Long-Acting Injectable Antipsychotics in Schizophrenia: Literature Review and Practical Perspective, with a Focus on Aripiprazole Once-Monthly

In vitro cytogenotoxic evaluation of aripiprazole on human peripheral lymphocytes and computational molecular docking analysis

Two different drug groups, typical (classic) and atypical (new), are used in the treatment of schizophrenia. Aripiprazole, an atypical antipsychotic chemical, is the active ingredient of the drug Abilify. This study was conducted to determine the possible genotoxic effect of aripiprazole. For this purpose, four different doses of aripiprazole (5; 10; 20, and 40 µg/mL) were examined with Chromosome Abnormality (CA), Sister Chromatid Exchange (SCE), Micronucleus (MN) tests. Based on these tests, Proliferation Index (PI), Percent Abnormal Cells (AC), Mitotic Index (MI), Micronuclear Binuclear Cell (MNBN), and Nuclear Division Index (NDI) levels were determined in human peripheral lymphocytes treated for 24 and 48 hours. Also, to determine possible binding sites of Aripiprazole on B-DNA molecular docking analysis was performed using AutoDock 4.0 (B-DNA dodecamer, PDB code: 1BNA). Aripiprazole binds to B-DNA with a very significant free binding energy (-11.88 Kcal/mol). According to our study, aripiprazole did not significantly change SCE, CA, AC percentage, MN frequencies when compared with control. According to these results, aripiprazole does not have a genotoxic effect. At the same time, no significant change was observed in the PI, MI, and NDI frequencies when compared with the control. In line with these results, it was observed that the use of aripiprazole in the treatment of schizophrenia did not pose any acute genotoxic and cytotoxic risk.

Time-to-therapy discontinuation in patients newly diagnosed with schizophrenia initiated on long-acting injectable versus oral dopamine receptor blocking agents

AIM

The purpose of this project is to assess the time-to-therapy discontinuation and hospital readmission rate among patients newly diagnosed with schizophrenia who are prescribed long-acting injectable versus oral dopamine receptor blocking agents.

METHODS

A retrospective review of medical records was performed for adult patients admitted to an 80-bed inpatient behavioural health facility with a new diagnosis of schizophrenia. The primary outcome studied was time to therapy discontinuation within 1 year of discharge, while secondary outcomes assessed were time-to-therapy discontinuation within 90 days and readmission rate at 30-days, 6 months, and 1 year. Multivariate Cox proportional hazard and linear regression modelling were used for statistical analysis.

RESULTS

A total of 425 patients were included in the analysis, with 66.4% (n = 282) discharged on oral and 33.6% (n = 143) on long-acting injectable dopamine receptor blocking agents. At 1 year post-discharge, the rates of discontinuation were 49.7% for those prescribed long-acting injectable and 55.7% for those prescribed oral formulations (adjusted hazard ratio = 0.54, p = .012). There was no statistically significant difference in readmission rate between the patients prescribed long-acting injectable and oral dopamine receptor blocking agents at any timepoint tested.

CONCLUSIONS

The use of long-acting injectable dopamine receptor blocking agents was associated with longer time-to-discontinuation compared to oral agents when prescribed to patients newly diagnosed with schizophrenia in the inpatient setting. However, this was not associated with significant reductions in rehospitalization, calling into question the clinical impact. Future studies will seek to confirm these findings using a prospective study design.

Novel pharmacotherapy targeting the positive symptoms of schizophrenia

INTRODUCTION

The severity of positive symptoms in schizophrenia is associated with poor prognosis. About one-third of schizophrenia patients partially respond to treatment with available antipsychotics. The purpose of the present manuscript is to provide an updated overview of novel pharmacotherapy targeting positive symptoms in schizophrenia.

AREAS COVERED

A comprehensive research on the main database sources (PubMed, PsychINFO, Isi Web of Knowledge, MEDLINE, and EMBASE) was performed to obtain original articles published till 31st January 2023 about new pharmacological strategies for the treatment of positive symptoms in schizophrenia.

