A case report of pregnancy and paliperidone palmitate 3-monthly long-acting injection

Long-acting antipsychotic treatments: focus on women with schizophrenia

Effective management of schizophrenia (SZ) requires long-term treatment with antipsychotics (APs) to prevent clinical relapse, attain remission and improve patients' personal and social functioning, and quality of life. Although APs remain the cornerstone treatment for patients with SZ, despite their potential benefits, long-acting injectable APs (LAI-APs) remain underused, most notably in women with SZ. The efficacy and tolerability of APs differ significantly between men and women, and some of these differences are more noticeable depending on the patient's age and the stage of the disorder. Although sex differences may influence treatment outcomes in SZ, their pertinence has been insufficiently addressed, especially regarding the use of LAI-APs. Some biological and social experiences, such as pregnancy, lactation, contraception and menopause, are specific to women, but these remain under-researched issues. Implications of this disorder in parenting are also of special pertinence regarding women; therefore, taking sex differences into account when treating SZ patients is now recommended, and improving personalized approaches has been proposed as a priority in the management of psychosis. In this narrative, critical review, we address some aspects specific to sex and their implications for the clinical management of women with SZ, with a special focus on the potential role of LAI-AP treatments.

Outcomes of long-acting injectable antipsychotics use in pregnancy: A literature review

BACKGROUND

Women with a history of serious psychotic disorders are at increased risk of disease relapse during pregnancy. Long-acting injectable (LAI) antipsychotics have been widely used to improve adherence and prevent relapse in patients with various severe psychotic disorders, but there is a lack of high-quality data from previous research on the safety of LAI antipsychotics during pregnancy.

AIM

To summarize relevant data on maternal, pregnancy, neonatal, and developmental outcomes from published cases of LAI antipsychotic use in pregnancy.

METHODS

A literature search was performed through November 11, 2023, using three online databases: PubMed/MEDLINE, Scopus, and Web of Science. Case reports or case series that reported information about the outcomes of pregnancy in women who used LAI antipsychotics at any point in pregnancy, with available full texts, were included. Descriptive statistics, narrative summation, and tabulation of the extracted data were performed.

RESULTS

A total of 19 publications satisfied the inclusion criteria: 3 case series, 15 case reports, and 1 conference abstract. They reported the outcomes of LAI antipsychotic use in 74 women and 77 pregnancies. The use of second-generation LAI antipsychotics was reported in the majority (n = 47; 61.0%) of pregnancies. First-generation LAI antipsychotics were administered during 30 pregnancies (39.0%). Most of the women (approximately 64%) had either satisfactory control of symptoms or no information about relapse, while approximately 12% of them had developed gestational diabetes mellitus. A minority of cases reported adverse outcomes such as stillbirth, spontaneous abortion, preterm birth, low birth weight, congenital anomalies, and neurological manifestations in newborns. However, there were no reports of negative long-term developmental outcomes.

CONCLUSION

Currently available data seem reassuring, but further well-designed studies are required to properly evaluate the risks and benefits of LAI antipsychotic use during pregnancy.

Concepts for selection and utilization of psychiatric medications in pregnancy

Psychiatric illness may develop or relapse during pregnancy, and understanding best practices is paramount. In 2017, the British Association for Psychopharmacology (BAP) consensus guidance on the use of psychotropic medication preconception, in pregnancy, and postpartum was released. The BAP guidelines provide concise evidence and additional insight and flexibility for use of psychiatric medication. Key takeaways of these guidelines are highlighted serving as a concise reference for practitioners. Additionally, practice points, such as recommendations for rapid tranquilization and the role of long-acting injectable antipsychotic medications as well as additional insights to the growing body of literature associated with psychiatric medications in pregnancy since 2017 are summarized. Providers are strongly encouraged to stay up to date to provide optimal care for pregnant patients and their babies.

Cumulative Clinical Experience of the Use of Paliperidone Palmitate 3-Monthly Long-Acting Injection in the Treatment of Schizophrenia: A Critical Appraisal

Paliperidone palmitate 3-monthly (PP3M), an approved maintenance treatment for patients with schizophrenia, was the first long-acting antipsychotic injectable (LAI) to require only four administrations per year. Here, we aimed to review the available evidence about its use in the management of schizophrenia to date and highlight key study findings in order to provide a balanced overview of current experience in clinical practice. For that purpose, an extensive search of available literature from PubMed, Embase, and Web of Science was conducted in March 2023. Emerging data from real-world studies appear to signal that the benefits of the use of PP3M may well extent beyond the obvious convenience for patients and resource efficiency for services and may be actually associated with improved effectiveness and patient satisfaction. Large naturalistic studies from Australia, Europe and the US comparing treatment continuation between newer LAIs and/or oral antipsychotics showed that patients treated with PP3M had higher compliance rates and a longer period of continuous use. The risk of relapse, re-hospitalization and number of bed days was also lower with PP3M compared to PP1M and other LAIs as demonstrated by several cohort studies. Furthermore, patients treated with PP3M were using lower doses of benzodiazepines and concomitant oral antipsychotics compared with other LAIs. What is more, PP3M appears to positively impact patients' satisfaction and quality of life, facilitating long-term goals. In fact, recent studies recorded better quality-adjusted life years and decreased stigma, with improved social acceptability and promotion of rehabilitation for patients transitioning to PP3M. The rates of general satisfaction rates with PP3M were also higher among psychiatrists and caregivers who reported overall less concerns. In conclusion, clinical exposure and a growing body of evidence thus far, reinforce the use of PP3M in an effort to enhance patient outcomes alongside individual experience and treatment persistence.

