODUCTION

Colombia is developing multiple national practice guidelines from a range of diseases. Clinical practice guidelines represent a very useful tool to be able to take decision over a patient care that is widely available for the clinician. In psychiatry there are a good number of international clinical guidelines for the treatment of schizophrenia nevertheless there is no article that evaluate them scientifically

METHODS

In the settings of developing a Colombian schizophrenia practice guideline, a systematic search was performed in multiple databases and the results were then evaluated by two trained persons. We present the results globally and by domains.

RESULTS

We found 164 matches for possible guidelines. After screening 7 guidelines were evaluated with the AGREE II instrument. Globally and by the different domains, the National Institute for Health and Care Excellence (NICE) was the guideline that got the best score. From the guidelines that were reviewed, 4 were from Europe and only 2 were from Latin America. None of the guidelines used GRADE methodology for the recommendations.

CONCLUSION

The diversity of the schizophrenia treatment guidelines does not allow an easy adoption of the recommendation by a psychiatrist in Colombia.

[Prevention and Treatment of Common Acute Adverse Effects With Antipsychotic Use in Adults With Schizophrenia Diagnosis]

OBJECTIVE

To determine the most adequate strategies for the prevention and treatment of the acute adverse effects of the use of antipsychotics.

METHODS

A clinical practice guideline was elaborated under the parameters of the Methodological Guide of the Ministerio de Salud y Protección Social to identify, synthesize and evaluate the evidence and make recommendations about the treatment and follow-up of adult patients with schizophrenia. A systematic literature search was carried out. The evidence was presented to the Guideline Developing Group and recommendations, employing the GRADE system, were produced.

RESULTS

The non-pharmacological interventions such as nutritional counseling by a nutritionist, exercise and psychotherapy are effective in preventing weight gain with the use of antipsychotics. (Kg Weight reduction in DM of -3.05 (-4.16, -1.94)). The antipsychotic change from olanzapine to aripiprazole showed weight loss and decreased BMI (decreased weight in KG DM -3.21 (-9.03, -2.61). The use of beta blockers was ineffective in reducing akathisia induced by antipsychotic; using as outcome the 50% reduction of symptoms of akathisia comparing beta-blockers with placebo RR was 1.4 (0.59, 1.83).

CONCLUSION

It is recommended to make psychotherapeutic accompaniment and nutrition management of overweight for patients with weight gain. If these alternatives are ineffective is suggested to change the antipsychotic or consider starting metformin. For the management of drug-induced akathisia it is recommended to decrease the dose of the drug and the addition of lorazepam. It is recommended using 5mg biperiden IM or trihexyphenidyl 5mg orally in case of secondary acute dystonia and for the treatment of antipsychotic-induced parkinsonism to decrease the dose of antipsychotic or consider using 2 - 4mg/day of biperiden or diphenhydramine 50mg once daily.