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Node 1: Drugs Not Recommended at Node 1 David N. Osser, MD Associate Professor of Psychiatry Harvard Medical School Brockton Division of the VA Boston Healthcare System General Editor - Psychopharmacology Algorithm Project Harvard South Shore Residency Training Program

Not recommended for first-onset patients Clozapine Olanzapine Quetiapine

Active suicide thoughts and behavior 1st Trial 2nd Trial Clozapine Clozapine Clozapine Active suicide thoughts and behavior

Olanzapine Not recommended as first-line agent Severe weight gain and metabolic effects Even one dose: Insulin resistance Endocrine/ inflammatory dysfunction

Olanzapine Not recommended as first-line agent Severe weight gain and metabolic effects Even one dose: Insulin resistance Endocrine/ inflammatory dysfunction Hahn, M. K., Wolever, T. M., Arenovich, T., Teo, C., Giacca, A., Powell, V., ... & Gomes, S. (2013). Acute effects of single-dose olanzapine on metabolic, endocrine, and inflammatory markers in healthy controls. Journal of clinical psychopharmacology, 33(6), 740-746.

Quetiapine Higher weight gain and metabolic problems than: Risperidone Ziprasidone CAFÉ study Weight gain: second to olanzapine QTc prolongation warning Time to rehospitalization Poor maintenance effectiveness

Quetiapine Higher weight gain and metabolic problems than: Risperidone Ziprasidone CAFÉ study Weight gain: second only to olanzapine QTc prolongation warning Time to rehospitalization Poor maintenance effectiveness Patel, J. K., Buckley, P. F., Woolson, S., Hamer, R. M., McEvoy, J. P., Perkins, D. O., ... & Cafe Investigators. (2009). Metabolic profiles of second-generation antipsychotics in early psychosis: findings from the CAFE study. Schizophrenia research, 111(1), 9-16.

Quetiapine Higher weight gain and metabolic problems than: Risperidone Ziprasidone CAFÉ study Weight gain: second only to olanzapine QTc prolongation warning Time to rehospitalization Poor maintenance effectiveness

Quetiapine Higher weight gain and metabolic problems than: Risperidone Ziprasidone CAFÉ study Weight gain: second to olanzapine QTc prolongation warning Time to rehospitalization Poor maintenance effectiveness Kreyenbuhl, J., Slade, E. P., Medoff, D. R., Brown, C. H., Ehrenreich, B., Afful, J., & Dixon, L. B. (2011). Time to discontinuation of first-and second-generation antipsychotic medications in the treatment of schizophrenia. Schizophrenia research, 131(1), 127-132.

Not a first-line agent Quetiapine Higher weight gain and metabolic problems than: Risperidone Ziprasidone CAFÉ study Weight gain: second to olanzapine QTc prolongation warning Time to rehospitalization Poor maintenance effectiveness Not a first-line agent

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