Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia

Long-term effectiveness of aripiprazole once-monthly for schizophrenia is maintained in the QUALIFY extension study

OBJECTIVE

To evaluate long-term safety and effectiveness of continued treatment with aripiprazole once-monthly 400mg (AOM 400) in patients with schizophrenia.

METHODS

Patients who completed the QUALIFY study (NCT01795547) in the AOM 400 arm were eligible for 6 additional once-monthly injections of AOM 400 during an open-label, 24-week extension (NCT01959035). Safety data were collected at each visit. Effectiveness measures included change from baseline in health-related qualify of life and functioning on the Heinrichs-Carpenter Quality of Life scale (QLS) and Clinical Global Impression - Severity (CGI-S) scale.

RESULTS

Of the 88 patients enrolled, 77 (88%) completed the extension study. Most common treatment-emergent adverse events (incidence ≥2%) were weight increased (6/88, 7%), toothache (3/88, 3%) and headache (3/88, 3%). Effectiveness was maintained during the extension study, with small but continued improvements from baseline: the least squares mean (LSM) change (95% CI) from baseline to week 24 was 2.32 (-1.21 to 5.85) for the QLS total score and -0.10 (-0.26 to 0.06) for the CGI-S score. The aggregated LSM change (95% CI) from baseline of the lead-in study to week 24 of the extension study was 11.54 (7.45 to 15.64) for the QLS total score and -0.98 (-1.18 to -0.79) for the CGI-S score.

CONCLUSIONS

AOM 400 was well tolerated in patients continuing AOM treatment during the extension phase of the QUALIFY study. Robust and clinically meaningful improvements in health-related quality of life and functioning were maintained, further supporting the long-term clinical benefits of AOM 400 for the treatment of patients with schizophrenia.

Adherence, persistence, and inpatient utilization among adult schizophrenia patients using once-monthly versus twice-monthly long-acting atypical antipsychotics

AIMS

This study compared healthcare resource utilization (HRU), healthcare costs, adherence, and persistence among adult patients with schizophrenia using once-monthly (OM) vs twice-monthly (TM) atypical long-acting injectable (LAI) antipsychotic (AP) therapy.

MATERIALS AND METHODS

A longitudinal retrospective cohort study was conducted using Medicaid claims data from six states. Patients initiated on aripiprazole or paliperidone palmitate were assigned to the OM cohort; risperidone-treated patients were assigned to the TM cohort. HRU and healthcare costs were assessed during the first 12 months following stabilization on the medication. Adherence was measured using the proportion of days covered (PDC) during the first year of follow-up. Persistence to the index medication was measured during the first 2 years following the index date. Comparison between the cohorts was achieved using multivariable generalized linear models, adjusting for demographic and clinical characteristics.

RESULTS

Patients in the OM LAI cohort had lower inpatient HRU and medical costs when compared with patients in the TM cohort. Higher medical costs in the TM LAI cohort offset the higher pharmacy costs in the OM LAI cohort. Mean PDC during the first 12 months of follow-up was higher in the OM cohort than in the TM cohort (0.56 vs 0.50, p < .01). Median persistence was longer in the OM cohort than in the TM cohort (7.5 months vs 5.5 months), as was the hazard of discontinuing the index medication (hazard ratio = 0.83, p = .01). Kaplan-Meier rates of persistence at 1 year were higher for OM patients than for TM patients (37.6% vs 29.6%, p < .01).

LIMITATIONS

This was a Medicaid sample with few aripiprazole LAI patients (5.4% of OM cohort). Medication use was inferred from pharmacy claims.

CONCLUSIONS

Among Medicaid patients in these six states, OM AP treatment was associated with lower HRU, better adherence and persistence, and similar total costs compared to patients on TM treatment.

The Research and Evaluation of Antipsychotic Treatment in Community Behavioral Health Organizations, Outcomes (REACH-OUT) study: real-world clinical practice in schizophrenia

BACKGROUND

Outpatient facilities, such as community behavioral health organizations (CBHOs), play a critical role in the care of patients with serious mental illness, but there is a paucity of "real-world" patient outcomes data from this health care setting. Therefore, we conducted The Research and Evaluation of Antipsychotic Treatment in Community Behavioral Health Organizations, Outcomes (REACH-OUT) trial, a real-world, prospective, noninterventional observational study of patients with mental illness treated at CBHOs across the United States. We describe demographic and clinical characteristics, antipsychotic therapy (APT) treatment patterns, and health care resource utilization in patients with schizophrenia undergoing medical care as usual.

METHODS

This study enrolled adults with schizophrenia or bipolar I disorder who initiated APT treatment at various time points: 1) within 8 weeks of initiating risperidone long-acting injectables (RLAIs) or other APTs except paliperidone palmitate (PP), 2) after more than 24 weeks of continuous RLAI treatment, or 3) at any time after initiating PP LAI treatment (schizophrenia only). Study assessments were performed via participant interview, medical chart abstraction, and clinical survey at enrollment and at month 12.

