Clinical Pearls

Start outpatient XT at 50 mg/20 mg twice daily for 1 to 2 weeks and have patients begin the same evening; most patients stabilize on 100 mg/20 mg–125 mg/30 mg twice daily, but some early-illness patients may do well on 50 mg/20 mg.

Prevent early drop-off by prescribing ondansetron 4 mg for 14 days when XT is started, with instructions to re-dose after 30 minutes if symptoms persist.

Fasted dosing is a tolerability intervention, not a minor counseling point: XT should be taken on an empty stomach because food reduces trospium chloride absorption and can make nausea and vomiting problematic.

When switching to XT, taper the existing antipsychotic by class rather than using a one-size-fits-all schedule: risperidone or paliperidone can often be tapered over several days, while quetiapine, olanzapine, and clozapine usually need 1 to 3 weeks.

XT can be used as a dose-sparing add-on in patients already on antipsychotics or LAIs; many patients, possibly as many as 50%, were reported by the panel to be well managed with XT 100 mg/20 mg in combination with a low dose of an atypical antipsychotic.