EXPERT OPINION

The most promising compounds include: lamotrigine, pro-cognitive-compounds (donepezil - in the short term, idazoxan and piracetam) and drugs acting partially or totally outside the Central Nervous System (CNS) (anti-inflammatory drugs: celecoxib, methotrexate; cardiovascular compounds: L-theanine, mononitrate isosorbide, propentofylline, sodium nitroprusside; metabolic regulators: diazoxide, allopurinol; others: bexarotene, raloxifene [in women]). The effectiveness of the latter compounds indicates that other biological systems, such as immunity or metabolism can be object of future research to identify pharmacological targets for positive symptoms of schizophrenia. Mirtazapine could be useful for treating negative symptoms without increasing the risk of a worsening of delusions/hallucinations. Nevertheless, the lack of replication of studies prevents to draw definitive conclusions and future studies are needed to confirm the findings presented in this overview.

A Rapid Review of "Low-Threshold" Psychiatric Medication Prescribing: Considerations for Street Medicine and Beyond

OBJECTIVE

No widely accepted clinical guidelines, and scant directly applicable pragmatic research, are available to guide the prescription of psychiatric medications in "low-threshold" outpatient settings, such as street outreach, urgent care, and crisis care, as well as walk-in, shelter, and bridge and transition clinics. Providers frequently prescribe medications in these settings without patients' having firm psychiatric diagnoses and without medical records to guide clinical decision making. Persons who receive medications in these settings often seek help voluntarily and intermittently for mental illness symptoms. However, because of structural and individual factors, such patients may not engage in longitudinal outpatient psychiatric care. The authors reviewed the literature on psychiatric medication prescribing in low-threshold settings and offer clinical considerations for such prescribing.

METHODS

The authors conducted a rapid literature review (N=2,215 abstracts), which was augmented with up-to-date clinical prescribing literature, the authors' collective clinical experience, and DSM-5 section II diagnostic criteria to provide considerations for prescribing medications in low-threshold settings.

RESULTS

For individuals for whom diagnostic uncertainty is prominent, a symptom-based diagnostic and treatment approach may be best suited to weigh the risks and benefits of medication use in low-threshold settings. Practical considerations for treating patients with clinical presentations of psychosis and trauma, as well as mood, anxiety, and substance use disorders, in low-threshold settings are discussed.

CONCLUSIONS

An urgent need exists to invest in pragmatic research and guideline development to delineate best-practice prescribing in low-threshold settings.

High Rate of Discontinuation during Long-Acting Injectable Antipsychotic Treatment in Patients with Psychotic Disorders

Treatment discontinuation is a major challenge in routine clinical settings. Despite poor adherence to antipsychotic medication, long acting injectable (LAI) formulations are an underutilized option in psychotic disorders. Recently, an earlier and broader use of LAIs has been emphasized. However, few studies have evaluated the factors associated with LAI antipsychotic discontinuation in ordinary clinical practice. The main purpose of the present study was, therefore, to identify the factors associated with LAI discontinuation in a real-world setting. Patients in treatment with LAI antipsychotics were recruited. A Cox regression analysis was applied considering a 12-month follow-up period. Moreover, a Kaplan-Meier survival analysis was applied to compare the single treatment LAI antipsychotic groups in terms of time to discontinuation. Our analysis showed an LAI discontinuation rate at 12 months, corresponding to 28.8%, with olanzapine and aripiprazole having a longer time to discontinuation compared to zuclopenthixol. The results of the present study can help clinicians with their choice of LAI antipsychotic according to patients' characteristics and in a context of precision medicine. Increasing knowledge about factors affecting discontinuation of LAI antipsychotics can improve the prescribing practices of these compounds. Individualized approaches may ameliorate long-term patients' treatment adherence, thus preventing the long-term disability caused by psychotic disorders.