RESULTS

A total of 1065 patients from 46 CBHOs were enrolled. Of these, 944 (88.6%) had a diagnosis of schizophrenia and 121 (11.4%) had bipolar I disorder. At enrollment, 599 (63.5%) of patients with schizophrenia were receiving RLAIs or PP LAI, 281 (29.8%) were receiving oral APTs, and 64 (6.8%) were receiving other injectable APTs. A number of differences in patient characteristics and outcomes were observed between patients in the LAI APT cohort and the oral APT cohort.

CONCLUSION

Descriptive analyses from this observational study suggest differences in the patient characteristics, treatment patterns, and clinical and economic outcomes among those with schizophrenia treated at CBHOs with LAI APT or oral APTs. Additional analyses will be conducted to delineate the impact of LAI APT versus oral APTs on patient outcomes.

TRIAL REGISTRATION

Clinical Trial Registry: NCT01181960 . Registered 12 August 2010.

Development and Evaluation of pH-Responsive Cyclodextrin-Based in situ Gel of Paliperidone for Intranasal Delivery

Paliperidone (PLPD) is approved for treatment and management of schizophrenia. The current study demonstrates the potential of in situ gel of PLPD for nasal delivery. The permeation of drug through sheep nasal mucosa was analyzed since the nose-to-brain pathway has been indicated for delivering drugs to the brain. The carbopol 934 (CP)- and hydroxypropyl methyl cellulose K4M (HPMC)-based in situ gels containing 0.2% CP and 0.4% w/v HPMC were optimized using experimental design software. The use of hydroxypropyl-β-cyclodextrin (HP-β-CD) in nasal permeation of drug was investigated. Transmucosal permeation of PLPD was examined using sheep nasal mucosa. The in situ gels of PLPD exhibited satisfactory mucoadhesion and showed sustained drug release. The mucocilliary toxicity and histopathological examination confirmed that the nasal mucosa architecture remains unaffected after treatment with PLPD in situ gel. The formulation containing HP-β-CD complex of PLPD exhibited higher rate of drug permeation through sheep nasal mucosa revealing the role of HP-β-CD as nasal absorption enhancer. Thus, CP- and HPMC-based pH-triggered in situ gel containing HP-β-CD-drug inclusion complex demonstrates a novel nasal delivery of PLPD.

A New Level A Type IVIVC for the Rational Design of Clinical Trials Toward Regulatory Approval of Generic Polymeric Long-Acting Injectables

Chronic neuropsychiatric disorders and diabetes mellitus affect millions of patients and require long-term supervision and expensive medical care. Although repeated drug administration can help manage these diseases, relapses and re-hospitalization owing to patient non-adherence and reduced therapeutic efficacy remain challenging. In response, long-acting injectables, which provide sustained drug release over longer periods at concentrations close to therapeutic ranges, have been proposed. Recent advancements include polymeric long-acting injectables (pLAIs), in which the active pharmaceutical ingredient (API) is encapsulated within U.S. Food and Drug Administration (FDA)-approved biocompatible polymers, such as poly(lactic-co-glycolic acid), or PLGA. Despite significant progress and development in the global pLAI market, FDA guidance for the approval of complex drug products, such as generic pLAIs, is not clearly defined. Although in vitro to in vivo correlation (IVIVC) can facilitate the identification of critical quality attributes (CQAs), drug formulations, and in vitro test platforms for evaluating drug performance in vivo, the application of IVIVC in order to shortlist time- and resource-intensive clinical trials for generic pLAIs has not been reported. Here, we propose a new Level A Type IVIVC that directly correlates the in vitro outcomes, such as drug dissolution, of candidate generic formulations with the clinical characteristics, such as drug absorption, of a reference listed drug (RLD), to help identify the specific generic pLAI formulations with clinical absorptions that are likely to be similar to that of the RLD, thereby reducing the number of clinical trials required for evaluation of clinical bioequivalence (BE). Therefore, the scope of the proposed method is intended only for the rational design of clinical trials, i.e., to shortlist the specific pLAI generic formulations for clinical BE evaluation, and not necessarily to analyze drug performances (i.e., drug safety and effectiveness) in the shortlisted clinical trials or post-approval. Once validated, this method will be of great value to developers of generic pLAIs and regulatory bodies to accelerate their approval of these generic pLAIs.

Theoretical Approaches to Enhancing Motivation for Adherence to Antidepressant Medications

PROBLEM

Adherence to antidepressants is a major challenge in our health care system, with a high percentage of patients discontinuing their medications within six months.

AIMS

The purpose of this position paper is to discuss theoretical frameworks that address the psychological beliefs, benefits and barriers and feelings of autonomy that affect a person's willingness and motivation to take anti-depressant medications within a therapeutic relationship with a nurse practitioner.

METHODS

Three theoretical frameworks were selected to highlight particular perspectives relevant to enhancing patient motivation for medication adherence. The Self-Regulation Model, Health Belief Model, and Self-Determination Theory combined with motivational interviewing all offer guidance on strategies for improving adherence to antidepressants.

CONCLUSIONS

The Self-Regulation Model underscores the importance of illness representations that prompt considering patient perceptions of depression that affect adherence. The Health Belief Model focuses on cost-benefit considerations that affect patient's adherence, along with perceived control. Finally, Self-Determination Theory combined with motivational interviewing offers strategies that enhance autonomy and optimize collaboration and motivation for adherence.

