Canadian Agency for Agence canadienne Drugs and Technologies des médicaments et des in Health technologies de la santé Optimal Use Report CADTH A Systematic Review of Combination and Volume 1, Issue 1b High-Dose Atypical Antipsychotic Therapy December 2011 in Patients with Schizophrenia Supporting Informed Decisions This report is prepared by the Canadian Agency for Drugs and Technologies in Health (CADTH). This report contains a review of existing public literature, studies, materials, and other information and documentation (collectively the ―source documentation‖) available to CADTH at the time it was prepared, and it was guided by expert input and advice throughout its preparation. The information in this report is intended to help health care decision-makers, patients, health care professionals, health systems leaders, and policy-makers make well- informed decisions and thereby improve the quality of health care services. The information in this report should not be used as a substitute for the application of clinical judgment in respect to the care of a particular patient or other professional judgment in any decision-making process, nor is it intended to replace professional medical advice. While CADTH has taken care in the preparation of this report to ensure that its contents are accurate, complete, and up-to-date, CADTH does not make any guarantee to that effect. CADTH is not responsible for any errors or omissions or injury, loss, or damage arising from or as a result of the use (or misuse) of any information contained in or implied by the information in this report. CADTH takes sole responsibility for the final form and content of this report. The statements, conclusions, and views expressed herein do not necessarily represent the view of Health Canada or any provincial or territorial government. Production of this report is made possible through a financial contribution from Health Canada. Copyright © 2011 CADTH. This report may be reproduced for non-commercial purposes only and provided that appropriate credit is given to CADTH. ISSN: 1927-0127 Contributors from CADTH Tarun K. Ahuja, PhD David Kaunelis, MLIS Research Officer Information Specialist Chris Cameron, BSc, EngDip, MSc Sumeet R. Singh, BScPhm, MSc, RPh Health Economist Manager, Clinical Research Samantha Verbrugghe, BSc Research Assistant Changhua Yu, MD, MSc Kristen Moulton Research Officer Research Assistant Nancy Robertson Janet Crain Knowledge Exchange Officer Manager, Knowledge Exchange Janice Mann, MD Doug Lentz Knowledge Exchange Officer Project Manager Systematic Review of Combination and High Dose AAPs for Schizophrenia i Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) Expert Review Committee Dr. Lisa Dolovich, Chair Dr. Mike Evans, Vice-Chair Research Director and Associate Professor, Director, Patient Self-Management and Department of Family Medicine, Knowledge Support Centre for Effective McMaster University; Practice, Department of Family and Ambulatory Care Pharmacotherapy Community Medicine, and Associate Specialist and Associate Director, Centre Professor, University of Toronto; for Evaluation of Medicines, St. Joseph’s Director, Health Media Lab, Li Ka Shing Healthcare Hamilton Knowledge Institute, St. Michael’s Hospital; Staff Physician, Toronto Western Hospital Members Dr. Michael Allen Dr. James L. Silvius Associate Professor, Associate Professor, University of Calgary; Director, Evidence-based Programs, Senior Medical Director, Continuing Medical Education, Seniors’ Health and Living Options, Dalhousie University Alberta Health Services Dr. Scott Klarenbach Dr. Adil Virani Associate Professor, Department of Director, Pharmacy Services, Fraser Health Medicine, Division of Nephrology, Authority; University of Alberta; Associate Professor, Faculty of Pharmaceutical Fellow, Institute of Health Economics Sciences, University of British Columbia Mr. Panos Petrides Ms. Cathy MacNutt Public Member Public Member Specialist Expert Members Dr. William G. Honer Dr. Richard Williams Professor of Psychiatry, Professor, Department of Psychiatry, University University of British Columbia; of British Columbia; Scientific Director, BC Mental Health & Adjunct Professor, Department of Psychology, Addictions Research Institute; University of Victoria; Director, Centre for Complex Disorders Director of Schizophrenia Services, Royal Jubilee Hospital, Victoria Dr. Gary Remington Dr. Heather Milliken Professor of Psychiatry, Head of Associate Professor and Director of Continuing Schizophrenia Program, Faculty of Medical Education, Department of Psychiatry, Medicine, University of Toronto; Dalhousie University; Director, Medication Assessment Clinic & Nova Scotia Early Psychosis Program Deputy Director of Research and Education, Schizophrenia Program, Centre for Addiction