Invega Hafyera (Paliperidone Palmitate): Extended-Release Injectable Suspension for Patients With Schizophrenia

Objective: The objective of this study was to describe the safety, efficacy, and potential role in therapy of once in 6 months paliperidone palmitate formulation (PP6M; Invega Hafyera). PP6M is a long-acting injectable antipsychotic recently approved by the Food and Drug Administration (FDA) for the treatment of schizophrenia. Data Sources: A PubMed literature search was conducted using the following terms: paliperidone palmitate and long-acting antipsychotic injections (January 1, 2017, to November 1, 2022). FDA product labeling was also reviewed for pertinent data. Study Selection and Data Extraction: All relevant English-language articles focused on the efficacy and safety of PP6M were considered for inclusion. Data Synthesis: A multicenter, randomized, active controlled relapse prevention noninferiority study showed that PP6M is comparable to paliperidone palmitate once in 3 months formulation (PP3M) in terms of efficacy and safety in clinically stable schizophrenia patients. Place in Therapy: PP6M is indicated in the treatment of adult patients with schizophrenia, who need treatment over a prolonged period. It improves adherence and decreases the rate of relapse and hospitalizations among patients with schizophrenia. It is useful for patients who may have difficulty accessing health care or would prefer the convenience of less frequent injections. Conclusion: PP6M with its long duration of action and lowered frequency of administration (once every 6 months) expands the therapeutic choices available to patients with schizophrenia. More studies in patients with schizophrenia with PP6M, and perhaps other mental illnesses (eg, schizoaffective disorder), are required to fully elucidate the therapeutic potential of PP6M.

Long-acting injectable antipsychotic treatment during pregnancy: Outcomes for women at a tertiary maternity hospital

Our study aimed to examine pregnancy, neonatal and psychosocial outcomes for women treated with LAIs at tertiary maternity hospital. A retrospective review of all women who were treated with LAIs between 1999 and 2017. Cases were identified via the hospital dispensary system and outcome data were extracted case notes as well as the midwifery notification system. Measures included sociodemographic data, smoking, alcohol and illicit substance use, pregnancy complications such as gestational diabetes, and neonatal outcomes. Psychosocial profiles such as psychiatric admission during pregnancy and statutory child protection involvement were also assessed. Where available, outcomes were compared with state population data. The study found 38 pregnancies to 36 women, who had LAI treatment. Two congenital malformations (5.7%) were recorded. Compared to general population data, pregnant women treated with LAIs were more likely to have obstetric complications including gestational diabetes and pregnancy hypertension and special care nursery admission for their babies. They also had elevated rates of psychiatric admissions during pregnancy and statutory child protection involvement. Outcomes were similar first and second generation LAIs exposure. As women on LAI have limited options for treatment of their psychotic disorders, the findings point towards a need for enhanced multidisciplinary pregnancy care for this vulnerable cohort.

Long-Acting Injectable Antipsychotic Medications in Pregnancy: A Review

BACKGROUND

Long-acting injectable antipsychotic medications (LAIs) are an evidence-based treatment option for people with severe mental illness. While women with severe mental illness who are prescribed LAIs can become pregnant, there is a dearth of research examining the safety of these medication formulations during pregnancy.

OBJECTIVE

This article summarizes available literature on the use of LAIs in pregnancy to help inform clinical decisions and guide future research.

METHODS

PubMed literature searches were completed using combinations of keywords including "antipsychotic" and "long-acting injectable" or "depot," or generic or brand names of LAIs with "pregnancy." Pregnancy outcomes were compared across studies.

RESULTS

Twelve relevant case reports of 13 pregnancies were identified. Six cases did not report any negative birth or infant outcomes, including prematurity, infants being born small for gestational age, congenital anomalies, and extrapyramidal symptoms. No cases reported abnormal Apgar scores, infants being born large for gestational age, or negative long-term developmental outcomes after exposure to LAIs during pregnancy. Cesarean section rate was comparable to the general population. Specific adverse outcomes included one infant with multiple congenital anomalies, 3 infants with minor congenital anomalies, and one infant with possible extrapyramidal symptoms. One infant was born prematurely, one infant was born small for gestational age, and 2 infants were born both prematurely and small for gestational age.

CONCLUSIONS

There is little research specifically examining the use of LAIs in pregnancy, so risks must be extrapolated from studies on oral antipsychotics in pregnancy. While the few published case reports examining LAIs in pregnancy somewhat align with research examining oral antipsychotics, these findings are inconclusive due to the inherently limited nature of case reports. Further investigation into the use of LAIs in pregnancy is warranted.