Aripiprazole versus other atypical antipsychotics for schizophrenia

Komossa K, Rummel-Kluge C, Schmid F, Hunger H, Schwarz S, El-Sayeh HGG, Kissling W, Leucht S

Published Online:

October 7, 2009

This review compares aripiprazole with other second generation antipsychotic drugs. There were only four studies on two comparisons - aripiprazole compared to olanzapine and aripiprazole compared to risperidone. On the basis of very limited data aripiprazole was not as effective as olanzapine but as good as risperidone. Aripiprazole was associated with less weight gain, cholesterol increase, sedation and prolactin related effects than olanzapine. Compared to risperidone aripiprazole produced fewer dystonias, cardiac arrhythmias, prolactin and cholesterol increase.

Abstract (click to read)

Background:

In many countries of the industrialised world second generation (atypical) antipsychotics have become first line drug treatments for people with schizophrenia. The question as to whether, and if so how much, the effects of the various second generation antipsychotics differ is a matter of debate. In this review we examine how the efficacy and tolerability of aripiprazole differs from that of other second generation antipsychotics.

Objectives:

To evaluate the effects of aripiprazole compared with other atypical antipsychotics for people with schizophrenia and schizophrenia-like psychoses.

Search strategy:

We searched the Cochrane Schizophrenia Group Trials Register (March 2007) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO.

Selection criteria:

We included all randomised trials comparing oral aripiprazole with oral forms of amisulpride, clozapine, olanzapine, quetiapine, risperidone, sertindole, ziprasidone or zotepine in people with schizophrenia or schizophrenia-like psychoses.

Data collection and analysis:

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random-effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (MD) again based on a random-effects model.

Main results:

The review currently includes four trials with 1404 participants on two out of eight possible comparisons - aripiprazole versus olanzapine and aripiprazole versus risperidone. The overall number of participants leaving the studies early was considerable (38.5%), limiting the validity of the findings, but with no significant differences between groups. Aripiprazole was less efficacious than olanzapine in terms of the general mental state (PANSS total score: n=794, 2 RCTs, MD 4.96 CI 1.85 to 8.06), but it was associated with fewer side-effects such as cholesterol increase, weight gain, sedation and prolactin associated side-effects. Compared with risperidone there was no difference in efficacy (PANSS total score: n=372, 2 RCTs, MD 1.50 CI -2.96 to 5.96). Dystonia, QTc abnormalities, prolactin and cholesterol increase were less frequent in the aripiprazole group, while tremor was more frequent in the aripiprazole group compared with those allocated risperidone.

Authors' conclusions:

Aripiprazole may be somewhat less effective than olanzapine, but more tolerable in terms of metabolic effects and sedation. There is no evidence for a difference in efficacy compared to risperidone, but for better tolerability in terms of dystonias, cholesterol prolactin increase and QTc prolongation. Randomised evidence comparing aripiprazole with other second generation antipsychotic drugs is currently not available.

This record should be cited as:

Komossa K, Rummel-Kluge C, Schmid F, Hunger H, Schwarz S, El-Sayeh HGG, Kissling W, Leucht S. Aripiprazole versus other atypical antipsychotics for schizophrenia. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006569. DOI: 10.1002/14651858.CD006569.pub3

Assessed as up to date:

May 14, 2007

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Primary Review Group:

Schizophrenia Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is aripiprazole compared with other atypical antipsychotics for people with schizophrenia and schizophrenia-like psychoses?

Bottom line:

On the basis of very limited data, aripiprazole was not as effective (in terms of general mental state) as olanzapine but was as effective as risperidone. Aripiprazole was associated with less weight gain, cholesterol increase and sedation, and fewer prolactinrelated effects than olanzapine. Compared to risperidone, aripiprazole produced fewer dystonias, cardiac arrhythmias, and prolactin and cholesterol increases. However, tremor was more frequent in the aripiprazole group compared to those allocated risperidone.

Caveat:

The overall premature discontinuation rate of 38.5% was considerable, clearly limiting the validity of the results. Long term data (longer than 26 weeks) are not available. All of the four included studies were sponsored by the manufacturer of aripiprazole.

Context:

Schizophrenia is usually a chronic and disabling psychiatric disorder, which affects approximately 1 per cent of the population worldwide, with little gender difference. In many countries of the industrialised world, second generation (atypical) antipsychotics have become first-line drug treatments for people with schizophrenia. The question as to whether, and if so how much, the effects of the various second generation antipsychotics differ is a matter of debate.

Cochrane Systematic Review:

Komossa K et al. Aripiprazole versus other atypical antipschotics for schizophrenia. Cochrane Reviews 2009, Issue 4. Article No. CD006569. DOI: 10.1002/14651858. CD006569.pub2. This review contains 4 studies involving 1404 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Mental health > Schizophrenia & psychosis > Antipsychotic medication: atypical

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Aripiprazole versus other atypical antipsychotics for schizophrenia

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