A 10-Year Observational Study of the Use, Acceptability and Effectiveness of Long-Acting Paliperidone Palmitate: Implications for Clinical Decision Making

BACKGROUND

Long-acting injectable antipsychotics (LAIs) have been shown to improve adherence and prevent relapse in the treatment of schizophrenia and psychotic disorders, though longitudinal data on treatment outcomes are limited.

OBJECTIVES

To establish the long-term acceptability and effectiveness of paliperidone palmitate once monthly (PP1M).

METHODS

This independent 10-year mirror image study was carried out in a large urban mental health provider. The study evaluated the retention and hospitalization rates 5 years following initiation of PP1M in a naturalistic patient cohort of all adult patients who were newly initiated on PP1M between 2011 and 2015. Electronic records were used to compare the frequency and length of hospital admissions in the 5 years before and after introduction of PP1M. Switching and discontinuation rates and reasons were also recorded with a separate analysis of patients who continued and discontinued PP1M during the study period.

RESULTS

A total of 167 patients were included in the study (70% with schizophrenia, 30% with other diagnoses). Discontinuation rates were 24%, 15%, 17%, 5% and 8% in years 1-5, respectively; poor tolerability was the most common cause for stopping PP1M. Demographic and clinical factors such as age, sex, diagnosis and care setting did not discriminate between continuers and discontinuers. The group that completed 5 years on PP1M (46%) showed an overall reduction of 72% in the mean number and 68% in the mean length of admissions compared to the 5-year period before initiation, with more than half of the patients requiring no admission at all during this period of time (median = 0). On the contrary, discontinuers demonstrated worse outcomes in overall bed occupancy than continuers. Findings were overall similar across the total cohort and schizophrenia-only group.

CONCLUSIONS

Our study has one of the longest durations of follow up of a naturalistic cohort treated with LAIs confirming sustained improvements for patients who continued treatment for up to 5 years with implicit implications for cost effectiveness. Study findings may facilitate shared decision making in this area, overcoming some of the common barriers for use.

10-Year Trends in Healthcare Spending among Patients with Schizophrenia in Alberta, Canada

OBJECTIVES

Schizophrenia is characterized by high levels of disability often resulting in increased healthcare utilization and spending. With expanding healthcare costs across all healthcare sectors, there is a need to understand how healthcare spending has changed over time. We conducted a population-based study using administrative health data from Alberta, Canada, to describe changes in medical complexity and direct healthcare spending among patients with schizophrenia over a 10-year period.

METHODS

A serial cross-sectional study from January 1, 2008, to December 31, 2017, was conducted to determine changes in demographic characteristics, medical complexity, and costs among all adults (18 years or older) with schizophrenia. Total healthcare spending and sector-specific costs attributable to hospitalizations, emergency department visits, practitioner billings, and prescriptions were calculated and compared over time.

RESULTS

Over the 10-year period the contact prevalence of patients with schizophrenia increased from 0.6% (n  =  16,183) to 1.0% (n  =  33,176) within the province. There was a marked change in medical complexity with the number of patients living with 3 or more comorbidities increasing from 33.0% to 47.3%. Direct annual healthcare costs increased 2-fold from 321 to 639 million CAD (493 million USD) with a 7-fold increase in medication expenditures over the 10-year time frame. As of 2017, spending on pharmaceutical treatment surpassed hospitalizations as the leading spending category in this population.

CONCLUSIONS

Healthcare spending among patients with schizophrenia continues to increase and may be partially attributable to growing rates of multimorbidity within this population. Although promising second-generation antipsychotic medications have entered the market, this has resulted in considerable changes in the distribution of healthcare spending over time. These findings will inform policy discussions around resource allocation and efforts to curb health spending while also improving care for patients with schizophrenia.

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications

BACKGROUND

Long-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections.

OBJECTIVE

This study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications.

METHODS

A systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded.

RESULTS

Of 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists' mixed attitudes regarding LAIA administration and time and safety barriers to offering the service.