RELEVANCE FOR CLINICAL PRACTICE

These three theoretical models are applied to a vignette for a patient who is having difficulty with adherence to antidepressant medication.

Long acting antipsychotics treatment of schizophrenia: A 24-month prospective study on patient's attitude towards treatment

Introduction

Long-acting injectable (LAI) second-generation antipsychotics (SGAs) are considered an alternative to oral antipsychotics for schizophrenic patients with low adherence to therapy. However, it is still a matter of debate whether LAI-SGAs are able to significantly improve patient's attitudes towards treatment (ATT) [1].

Objective

To investigate the impact of LAI on ATT over 24 months.

Methods

Nineteen schizophrenic patients were switched from either oral olanzapine (11) or paliperidone (8) to the corresponding LAI. Patients were assessed at baseline (T0), after 6 (T1), 12 (T2) and 24 months (T3). Drug Attitude Inventory-10 (DAI-10) [2] was used to assess ATT. Young Mania Rating Scale (YMRS), Montgomery-Asberg Depression Rating Scale (MADRS), Positive and Negative Syndrome Scale (PANSS), and Short Form Health Survey (SF-36) were used for psychopathology evaluations.

Results

Eleven patients reached T3. Eight patients were excluded (4 olanzapine, 4 paliperidone): 4 required a significant change in concomitant treatment, 4 a change of antipsychotic (metabolic comorbidity). No changes in psychopathology occurred between T2 and T3, some scales improved from baseline to T2. DAI-10 mean scores were improved after 12 months, thus not significantly, and were further improved at 24 months (P = .008 vs baseline).

Conclusions

ATT keeps improving after one year of LAI treatment, unrelated to clinical response.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Safety and efficacy of paliperidone palmitate 1-month formulation in Chinese patients with schizophrenia: a 25-week, open-label, multicenter, Phase IV study

RATIONALE

Long-acting injectable (LAI) paliperidone palmitate 1-month formulation (PP1M) has demonstrated acceptable tolerability and favorable clinical outcomes in Western and Asian patients with schizophrenia. Hence, analysis of the outcomes of long-term PP1M treatment specifically in Chinese patients is of interest.

OBJECTIVE

The aim of this study is to evaluate the long-term safety and efficacy of PP1M treatment in Chinese patients with schizophrenia.

METHODS

In this 25-week, open-label, Phase IV study, patients (18-65 years) diagnosed with schizophrenia and having a baseline Positive and Negative Syndrome Scale (PANSS) total score of 60-120 (inclusive) were enrolled. All patients received injections of PP1M 150 mg eq. (day 1) and 100 mg eq. (day 8), followed by a flexible once-monthly maintenance dosing (75, 100, or 150 mg eq.).

RESULTS

Of the 353 patients, 234 (66.3%) completed the study treatment (mean age, 31.1 years; 52.7% men). The PANSS total score (primary end point) improved significantly over the 6-month treatment period (mean [standard deviation] change from baseline to end of treatment, -27.2 [18.30]; P<0.0001). The Clinical Global Impressions-Severity and Personal and Social Performance scores (secondary end points) also improved significantly (P<0.0001). At 6 months, PP1M had a positive impact on medication satisfaction, adherence, and increased preference for LAIs. Treatment-emergent adverse events (TEAEs) were reported by 181 (51.3%) patients (TEAEs ≥5%: extrapyramidal disorder [15.3%], akathisia [10.5%], blood prolactin increase [8.8%], insomnia [5.4%]). A total of 8 deaths were reported, including 4 completed suicides.

CONCLUSION

Long-term treatment with PP1M was efficacious, and no new safety concerns were identified in Chinese patients with schizophrenia. Overall, the results were comparable with observations from previous studies.

Impact on length of stay and readmission rates when converting oral to long-acting injectable antipsychotics in schizophrenia or schizoaffective disorder

Introduction

Nonadherence with oral antipsychotics in patients with schizophrenia has been associated with symptom relapse and rehospitalizations, resulting in increased morbidity and health care costs. Long-acting injectable antipsychotics (LAIAs) are an alternative to enhance adherence and decrease relapse requiring hospitalization. The objectives of this study are to determine the impact of LAIAs on reducing length of stay, the rate of annual readmissions, and the number of failed annual discharges (defined as a readmission in less than 30 days) in patients with schizophrenia or schizoaffective disorder admitted to an acute inpatient psychiatric unit.

Methods

Using the hospital database, 52 patients receiving a diagnosis of schizophrenia or schizoaffective disorders treated with oral antipsychotics and later transitioned to LAIAs were evaluated retrospectively.

Results

Patients treated with LAIAs did not show a statistically significant reduction in length of stay compared with their length of stay on oral antipsychotics. Patients treated with LAIAs experienced a statistically significant reduction in the rate of annual readmissions and a reduction in the number of failed annual discharges, although the latter was not statistically significant (P = .076 when compared to treatment with oral antipsychotics).