and Mental Health ii Systematic Review of Combination and High-Dose AAPs for Schizophrenia Conflicts of Interest Dr. Michael Evans has received grant support from AstraZeneca Canada Inc. to offset the cost of Mini Medical School, an educational program for the public. Dr. Scott Klarenbach is a member of a research group funded by an unrestricted grant to the Alberta Kidney Disease Network from Amgen Canada Inc. and Merck Frosst Canada Ltd. Dr. Richard Williams has received funding for educational lectures from Eli Lilly and funding for conferences from Pfizer. He has received compensation for consulting services from Bristol- Myers Squibb Canada. He has received compensation for consulting services and research funding from Organon Canada Ltd., Janssen-Ortho Inc., Pfizer, Eli Lilly, and AstraZeneca Canada. He has received research funding from Obecure, Sanofi-aventis Canada, and Solvay. Dr. Gary Remington has received financial support for his research from Novartis Canada, Medicure, and Merck KGaA (Germany). He is also involved in a phase 1 clinical trial with Neurocrine Biosciences. Dr. Heather Milliken has received funding for educational lectures and compensation for consulting services from Pfizer and Janssen-Ortho Inc. She has also received research funding from Janssen-Ortho Inc. and Eli Lilly. Systematic Review of Combination and High Dose AAPs for Schizophrenia iii ABBREVIATIONS AAP atypical antipsychotics AMI amisulpride APD antipsychotic drugs AE adverse event AIMS Abnormal Involuntary Movement Scale ANCOVA analysis of covariance ARI aripiprazole BA(R)S Barnes Akathisia Rating Scale BPRS Brief Psychiatric Rating Scale CGI Clinical Global Impression CGI-I Clinical Global Impression — Improvement CGI-S Clinical Global Impression — Severity CI confidence interval CLZ clozapine DIEPSS Drug-induced Extrapyramidal Symptoms Scale DSM-III Diagnostic and Statistical Manual of Mental Disorders (3rd Edition) DSM-IV Diagnostic and Statistical Manual of Mental Disorders (4th Edition) EPS extrapyramidal symptoms ESRS Extrapyramidal Symptoms Rating Scale ESRS-T Extrapyramidal Symptoms Rating Scale — Total GAF Global Assessment of Functioning scale HRQoL health-related quality of life ITT intention to treat LDL low-density lipoprotein LSM least squares mean OLZ olanzapine PANSS Positive and Negative Syndrome Scale PANSS-T Positive and Negative Syndrome Scale —Total score PANSS-N Positive and Negative Syndrome Scale — Negative score PANSS-P Positive and Negative Syndrome Scale — Positive score QoL quality of life QUET quetiapine RCT randomized controlled trial RIS risperidone RR relative risk SAE serious adverse event SANS Scale for the Assessment of Negative Symptoms SAPS Scale for the Assessment of Positive Symptoms SA(R)S Simpson-Angus Scale SD standard deviation SE standard error SUL sulpiride TAP typical antipsychotics WDAE withdrawal due to adverse event WMD weighted mean difference ZIP ziprasidone iv Systematic Review of Combination and High-Dose AAPs for Schizophrenia TABLE OF CONTENTS ABBREVIATIONS .....................................................................................................................iv 1 INTRODUCTION ................................................................................................................ 1 1.1 The COMPUS Expert Review Committee .................................................................... 1 2 ISSUE .......................................................................................................................... 2 3 OBJECTIVES ..................................................................................................................... 4 3.1 Project Overview .......................................................................................................... 4 3.2 Research Questions .................................................................................................... 4 4 METHODS .......................................................................................................................... 5 4.1 Selection Criteria ......................................................................................................... 5 4.2 Inclusion criteria ........................................................................................................... 6 4.3 Exclusion criteria .......................................................................................................... 6 4.4 Quality Assessment and Data Extraction ..................................................................... 7 4.5 Data synthesis and analysis ......................................................................................... 7 5 RESULTS .........................................................................................................................