CONCLUSION

We found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

Population Pharmacokinetic Modeling and Simulation of TV-46000: A Long-Acting Injectable Formulation of Risperidone

TV‐46000 is a long‐acting subcutaneous antipsychotic that uses a novel copolymer drug delivery technology in combination with a well‐characterized molecule, risperidone, that is in clinical development as a treatment for schizophrenia. A population pharmacokinetic (PPK) modeling and simulation approach was implemented to identify TV‐46000 doses and dosing schedules for clinical development that would provide the best balance between clinical efficacy and safety. The PPK model was created by applying pharmacokinetic data from a phase 1 study of 97 patients with a diagnosis of schizophrenia or schizoaffective disorder who received either single or repeated doses of TV‐46000. The PPK model was used to characterize the complex release profile of the total active moiety (TAM; the sum of the risperidone and 9‐OH risperidone concentrations) concentration following subcutaneous injections of TV‐46000. The PK profile was best described by a double Weibull function of the in vivo release rate and by a 2‐compartment disposition and elimination model. Simulations were performed to determine TV‐46000 doses and dosing schedules that maintained a median profile of TAM concentrations similar to published TAM exposure following oral risperidone doses that have been correlated to a 40% to 80% dopamine‐D2 receptor occupancy therapeutic window. The simulations showed that therapeutic dose ranges for TV‐46000 are 50 to 125 mg for once‐monthly and 100 to 250 mg for the once every 2 months regimens. This PPK model provided a basis for prediction of patient‐specific exposure and dopamine‐D2 receptor occupancy estimates to support further clinical development and dose selection for the phase 3 studies.

Repetitive transcranial magnetic stimulation for psychiatric symptoms in long-term hospitalized veterans with schizophrenia: A randomized double-blind controlled trial

Multiple lines of evidence demonstrate that high-frequency (HF) repetitive transcranial magnetic stimulation (rTMS) may improve clinical outcomes in patients with schizophrenia (SCZ). However, the efficacy of HF-rTMS on psychiatric symptoms remains unknown in veterans with SCZ. This study aimed to investigate whether HF-rTMS was beneficial in alleviating the clinical symptoms in veterans with SCZ. Forty-seven long-term hospitalized veterans with SCZ were randomly allocated to receive neuronavigated 10 Hz rTMS or sham stimulation over the left dorsolateral prefrontal cortex once daily for four consecutive weeks. Symptoms were assessed by using the Positive and Negative Syndrome Scale at baseline and at the end of week 4. We also collected easily available routine biochemical markers including blood sugar, lipid profiles, hormone, and blood cell counts, considering that these markers may potentially be used to predict the outcomes of rTMS treatment. We found that there was a significant interaction effect of time and group on the positive symptoms. Compared with the sham group, the positive factor score of veterans with SCZ was significantly decreased after treatment in the real rTMS group. Interestingly, the improvement of positive symptoms from baseline to 4-week follow-up was significantly associated with the whole white blood cells (WBC) counts at baseline in the real rTMS group, and baseline WBC counts were predictive of the symptom improvement after rTMS treatment. Our findings indicate that add-on 10 Hz rTMS is beneficial for clinical symptoms in veterans with SCZ. In addition, the baseline WBC counts were predictive of the outcomes after treatment.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, identifier NCT03774927.

Effect of long-acting injectable antipsychotics on hospitalizations and global functioning in schizophrenia: a naturalistic mirror-image study

BACKGROUND

Partial adherence to antipsychotics is the most common cause of relapses and rehospitalization in patients with schizophrenia (SZ), leading to higher health care costs and psychosocial disability. The use of long-acting injectable (LAI) antipsychotics may improve therapeutic continuity and adherence to treatment.

OBJECTIVE

To assess the effectiveness of switching from oral antipsychotics (OAs) to long-acting antipsychotics.

