Strategies for switching antipsychotics

Explain to the doctor that there is a potential for relapse with any switching strategy and no method has been proven to be superior to another. Still, if relapse is a concern, the delayed withdrawal method is reasonable in theory. Suggest starting risperidone at 1 mg twice daily for one week, followed by 2 mg twice daily for one week, and then increasing to 3 mg twice daily, which is a reasonable initial target dose. After risperidone has been maintained at the target dose for one week, the olanzapine can be tapered by 5 mg weekly (i.e., decrease to 10 mg daily for one week, then 5 mg daily for one week) before being discontinued. Explain to [Jason] that risperidone is less likely to cause weight gain than olanzapine,8 but that he should still monitor his weight closely; emphasize the importance of healthy eating and exercise. Monitoring for side effects like extrapyramidal symptoms and drowsiness while on both medications is also advisable. Jason should be told about the potential for exacerbation of psychotic symptoms, and should also be given explicit instructions with respect to the medication switch process to prevent any errors.4 The primary reasons for switching antipsychotic drug therapy are lack of efficacy or presence of adverse effects.3 Lack of efficacy may manifest as persistent positive symptoms (e.g., delusions, hallucinations) or residual negative symptoms (e.g., flattened affect, anhedonia).4" Unresponsive cognitive symptoms (e.g., impaired attention or memory) or depressive symptoms may also be important factors when considering a medication switch.4 Side effects that may necessitate switching antipsychotics include extrapyramidal symptoms, anticholinergic effects, tardive dyskinesia, weight gain, sedation, and hyperprolactinemia (which can result in amenorrhea, gynecomastia, and sexual dysfunction).4,5