Efficacy and tolerability of aripiprazole versus D2 antagonists in the early course of schizophrenia: a systematic review and meta-analysis

David D Kim,Ric M Procyshyn,Alasdair M Barr,Jessica W Y Yuen,William G Honer,Allen E Thornton,Lulu Lian,Diane Fredrikson

doi:10.1038/s41537-021-00158-z

Abstract

Early intervention is essential for favorable long-term outcomes in schizophrenia. However, there is limited guidance in the scientific literature on how best to choose between dopamine D2 receptor (D2R) partial agonists and D2R antagonists in early stages of schizophrenia. The aim of this meta-analysis was to directly compare D2R partial agonists with D2R antagonists for efficacy and tolerability, using randomized controlled trials (RCTs) that involved participants diagnosed with first-episode psychosis, schizophrenia, or related psychotic disorders with a duration of illness ≤5 years. Fourteen RCTs, involving 2494 patients, were included in the meta-analysis. Aripiprazole was the only identified D2R partial agonist, and was not significantly different from pooled D2R antagonists for overall symptom reduction or all-cause discontinuation. However, aripiprazole was more favorable than pooled D2R antagonists for depressive symptoms, prolactin levels, and triglyceride levels. Specifically, aripiprazole was more favorable than paliperidone for triglyceride levels and more favorable than risperidone and olanzapine, but less favorable than ziprasidone, for weight gain. In addition, aripiprazole was less favorable for akathisia compared with second-generation D2R antagonists, in particular olanzapine and quetiapine, and less favorable for discontinuation due to inefficacy than risperidone. Lastly, aripiprazole was more favorable than haloperidol for various efficacy and tolerability outcomes. In conclusion, aripiprazole’s efficacy did not differ substantially from D2R antagonists in the early course of schizophrenia, whereas differential tolerability profiles were noted. More double-blind RCTs are required comparing the efficacy and tolerability of aripiprazole as well as other D2R partial agonists with D2R antagonists in early stages of schizophrenia.

Highlights

Schizophrenia is a debilitating psychiatric disorder that affects 0.87% of the general population over a lifetime[1]
In terms of other secondary outcomes, aripiprazole was more favorable than D2 receptor (D2R) antagonists for depressive symptoms (SMD = −0.17, 95% CI = −0.31 to −0.04), prolactin levels (SMD = −0.55, 95% CI = −0.94 to −0.16), and triglyceride levels (SMD = −0.23, 95% CI = −0.45 to −0.02) (Table 2)
Removal of haloperidol trials led to aripiprazole being less favorable than D2R antagonists for akathisia (RR = 1.42, 95% CI = 1.11 to 1.81) and use of anticholinergics (RR = 1.32, 95% CI = 1.01 to 1.72)

Summary

Introduction

Schizophrenia is a debilitating psychiatric disorder that affects 0.87% of the general population over a lifetime[1]. Recent research shows that antipsychotic treatment is associated with a lower mortality risk compared with no treatment during follow-up periods[4]. This illustrates the importance of utilizing antipsychotics in patients with schizophrenia, but how these medications should be used for optimal outcomes requires further research. The literature suggests that an illness duration of less than 5 years is considered an acceptable period of time to define the early stage of schizophrenia[6]. A person who has FEP, or is in an early stage of schizophrenia, should be provided with evidence-based pharmacotherapy in a timely manner

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