METHODS

This 1-year mirror-image study evaluated the effect of switching from OAs to LAIs on the reduction of psychiatric hospitalizations and the improvement of global functioning in patients with schizophrenia. Differences in outcomes between second-generation (SGA) LAIs and first-generation (FGA) LAIs were also analyzed.

RESULTS

In all, 166 patients were included: 32.5% treated by FGA-LAIs and 67.5% by SGA-LAIs. There was an overall reduction of 71% in the average number of hospital admissions and an overall improvement of 29.3% in the Global Assessment of Functioning (GAF) score between the previous 12 months and the 12 months following the switching to LAIs. Patients who switched to SGA-LAIs had no significant differences in hospitalization occurrences but a significant improvement in GAF scores when compared with patients who switched to FGA-LAIs.

CONCLUSION

Our results suggest that using LAIs could be the most adequate treatment choice for SZ patients with a high risk of relapse and low adherence rate. Patients with poorer social functioning may be ideal candidates for SGA-LAIs treatment. Our findings may be of particular interest from a clinical and health care management perspective.

An Integrated Pharmacokinetic-Pharmacodynamic-Pharmacoeconomic Modeling Method to Evaluate Treatments for Adults with Schizophrenia

INTRODUCTION

Schizophrenia is a chronic mental disorder that worsens with each relapse. Long-acting injectable (LAI) antipsychotics may prevent the exacerbation of symptoms and occurrence of relapses through improved continuity of care. Different dose regimens are available for the LAIs aripiprazole monohydrate (AM) and aripiprazole lauroxil (AL), but their cost effectiveness is unclear.

OBJECTIVES

The study aim was to compare costs and effects (relapses) of the different aripiprazole LAI dose regimens to inform clinical and US payer decisions.

METHODS

A state-transition model calculated the outcomes of eight LAI dose regimens based on their relapse rates. As effectiveness data from randomized controlled trials were unavailable, relapse rates were modeled using pharmacokinetic and pharmacodynamic evidence. These described blood plasma levels of aripiprazole as a function of AM and AL dose regimens and described the probability of relapse as a function of aripiprazole blood plasma levels. The analysis had a time horizon of 1 year and took the US healthcare payer perspective. The incremental cost per relapse avoided and the probability of cost effectiveness were calculated in deterministic and probabilistic analyses. Scenario analyses explored the model's main assumptions, and results were validated against external data and other cost-effectiveness analyses.

RESULTS

Monthly administration of AM 400 mg consistently yielded the lowest predicted number of relapses across deterministic, probabilistic, and scenario analyses. The costs of treatment and relapses were projected to be the lowest with a monthly administration of AL 441 mg. The incremental cost per relapse avoided with AM 400 mg ranged from AM 400 mg being dominant to $US83,300. From willingness-to-pay thresholds of $US30,000 per relapse avoided, the probability of cost effectiveness was highest for AM 400 mg. The validation showed alignment with external data.

CONCLUSION

The analysis highlighted the robustness of the novel framework based on pharmacokinetic and pharmacodynamic evidence and demonstrated an application in a postmarketing setting.

Risperidone ISM as a New Option in the Clinical Management of Schizophrenia: A Narrative Review

Antipsychotics are the cornerstone of schizophrenia treatment. Lack of treatment adherence encouraged the development of injectable long-acting antipsychotics. However, second-generation or atypical antipsychotics require a loading dose at the start of treatment and eventually oral supplementation to achieve therapeutic plasma levels. This review discusses the evidence emerging from studies evaluating the pharmacokinetics, efficacy and safety of the intramuscular formulation of risperidone based on in situ microparticles (ISM). ISM® technology applied to risperidone allows therapeutic levels of the active moiety to be achieved within 2 h of intramuscular administration without the need for loading doses or oral supplementation, leading to a constant release over the whole dosing period. Risperidone ISM showed significant antipsychotic efficacy versus placebo in the Positive and Negative Syndrome Scale (PANSS) total score (p < 0.0001) and on the subscales of positive symptoms after 8 days, negative symptoms in 8 weeks, and general psychopathology during the 12 weeks of treatment. The improvement was also statistically significant (p < 0.0001) against placebo in the Clinical Global Impressions-Severity of Illness scale (CGI-S) score at the end of the treatment. Risperidone ISM was generally well tolerated and the most frequently reported adverse events were similar to those observed with other risperidone formulations. There is clinical evidence that these results are maintained in the long term. In conclusion, four-weekly risperidone ISM (75 mg and 100 mg) is an adequate antipsychotic for treating schizophrenia, both in the short term when an exacerbation has recently occurred and for long-term maintenance, since it provides rapid onset of action and sustained efficacy, as well as being safe and well tolerated.