Discussion

These findings suggest a potential role for maintaining patients with a diagnosis of schizophrenia or schizoaffective disorder on LAIAs to prevent relapse and rehospitalizations. The reduction in the number of failed annual discharges between the oral versus LAIA group, although not statistically significant, warrants further investigation to determine the impact of LAIAs on readmission within 30 days.

LAI versus oral: A case-control study on subjective experience of antipsychotic maintenance treatment

BACKGROUND

To present real-world evidence on the differences between long-acting injectable (LAI) and oral antipsychotic maintenance treatment (AMT) in terms of subjective well-being, attitudes towards drug and quality of life in a sample of remitted schizophrenic subjects.

METHODS

Twenty outpatients with remitted schizophrenia treated with either olanzapine or paliperidone and switching from the oral to the LAI formulation of their maintenance treatment were recruited before the switch (LAI-AMT group). A group of 20 remitted schizophrenic subjects with oral AMT and matching main sociodemographic, clinical and treatment variables made up the control group (oral-AMT group). All participants were assessed in terms of objective (PANSS, YMRS, MADRS) and subjective (SWN-K, DAI-10, SF-36) treatment outcomes at baseline (T0) and after 6 months (T1).

RESULTS

Between T0 and T1, general psychopathology of the PANSS, DAI-10, and all but one of the SWN-K dimensions (except for social integration), showed significantly higher percentages of improvement in the LAI-AMT group compared to the oral-AMT group. A generalized expansion of health-related quality of life, with better functioning in almost all areas of daily living, was reported by the LAI-AMT group after the 6-month period. In contrast, the oral-AMT group reported a significant worsening of health-related quality of life in the areas of emotional role and social functioning in the same period.

CONCLUSIONS

Our study indicates possible advantages of LAI over oral antipsychotic formulation in terms of subjective experience of maintenance treatment in remitted schizophrenic patients. Size and duration of this study need to be expanded in order to produce more solid and generalizable results.

Efficacy of Long-Acting Injectable Antipsychotics in Adolescents

INTRODUCTION

The number of long-acting injectable antipsychotics (LAIA) has increased in recent years. The safety and efficacy of that treatment are not established in children. This study aims to address this gap of information by studying such treatments in a case series.

METHODS

This retrospective chart review of patients identified by the investigators at an academic acute inpatient psychiatric unit included all patients from the past 24 months who required new initial treatment with LAIA. This study included a case series of the nine patients along with Clinical Global Impression-Severity (CGI-S) scores from admission and discharge and Clinical Global Impression-Improvement (CGI-I) scores. Other observations included the presentation of primary psychiatric diagnosis, psychiatric and medical comorbidities, age, sex, previous and LAIA psychiatric medications, reasoning for LAIA treatment, adverse events, CGI-S and CGI-I scores, and outpatient resources utilized to continue treatment.

RESULTS

The case series included two females and seven males within the ages of 14-17 years. Of those patients, five were treated with paliperidone palmitate, one treated with risperidone, one treated with fluphenazine, and one treated with aripiprazole. Primary psychiatric diagnosis of the patients in the case series included five with schizophrenia, one with schizoaffective disorder, one with bipolar affective disorder-type I, one with bipolar affective disorder-not otherwise specified, and one with mood disorder-not otherwise specified. In all nine cases, noncompliance was a consideration in treatment with LAIA. Frequent running away and severity of illness were also considerations in one case each. All of the patients required community resources with injectable services.

CONCLUSION

This study describes initiation of treatment with LAIA in 14-17-year olds in an acute inpatient psychiatric unit with serious mental illness. This study also demonstrates the need for outpatient community resources with the ability to provide long-acting injectable medication. Limitations of this study include a small patient population, other factors changing CGI-S and CGI-I scores beyond the medication, and the nature of the study as a retrospective chart review. This study did not compare medications between each other. Maintenance dosing and long-term safety were beyond the scope of this study. Future directives for safety studies, open-label trials, and randomized double-blinded control trails in the pediatric population would be needed.

Invega Trinza: The First Four-Times-a-Year, Long-Acting Injectable Antipsychotic Agent

Paliperidone palmitate three-month injection (Invega Trinza): the first four-times-a-year, long-acting injectable antipsychotic agent for schizophrenia.

Targets, attitudes, and goals of psychiatrists treating patients with schizophrenia: key outcome drivers, role of quality of life, and place of long-acting antipsychotics

PURPOSE

This survey of Italian psychiatrists was conducted to better define drivers of schizophrenia treatment choice in real-life practice, particularly for use of long-acting injectable (LAI) antipsychotics.

METHODS

Between October 15 and December 15, 2014, 1,000 surveys were sent to psychiatrists who treat schizophrenic patients; 709 completed questionnaires were analyzed (71% response rate).

RESULTS

The two most important factors determining therapy success were efficacy (75% of responses) and tolerability (45%) followed by global functioning (24%) and quality of life (17%). LAI antipsychotics were most often used to facilitate regular treatment monitoring (49%), and 41% of psychiatrists thought that patients with low adherence who had failed oral therapy were well-suited for LAI antipsychotics. Only 4% of respondents saw LAI antipsychotics as appropriate for patients without other therapeutic options.

