Clotiapine for acute psychotic illnesses (Review)

Background Acute psychotic illnesses, especially when associated with agitated or violent behaviour, require urgent pharmacological tranquillisation or sedation. Clotiapine, a dibenzothiazepine neuroleptic, is being used for this purpose in several countries. Objectives To estimate the e@ects of clotiapine when compared to other 'standard' or 'non-standard' treatments for acute psychotic illnesses in controlling disturbed behaviour and reducing psychotic symptoms. Search methods We searched the Cochrane Schizophrenia Group Register (April 2004). We updated this search in July 2012 and added the results to the awaiting classification section of the review. Selection criteria The review included randomised clinical trials comparing clotiapine with any other treatment for people with acute psychotic illnesses. Data collection and analysis Relevant studies were selected for inclusion, their quality was assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow up. For binary outcomes we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were summated using a weighted mean di@erence (WMD). Main results We identified five relevant trials. None compared clotiapine with placebo, but control drugs were either antipsychotics (chlorpromazine, perphenazine, trifluoperazine and zuclopenthixol acetate) or benzodiazepines (lorazepam). Versus the antipsychotics, the results for 'no important global improvement' did not suggest clotiapine to be superior, or inferior, to chlorpromazine, perphenazine, or trifluoperazine (n = 83, 3 RCTs, RR 0.82 CI 0.22 to 3.05, I-squared 58%). Use of clotiapine when compared with chlorpromazine did change the proportion of people ready for hospital discharge by the end of the study (n = 49, 1 RCT, RR 1.04 95%CI 0.96 to 2.12). Overall, attrition rates were low. No significant di@erence was found for those allocated to clotiapine compared with people randomised to other antipsychotics (n = 121, RR 2.26 95%CI 0.40 to 13). Weak data suggests that clotiapine may result in less need for antiparkinsonian treatment compared with zuclopenthixol acetate (n = 38, RR 0.43 95%CI 0.02 to 0.98). Compared with lorazepam, clotiapine, when used to control aggressive/violent Clotiapine for acute psychotic illnesses (Review) Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1 Cochrane Library Trusted evidence. Informed decisions. Better health. Cochrane Database of Systematic Reviews outbursts for people already treated with haloperidol, did not significantly improve mental state (WMD -3.36 95%CI -8.09 to 1.37). We could not pool much data due to skew or inadequate presentation of results. Economic outcomes and satisfaction with care were not addressed. Authors' conclusions We found no evidence to support the use of clotiapine in preference to other 'standard' or 'non-standard' treatments for management of people with acute psychotic illness. All trials in this review have important methodological problems. We do not wish to discourage clinicians from using clotiapine in the psychiatric emergency, but well-designed, conducted and reported trials are needed to properly determine the e@icacy of this drug. [Note: the three citations in the awaiting classification section of the review may alter the conclusions of the review once assessed. ] P L A I N L A N G U A G E S U M M A R Y Clotiapine for acute psychotic illnesses Clotiapine is an antipsychotic drug and is currently used in the management of acute psychotic symptoms in Argentina, Belgium, Israel, Italy, Luxemburg, South Africa, Spain, Switzerland and Taiwan. This review highlights limited evidence for the e@ects of clotiapine compared with other drugs also used in this emergency situation. Clotiapine for acute psychotic illnesses (Review) Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2 Cochrane Library Trusted evidence. Informed decisions. Better health. Cochrane Database of Systematic Reviews