Adherence and persistence to long-acting injectable dopamine receptor blocking agent therapy in the United States: A systematic review and meta-analysis of cohort studies

The purpose of this systematic review and meta-analysis was to assess adherence and persistence to long-acting injectable dopamine receptor blocking agents (LAI DRBAs) in published observational cohort studies conducted in the United States. Adherence rate (proportion of days covered ≥80%) and persistence rate (no gap in therapy ≥60 days) to LAI DRBAs were examined in 26 articles for qualitative review and 8 articles for quantitative review. There was significant variability in adherence and persistence rates to LAI DRBAs in the reported observational cohort studies. The mean adherence and persistence rates to LAI DRBAs in the included studies were 36% (8-66%) and 56% (32-80%), respectively. The use of LAI DRBAs showed cumulative benefit of achieving adherence 1.40 times higher compared to oral agents. The persistence rate was measured by number of patients having no more than 60 days gap in therapy at follow-up, and the cumulative benefit of being persistently on the therapy was 1.65 times higher among the LAI agents-exposed group compared to the oral agents-exposed group. The use of LAI DRBAs confers benefit in adherence and persistence compared to oral DRBA formulations.

The Relation between the Plasma Concentrations of Long-Acting Atypical Antipsychotics and Clinical Effectiveness in Patients Affected by Schizophrenia or Schizoaffective Disorder: A Comprehensive Overview

Atypical antipsychotic depot medications are currently recommended for patients with schizophrenia (SCZ) to prevent relapse and ameliorate the long-term prognosis of these patients. This review critically summarizes the available data about the association between the plasma concentrations of long-acting Second- Generation Antipsychotics (SGAs) and the clinical effectiveness of these compounds in patients affected by SCZ or schizoaffective disorder. Our question is if the measurement of these concentrations can be helpful for clinicians in predicting treatment response and clinical stabilization of patients. Bibliographic research on the main databases was performed, and 13 studies were finally included in this review. Contrasting results were found between plasma concentrations of long-acting injectable (LAI) risperidone and clinical amelioration according to rating scale scores. Data are too scanty to draw conclusions for olanzapine and paliperidone. In contrast, despite small sample sizes, data are quite concordant in showing a relation between long-acting SGA plasma concentrations and D2 receptor occupancy. Despite the preliminary encouraging results, particularly for D2 receptor occupancy, future research with larger samples will have to confirm the clinical usefulness of measuring LAI SGA plasma concentrations to predict the clinical response of patients affected by severe mental conditions such as SCZ.

Long acting aripiprazole influences cognitive functions in recent onset schizophrenia

RATIONALE

Beneficial effects of aripiprazole on cognition in schizophrenia have been previously reported, but not in recent onset schizophrenia. Cognitive impairments have also been associated with catechol-O-methyltransferase (COMT), methylenetetrahydrofolate reductase (MTHFR), and serotonin transporter (SERT) gene polymorphisms which were earlier implicated in the pathophysiology of schizophrenia.

OBJECTIVES

This study examined the short-term influence of aripiprazole long-acting injectable (LAI) as well as of COMT, MTHFR, and SERT gene polymorphisms and their interactions on clinical features and cognitive functions in inpatients with recent onset schizophrenia.