CONCLUSION

Although efficacy and tolerability were the most common factors used to evaluate treatment success in schizophrenia, psychiatrists also consider QoL and global functioning to be important.

Pharmacoeconomics of long-acting atypical antipsychotics for acutely relapsed chronic schizophrenia in Finland

BACKGROUND

Atypical long-acting injectable (LAI) antipsychotics are increasingly available for treating chronic schizophrenia in patients chronically non-adherent to prescribed regimens. Few economic studies have compared these products.

PURPOSE

To determine the cost-effectiveness of aripiprazole (ARI-LAI), paliperidone (PP-LAI), olanzapine (OLZ-LAI), and risperidone (RIS-LAI) in patients with chronic schizophrenia in Finland.

METHODS

A 1-year decision tree model was adapted with guidance from an expert panel. Patients started hospitalized in relapse; those who responded continued treatment, others were switched to secondary drugs, then clozapine in the event of 2nd line failure. Rates of adherence, stable disease, relapse, and hospitalization were taken from pivotal trials, and utilities from published research. Included were direct costs paid by the Finnish Ministry of Health, in 2015 euros. Outcomes included quality-adjusted life-years (QALYs), hospitalization rates, and rates of relapse not requiring hospitalization. Model robustness was assessed using a series of 1-way and multivariate sensitivity analyses.

RESULTS

Expected costs were lowest for PP-LAI at 41,148€, followed by 41,543€ for ARI-LAI, 42,067€ for RIS-LAI and 45,406€ for OLZ-LAI. Respective QALYs were 0.683, 0.671, 0.666, and 0.672. Re-hospitalization rates and non-admitted relapses were 23.6% and 3.9% for PP-LAI, 28.5% and 4.1% for ARI-LAI, 28.8% and 5.0% for RIS-LAI, 28.3% and 5.2% for OLZ-LAI. PP-LAI treatment was associated with the most days with stable disease (132.0), followed by OLZ-LAI (125.5), ARI-LAI (122.6), and RIS-LAI (114.4). Sensitive inputs between PP-LAI and ARI-LAI included rates of adherence, dropouts, and relapses plus drug prices; dropout and relapse rates for RIS-LAI; OLZ-LAI results were insensitive. In probability sensitivity analyses, PP-LAI dominated ARI-LAI in 75.8% of the 10,000 iterations, RIS-LAI in 83.1% and OLZ-LAI in 95.7%.

CONCLUSIONS

PP-LAI dominated the other atypicals. It appears to be the preferred option for treating chronic relapsing schizophrenia.

Physician and patient benefit-risk preferences from two randomized long-acting injectable antipsychotic trials

PURPOSE

To quantify clinical trial participants' and investigators' judgments with respect to the relative importance of efficacy and safety attributes of antipsychotic treatments for schizophrenia, and to assess the impact of formulation and adherence.

METHODS

Discrete-choice experiment surveys were completed by patients with schizophrenia and physician investigators participating in two phase-3 clinical trials of paliperidone palmitate 3-month long-acting injectable (LAI) antipsychotic. Respondents were asked to choose between hypothetical antipsychotic profiles defined by efficacy, safety, and mode of administration. Data were analyzed using random-parameters logit and probit models.

RESULTS

Patients (N=214) and physicians (N=438) preferred complete improvement in positive symptoms (severe to none) as the most important attribute, compared with improvement in any other attribute studied. Both respondents preferred 3-month and 1-month injectables to oral formulation (P<0.05), irrespective of prior adherence to oral antipsychotic treatment, with physicians showing greater preference for a 3-month over a 1-month LAI for nonadherent patients. Physicians were willing to accept treatments with reduced efficacy for patients with prior poor adherence. The maximum decrease in efficacy (95% confidence interval [CI]) that physicians would accept for switching a patient from daily oral to 3-month injectable was as follows: adherent: 9.8% (95% CI: 7.2-12.4), 20% nonadherent: 25.4% (95% CI: 21.0-29.9), and 50% nonadherent: >30%. For patients, adherent: 10.1% (95% CI: 6.1-14.1), nonadherent: the change in efficacy studied was regarded as unimportant.

CONCLUSION

Improvement in positive symptoms was the most important attribute. Patients and physicians preferred LAIs over oral antipsychotics, with physicians showing a greater preference for 3-month over 1-month LAI. Physicians and patients were willing to accept reduced efficacy in exchange for switching a patient from an oral formulation to a LAI.

Aripiprazole once-monthly 400 mg for long-term maintenance treatment of schizophrenia: a 52-week open-label study

BACKGROUND

Long-term maintenance treatment with an antipsychotic is often required to prevent relapse and mitigate functional deterioration in patients with schizophrenia.

AIMS

This study assessed the long-term safety, tolerability, and maintenance of the therapeutic effect of aripiprazole once-monthly 400 mg (AOM 400) in patients with schizophrenia.

METHODS

This 52-week, open-label study included patients previously enrolled in 1 of 2 AOM 400 randomized controlled trials (RCTs) and de novo patients. Safety endpoints included adverse events (AEs), suicidality, extrapyramidal symptoms, injection-site pain, and clinically relevant changes in clinical and laboratory values. The primary efficacy endpoint was the percentage of stable patients at baseline who remained stable at the last visit of the AOM 400 maintenance phase. All endpoints were assessed with descriptive statistics; there were no formal planned statistical analyses.

