Oral and long-acting antipsychotics for relapse prevention in schizophrenia-spectrum disorders: a network meta-analysis of 92 randomized trials including 22,645 participants

Abstract

According to current evidence and guidelines, continued antipsychotic treatment is key for preventing relapse in people with schizophrenia-spectrum disorders, but evidence-based recommendations for the choice of the individual antipsychotic for maintenance treatment are lacking. Although oral antipsychotics are often prescribed first line for practical reasons, long-acting injectable antipsychotics (LAIs) are a valuable resource to tackle adherence issues since the earliest phase of disease. Medline, EMBASE, PsycINFO, CENTRAL and CINAHL databases and online registers were searched to identify randomized controlled trials comparing LAIs or oral antipsychotics head-to-head or against placebo, published until June 2021. Relative risks and standardized mean differences were pooled using random-effects pairwise and network meta-analysis. The primary outcomes were relapse and dropout due to adverse events. We used the Cochrane Risk of Bias tool to assess study quality, and the CINeMA approach to assess the confidence of pooled estimates. Of 100 eligible trials, 92 (N=22,645) provided usable data for meta-analyses. Regarding relapse prevention, the vast majority of the 31 included treatments outperformed placebo. Compared to placebo, "high" confidence in the results was found for (in descending order of effect magnitude) amisulpride-oral (OS), olanzapine-OS, aripiprazole-LAI, olanzapine-LAI, aripiprazole-OS, paliperidone-OS, and ziprasidone-OS. "Moderate" confidence in the results was found for paliperidone-LAI 1-monthly, iloperidone-OS, fluphenazine-OS, brexpiprazole-OS, paliperidone-LAI 1-monthly, asenapine-OS, haloperidol-OS, quetiapine-OS, cariprazine-OS, and lurasidone-OS. Regarding tolerability, none of the antipsychotics was significantly worse than placebo, but confidence was poor, with only aripiprazole (both LAI and OS) showing "moderate" confidence levels. Based on these findings, olanzapine, aripiprazole and paliperidone are the best choices for the maintenance treatment of schizophrenia-spectrum disorders, considering that both LAI and oral formulations of these antipsychotics are among the best-performing treatments and have the highest confidence of evidence for relapse prevention. This finding is of particular relevance for low- and middle-income countries and constrained-resource settings, where few medications may be selected. Results from this network meta-analysis can inform clinical guidelines and national and international drug regulation policies.

Keywords: Relapse prevention; aripiprazole; long-acting antipsychotics; maintenance treatment; olanzapine; oral antipsychotics; paliperidone; schizophrenia-spectrum disorders.

Figure 1

PRISMA flow chart

Figure 2

Network plot of evidence for relapse. The thickness of lines is proportional to the number of studies comparing the two treatments, and the size of circles is proportional to the number of individuals for each treatment. LAI – long‐acting injectable antipsychotic, OS – oral antipsychotic

Figure 3

Network plot of evidence for tolerability. The thickness of lines is proportional to the number of studies comparing the two treatments, and the size of circles is proportional to the number of individuals for each treatment. LAI – long‐acting injectable antipsychotic, OS – oral antipsychotic

Figure 4

Forest plot comparing each antipsychotic with placebo for relapse, with the corresponding ranking probability (SUCRA) and certainty of evidence (CINeMA). LAI – long‐acting injectable antipsychotic, OS – oral antipsychotic, RR – relative risk, SUCRA – surface under the cumulative ranking, CINeMA – Confidence In Network Meta‐Analysis

Figure 5

Forest plot comparing each antipsychotic with placebo for tolerability, with the corresponding ranking probability (SUCRA) and certainty of evidence (CINeMA). LAI – long‐acting antipsychotic, OS – oral antipsychotic, RR – relative risk, SUCRA – surface under the cumulative ranking, CINeMA – Confidence In Network Meta‐Analysis