METHODS

This study included 98 inpatients suffering from recent onset schizophrenia diagnosed according to DSM-5 criteria. Three months after initiating aripiprazole LAI, the severity of symptoms was assessed by the Positive and Negative Syndrome Scale (PANSS), while cognitive functions were measured by 5-KOG test for cognition. Genotypes of SERT, MTHFR, and COMT gene were determined by different polymerase chain reaction (PCR) methods.

RESULTS

Three-month aripiprazole LAI treatment was associated with a statistically significant change of PANSS total (p<0.001) and subscale scores as well as cognitive parameters of delayed recall (p<0.03), attention (p<0.01), and executive functions in the form of less perseverations (p<0.03), without influencing other examined cognitive functions. However, it significantly influenced composite cognitive score (p<0.02). In regard to the investigated genetic polymorphisms, we established a positive association between the COMT polymorphism (M/M allele carriers) and attention (p<0.01). Additionally, we also established a positive association between the COMT - MTHFR interaction and attention (p<0.02), as well as perseveration item belonging to executive functions (p<0.01). Two other investigated polymorphisms (MTHFR and SERT) were not significantly associated with cognitive indices. Investigated genetic polymorphisms and their interactions were not associated with PANSS scores.

CONCLUSIONS

Our findings suggest that aripiprazole LAI improves individual cognitive functions in recent onset schizophrenia. Investigated COMT polymorphism (Met/Met genotype), as well as the COMT-MTHFR interaction, were positively associated with attention and executive functioning (perseveration), potentially implying COMT's biomarker potential in terms of cognition in schizophrenia.

Patients' perspectives on three-monthly administration of antipsychotic treatment with paliperidone palmitate - a qualitative interview study

INTRODUCTION

Three-monthly dosage of paliperidone palmitate entails longer time to relapse after discontinuation, is similarly tolerable and safe compared to monthly injections of paliperidone palmitate and is beneficial for the caregivers. However, few studies have so far explored in depth the patients' experiences with paliperidone palmitate medication every three months, or with switching from monthly to three-monthly injections of paliperidone palmitate.

MATERIAL AND METHODS

A qualitative study based on individual interviews with persons with schizophrenia who receive three-monthly paliperidone palmitate in Norway, Sweden and Denmark. Data was analysed according to qualitative content analysis.

RESULTS

Twenty-four patients, 16 men and 8 women, took part in individual interviews. The patients' mental health care professionals mainly recommended the switch to three-monthly paliperidone palmitate, and few or no disadvantages were described. According to the patients, three-monthly paliperidone palmitate had several advantages, such as less frequent injections, less administration and planning and less focus on the illness. In addition, the participants described feeling more stability, being more physically and socially active, and that improvement processes were supported. For some, the use involved practical and economic challenges, and some worried whether the medicine 'wore off' before the next injection. According to the patients, switching to three-monthly paliperidone palmitate did not influence the frequency or content of patients' interaction with health care professionals.

CONCLUSION

Switching from monthly to three-monthly injections with paliperidone palmitate seems to be experienced as advantageous for patients with schizophrenia.

Early administration of aripiprazole long-acting injectable in acute inpatients with schizophrenia: a clinical report

Fifty-one patients suffering an acute episode of schizophrenia and treated with aripiprazole long-acting injectable (ALAI) were chosen to elaborate an observational study in two in-patient units in Spain, in order to examine the effects of early administration during a hospital admission. When treatment with ALAI is administered in the first week of admission (in 31 patients, 60.78%), hospitalization time is significantly reduced, 12.1 days on average. It can be concluded that ALAI is an effective treatment for these patients. Analysis in economic terms and comparison with other LAI antipsychotics are interesting lines for further research.