RESULTS

Of 1,247 patients screened, 1,178 enrolled in the study (194 de novo and 984 patients from the RCTs) and 1,081 received maintenance treatment with AOM 400. The maintenance phase completion rate was 79.4% at 52 weeks. Treatment-emergent AEs in ⩾5% of patients during open-label AOM 400 treatment were headache (7.6%), nasopharyngitis (7.0%), anxiety (6.8%), and insomnia (6.6%). There were no clinically relevant changes in safety parameters of interest. Ninety-five percent of stable patients at baseline remained stable at their last visit during the AOM 400 maintenance phase.

CONCLUSIONS

The long-term safety and tolerability profile of AOM 400 was comparable to the RCTs, and the long-term therapeutic effect was maintained.

The Use of Continuous Treatment Versus Placebo or Intermittent Treatment Strategies in Stabilized Patients with Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with First- and Second-Generation Antipsychotics

BACKGROUND

Although continuous treatment with antipsychotics is still recommended as the gold standard treatment paradigm for all patients with schizophrenia, some clinicians question whether continuous antipsychotic treatment is necessary, or even justified, for every patient with schizophrenia who has been stabilized on antipsychotics.

OBJECTIVE

The primary objectives of this systematic review and meta-analysis were (i) to compare relapse/hospitalization risks of stabilized patients with schizophrenia under active versus intermittent or placebo treatment conditions; (ii) to examine the role of several study characteristics, possibly intervening in the relationship between relapse risk and treatment condition; and (iii) to examine whether time to relapse is associated with antipsychotic treatment duration.

METHODS

A systematic literature search, using the MEDLINE database (1950 until November 2014), was conducted for English-language published randomized controlled trials, covering a follow-up time period of at least 6 months, and investigating relapse/rehospitalization and/or time-to-relapse rates with placebo or intermittent treatment strategies versus continuous treatment with oral and long-acting injectable first- or second-generation antipsychotics (FGAs/SGAs) in stabilized patients with schizophrenia. Additional studies were identified through searches of reference lists of other identified systematic reviews and Cochrane reports. Two meta-analyses (placebo versus continuous and intermittent versus continuous treatment) were performed to obtain an optimal estimation of the relapse/hospitalization risks of stabilized patients with schizophrenia under these treatment conditions and to assess the role of study characteristics. For time-to-relapse data, a descriptive analysis was performed.

RESULTS

Forty-eight reports were selected as potentially eligible for our meta-analysis. Of these, 21 met the inclusion criteria. Twenty-five records, identified through Cochrane and other systematic reviews and fulfilling the inclusion criteria, were added, resulting in a total of 46 records. Stabilized patients with schizophrenia who have been exposed for at least 6 months to intermittent or placebo strategies, respectively, have a 3 (odds ratio [OR] 3.36; 95% CI 2.36-5.45; p < 0.0001) to 6 (OR 5.64; 95% CI 4.47-7.11; p < 0.0001) times increased risk of relapse, compared with patients on continuous treatment. The availability of rescue medication (p = 0.0102) was the only study characteristic explaining systematic differences in the OR for relapse between placebo versus continuous treatment across studies. Studies reporting time-to-relapse data show that the time to (impending) relapse is always significantly delayed with continuous treatment, compared with placebo or intermittent treatment strategies. Although the interval between treatment discontinuation and symptom recurrence can be highly variable, mean time-to-relapse data seem to indicate a failure of clinical stability before 7-14 months with intermittent and before 5 months with placebo treatment strategies. For all reports included in this systematic review, median time-to-relapse rates in the continuous treatment group were not estimable as <50% of the patients in this treatment condition relapsed before the end of the study.

CONCLUSIONS

With continuous treatment, patients have a lower risk of relapse and remain relapse free for a longer period of time compared with placebo and intermittent treatment strategies. Moreover, 'success rates' in the intermittent treatment conditions are expected to be an overestimate of actual outcome rates. Therefore, continuous treatment remains the 'gold standard' for good clinical practice, particularly as, until now, only a few and rather general valid predictors for relapse in schizophrenia are known and subsequent relapses may contribute to functional deterioration as well as treatment resistance in patients with schizophrenia.

The effects of switching from oral to LAI antipsychotic treatment on subjective experience of schizophrenic and schizoaffective patients: Preliminary results

OBJECTIVE

To present real-world preliminary evidence on the specific effects of switching from oral to long-acting injectable (LAI) antipsychotic treatment on patient's subjective experience and quality of life (QoL) in a sample of clinically stable psychotic subjects.

METHODS

Twenty-six clinically stable adult schizophrenic and schizoaffective outpatients were recruited. All patients were under a stabilized therapy with a single oral second-generation antipsychotic and were switched to the equivalent maintenance regimen with the long-acting formulation of the same antipsychotic. Two subgroups of patients were created on the basis of the presence/absence of a complete clinical remission at enrollment. Anthropometric (body mass index), psychometric (Montgomery-Asberg Depression Rating Scale, Young Mania Rating Scale, and Positive And Negative Syndrome Scale), and patient's reported outcome (Subjective Well-Being Under Neuroleptics scale short form, Drug Attitude Inventory short version, and Short Form-36 health survey) data were collected at enrollment (T0) and after 6 months from the treatment switch (T1).

