Dr. Weiden gave a great presentation on switching medicines.  I hope to
post a more complete report on his presentation in the future.  In the
interim, here is the 2nd half of his presentation.

Dr. Weiden says switching meds is a time consuming, often troubling
process that is still very often worth it.  This is because in lots of cases
(most?), the newer meds are better than the old.

TIMING THE SWITCH CAN TAKE 3 MONTHS

It can take three months to switch from one med to another.  This is
important to remember.  Do not switch from one med to another if you
or your doctor are going away.  Do not switch unless you are
emotionally ready to switch (and experience the possible setbacks).  It
can take three months to entirely stop one medicine while crossing over
to another and letting the dose of the new med take effect.

PSYCHOEDUCATION IS IMPORTANT BEFORE SWITCHING

Before switcing it is important to review your goals.  What you do and
don't expect to accomplish by the switch.  You have to have realistic
expectations.  And you have to understand what the meds can and can't
do and the side effects they may have.  You should learn about the short
term risks of switching meds; what the withdrawal effects (ex:
anxiety) might be, and the warning signs of breakthrough psychosis.

CHOOSE THE RIGHT MED TO SWITCH TO

For example, olanzapine is better than resperdal on extrapyramidal
(EPS) symptoms.

CROSSOVER ISSUES

It can take three months to switch meds.  During that time you may need
more support than usual.  You may need more, longer, and more frequent
contact with the doctor.  You need to perservere
 You should be made aware that side effects may increase or decrease.
Doctor may switch you faster or slower depending on how process is
going.  35% of those switching meds have an increase in anxiety, while
20% experience an increase in side effects.
 A big problem with switching meds is that many people give up to soon
on switching. Patients start to 'chicken out' when they get nervous or a
slight increase in symptoms.

IMPROVING  COMPLIANCE DURING CROSS OVER
 The doc should review with patients the cross over protocol.  The doc
and patient should expect misunderstandings to arise and should schedule
more frequent visits.

PSYCHOEDUCATION AFTER SWITCHING
 Has enough time gone by?  Were expectations for the result of the
switch too high.  What else is going on that might be affecting
compliance.  Have other atypical antipsychotics been tried?

AWAKENINGS ISSUES SHOULD BE ADDRESSED
 If the crossover works and the individual starts to feel better, many
issues have to be addressed.  The individual may feel overwhelmed.
They may find their maturity not up to expectations because of loss of
maturation process that was result of the illness.  They may expose
themselves to new stressors by trying to take on too much.  There may
be an initial honeymoon period of elation followed by a depression when
it is over.  Watch for impulsive behavior.  Tell the individual not to over
do it.  Address the 'fantasy of a cure' with family.
 After a period of time of success, individuals may start to claim that
the med is no longer working is well.  This may or may not be true.  Try
to determine if it is or not.  For ex., the person may be complaining, but
working, something that may not have been possible before the switch.
IOTW, they may be functioning at a higher level, albeit still bothered.

...

Dr. Weiden says if one atypical does not work, try another.  This is
different from conventional wisdom, which used to say if one 'class' of
meds doesn't work try another 'class'.  He says that Clozaril and
resperidal represent two different classes of meds w/in the atypical
class.

Both Dr. Keith and Weiden in response to audience questions noted that
many are adding anti obsessive meds (ex prozac) to clozaril.  THe
development of OCD like symptoms when on CLZ has been widely
anecdotally reported.

Dr. Keith noted that older meds give Tardive Dyskinesia (a movement
muscle disorder) to 4%of the people on them in year one.  In each of the
remaining years 4% of the people remaining on the med will develop TD.
IOTW, if 100 people start a typical antipsychotic, in year one, 4 will get
TD.  In year two, 4% of the 96 people remaining will get it.  And so on
and so on.

There is no clear data of the rate of TD for atypical antipsychotics, but
rate is believed to be around 1/2 that of typical antipsychotics.

Dr. Weiden noted the importance of differentiating malignant
hyperthermia from neuroleptic malingnancy syndrome (NMS).  Malignant
hyperthermia is an increase in body temperature associated with high
outside temperatures and or excessive exercise.  NMS is increase in
body temperature caused by the med and may be independent of the
outside temperature.

Dr. Weiden said that many should consider taking zyprexa/olanzapine at
15mg for 3 months before quitting it, but official dose is 10mg.