RESULTS

Significant improvements in psychometric indexes, and patients' subjective experience of treatment and attitudes toward drug (reflecting in an enrichment of patients' health-related QoL) were found both in initial remitters and non-remitters.

CONCLUSIONS

Our preliminary results suggest that the switch from oral to LAI antipsychotic treatment may help to address the subjective core of an optimal and satisfying recovery of psychotic patients. Size and duration of this study need to be expanded in order to produce more solid and generalizable results.

Intramuscular long-acting paliperidone palmitate in acute patients with schizophrenia unsuccessfully treated with oral antipsychotics

In this prospective multicentre, open-label, 6-month study (Paliperidone Palmitate Flexible Dosing in Schizophrenia [PALMFlexS]), tolerability, safety and treatment response with paliperidone palmitate (PP) were explored in patients with acute symptoms of schizophrenia following switching from previously unsuccessful treatment with oral antipsychotics. This pragmatic study was conducted in a large, more representative sample of the general schizophrenia population compared to randomized controlled pivotal trials, to specifically mimic real-world clinical situations. After initiation on Day 1 and Day 8, patients received PP once monthly at flexible doses (50-150mgeq.) intramuscularly. The primary efficacy outcome was defined as the percentage of patients achieving ≥30% improvement in PANSS total score from baseline (BL) to last-observation-carried-forward (LOCF) endpoint (EP). Safety and tolerability assessments included Extrapyramidal Symptom Rating Scale (ESRS) total score and treatment-emergent adverse events (TEAEs). Overall, 212 patients received PP at least once after switching from oral antipsychotics, primarily due to lack of efficacy (45.8%). Significant improvements from BL in mean (SD) PANSS total score were observed from Day 8 onwards (BL to LOCF EP: -31.0 [29.0]; p<0.0001). At endpoint, two-thirds (66.7%) and 43.5% of patients achieved a ≥30% and ≥50% improvement in mean PANSS total score, respectively. PP was associated with significant improvements across secondary measures of symptom severity, subjective well-being, medication satisfaction, illness-related disorders of activity and participation, and patient functioning (p<0.0001; BL to LOCF EP). PP was generally well tolerated, with significant reductions in ESRS total score (p<0.0001) and mainly mild-to-moderate TEAEs. TEAEs reported in ≥5% of patients were injection-site pain (13.7%), insomnia (10.8%), psychotic disorder (10.4%), headache and anxiety (both 6.1%). The PALMFlexS study findings provide valuable pragmatic clinical data on PP treatment in patients with acute schizophrenia previously unsuccessfully treated with oral antipsychotics.

Medication adherence in patients with psychotic disorders: an observational survey involving patients before they switch to long-acting injectable risperidone

BACKGROUND

Maintaining antipsychotic therapy in psychosis is important in preventing relapse. Long-acting depot preparations can prevent covert non-adherence and thus potentially contribute to better patient outcomes. In this observational survey the main objective is to evaluate medication adherence and its determinants for oral treatment in a large sample of patients with psychosis.

METHODS

In this cross-sectional survey medication adherence for oral treatment was assessed by patients using the patient-rated Medication Adherence Questionnaire (MAQ). Data were collected by physicians on patients with a recent acute psychotic episode before switching to long-acting injectable risperidone. Other evaluations included disease severity (Clinical Global Impression - Severity), patients' insight (Positive and Negative Syndrome Scale item G12), treatment acceptance (clinician-rated Compliance Rating Scale), and therapeutic alliance (patient-rated 4-Point ordinal Alliance Scale).

RESULTS

A total of 399 psychiatrists enrolled 1,887 patients (mean age 36.8±11.9 years; 61.6% had schizophrenia). Adherence to oral medication was "low" in 53.2% of patients, "medium" in 29.5%, and "high" in 17.3%. Of patients with psychiatrist-rated active acceptance of treatment, 70% had "medium" or "high" MAQ scores (P<0.0001). Medication adherence was significantly associated with therapeutic alliance (4-Point ordinal Alliance Scale score; P<0.0001). Patient age was significantly associated with adherence: mean age increased with greater adherence (35.6, 36.7, and 38.6 years for patients with "low", "medium", and "high" levels of adherence, respectively; P=0.0007), while age <40 years was associated with "low" MAQ classification (P=0.0003). Poor adherence was also associated with a diagnosis of schizophrenia (P=0.0083), more severe disease (Clinical Global Impression - Severity ≥4; P<0.0001), and lower insight (Positive and Negative Syndrome Scale-G12 ≥4; P<0.0001).

CONCLUSION

Self-reported adherence was low in most patients, with a strong positive association between self-reported adherence and psychiatrists' assessment of treatment acceptance. Understanding factors associated with poor medication adherence may help physicians to better manage their patients, thereby improving outcomes.

Evaluation of a comprehensive information and assistance program for patients with schizophrenia treated with long-acting injectable antipsychotics

OBJECTIVE

While atypical long-acting injectable antipsychotics (LAIs) offer the potential for increased adherence, access to medication poses challenges that may hinder their use. Janssen Connect * *Janssen Connect is a registered trade name of Janssen Scientific Affairs, LLC, Titusville, NJ, USA. (JC), a comprehensive information and assistance program, was designed to help patients who received a Janssen LAI initiate and maintain treatment after their health care professional (HCP) determined that the medication was the most clinically appropriate option. We conducted a formative and impact evaluation on early medication adherence of patients enrolled in JC and prescribed paliperidone palmitate.

METHODS

Using the program administrative files (December 2010-April 2014), 9354 patients whose HCP ordered paliperidone palmitate were included. Patient demographics, clinical characteristics, and request of JC program offerings were reported overall, and compared between patients requesting the injection center versus those who did not. Medication adherence based on the first 6 months of treatment while in the program and defined as achieving ≥80% proportion of days covered (PDC) was measured for patients receiving ≥2 paliperidone palmitate injections (n = 2659). Logistic models evaluated the association between requests for injection centers on medication adherence.

RESULTS

Mean age of program enrollees was 40.6 (standard deviation = 13.9 years), 59.3% were men, and 42.5% were Medicare covered. While in the program, 79.9% did not experience a medication gap of ≥7 weeks and 87.0% achieved adherence. Injection center request was associated with medication adherence (adjusted odds ratio (aOR) ≤5 months: 0.03; 95% confidence interval (CI): 0.02-0.05; ≥6 months: aOR: 4.16; 95% CI: 2.72-6.36).

LIMITATIONS

The data sources used were designed for program implementation and not for research purposes.

CONCLUSIONS

The high percentage of patients requesting injection center support and medication shipment in addition to other insurance-related program offerings signals the need for and value of a comprehensive support program for patients seeking LAI therapy. Providing patients with the option of alternative and more conveniently located injection centers may help them start and maintain their treatment.

Treatment of early episode in patients with schizophrenia: the role of long acting antipsychotics

The use of long-acting injectable antipsychotics (LAIs) in schizophrenia is usually restricted to patients in long-term treatment, who prefer them to oral antipsychotics, and to patients with multiple relapses who have a history of non-adherence. However, preliminary evidence from patients in the early phases of the disease suggest that second generation LAIs may be superior to second generation oral medications with regard to the control of negative symptoms and psychosocial functioning. Moreover, several studies have found that psychiatrists are generally reluctant to prescribe LAI antipsychotics and under-estimate their acceptability by patients. Key elements to take into account when offering a LAI in the early course of schizophrenia should include their potential superiority in allowing early detection of non-adherence and in reducing the number of rehospitalisations and relapses.

The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal

Despite their widespread use, long-acting injectable (LAI) antipsychotics (APs) are often regarded with some negativity because of the assumption of punishment, control and insufficient evolution towards psychosocial development of patients. However, LAI APs have proved effective in schizophrenia and other severe psychotic disorders because they assure stable blood levels, leading to a reduction of the risk of relapse. Therapeutic opportunities have also arisen after introduction of newer, second-generation LAI APs in recent years. Newer LAI APs are more readily dosed optimally, may be better tolerated and are better suited to integrated rehabilitation programmes. This review outlines the older and newer LAI APs available for the treatment of schizophrenia, with considerations of past and present pharmacological and therapeutic issues. Traditional, evidence-based approaches to systematic reviews and randomized clinical trials are of limited utility in this area so this paper's blending of experimental trials with observational research is particularly appropriate and effective.

Schizophrenia therapy options increasing

New medications may soon offer more effective treatments for the approximately 2.5 million patients globally with schizophrenia. Current therapies in 2012 yielded $5.2 billion in global market sales, but by 2022 that is expected to reach $7.9 billion.

Making the leap from daily oral dosing to long-acting injectables: lessons from the antipsychotics

There are now long-acting versions of six antipsychotic drugs on the U.S. market, and with them, five unique combinations of molecular form and delivery strategy long-acting-injectable-antipsychotics (LAIAs) show evidence of reduced relapses of schizophrenia, but their introduction has been slow, taking at least nine years after the approval of each oral drug. Oily solutions of lipophilic prodrugs were the first to enter the LAIA market, but they relied on esterification of a hydroxyl handle that was lost with the emergence of the atypical antipsychotics. A review of the literature and patents shows that companies tested many different approaches before reaching the currently marketed versions, including aqueous suspensions of poorly soluble salts, polymeric microspheres, and new approaches to making prodrugs. Yet, very little has been published to support faster development of safe long-acting injectables (LAIs). This review introduces some of the critical considerations in creating an LAI; then it analyzes the existing products and discusses areas where further research is needed. The available literature suggests that lipophilic prodrugs may be inherently safer than poorly soluble salts as LAIs. Other areas needing additional study include (1) the range of physical properties acceptable for LAIs and the effect of prodrug tail length in achieving them, and (2) the role of physiological responses at the injection site in the release of drug from a depot.