Effectiveness of 2-year treatment with aripiprazole long-acting injectable and comparison with paliperidone palmitate

BACKGROUND

The pragmatic management of psychotic disorders is more complex than that delivered in a controlled trial environment. Therefore, this study aims to evaluate the real-world effectiveness of aripiprazole long-acting injectable (ALAI) and compare it with another commonly used long-acting anti-psychotic, once-monthly paliperidone palmitate (PP1M).

METHODS

This naturalistic, independent 4-year mirror image study compared the mean number and length of hospital admissions 2 years before and 2 years after treatment initiation with ALAI. Retention rates, discontinuation reasons and level of adherence were also recorded. Furthermore, indirect comparisons were made between treatment outcomes on ALAI and PP1M.

RESULTS

A total of 109 eligible patients with a severe mental illness (65% with schizophrenia and 35% with other diagnosis) commenced on ALAI and 173 patients (69% with schizophrenia and 31% with other diagnoses) initiated on PP1M were included. Of these, 37% on ALAI and 34% on PP1M stopped treatment at 2 years; retention rates were most favourable for the schizophrenia group on PP1M. Patients were more likely to discontinue due to lack of effectiveness on ALAI and due to tolerability issues on PP1M. Those who continued for 2 years on ALAI (n = 69), demonstrated an overall decrease of 84% in the mean number and 88% in the mean length of hospital admissions compared with the 2 years before initiation. Although patients on ALAI appeared to have a significantly higher bed occupancy the 2-year period before initiation than patients on PP1M, the reductions in hospitalizations were comparable across both cohorts after 2 years of treatment.

CONCLUSIONS

The introduction of ALAI had a substantial impact on long-term clinical outcomes in this naturalistic cohort; more than half of patients continued treatment and had no admission during 2 years of follow up. There were no significant differences in hospitalisation rates between patients on ALAI and PP1M at 2 years.

Real-World Outcomes and Costs Following 6 Months of Treatment with the Long-Acting Injectable (LAI) Aripiprazole Lauroxil for the Treatment of Schizophrenia

BACKGROUND

Continuous antipsychotic therapy is recommended as part of long-term maintenance treatment of schizophrenia, and gaps in antipsychotic treatment have been associated with increased risks of relapse and rehospitalization. Because the use of long-acting injectable (LAI) antipsychotics may reduce the likelihood of undetected medication gaps, initiating an LAI medication may affect resource utilization and costs. The LAI aripiprazole lauroxil (AL) was approved in the United States (US) in 2015 for the treatment of schizophrenia in adults.

OBJECTIVE

The objective of this retrospective observational cohort study was to examine treatment patterns, resource utilization, and costs following initiation of AL for the treatment of schizophrenia in adults.

METHODS

A retrospective analysis of Medicaid claims data identified a cohort of patients (N = 485) starting AL shortly after Food and Drug Administration approval in October 2015. Treatment patterns, resource utilization, and costs were compared 6 months before and after treatment initiation. Subgroup analyses were conducted based on the type of antipsychotic (LAI, oral, or none) received before initiation of AL.

RESULTS

Over 6 months of follow-up, patients received an average of 4.6 injections out of a maximum of six (77%). After initiating AL, all-cause inpatient admissions decreased by 22.4%; other significant reductions were observed in mental health-related admissions and emergency room (ER) visits. All-cause inpatient costs decreased by an average of US$2836 per patient (p < 0.05) in the 6-month post-AL period, whereas outpatient pharmacy costs increased by US$4121 (p < 0.05), resulting in no significant difference in overall costs between the pre- and post-AL periods. The subgroup of patients who had been prescribed an oral antipsychotic before starting AL had significant reductions in proportion of patients with inpatient and ER visits and costs, but also reported a significant increase in pharmacy costs.

CONCLUSIONS

AL was associated with a significant reduction in inpatient costs and an increase in outpatient pharmacy costs, resulting in no changes in total healthcare costs over 6 months. The adherence rate and reductions in inpatient use may indicate the potential for greater clinical stability among patients initiated on AL compared with their previous treatment.

Regulation of Reactive Oxygen Species-Mediated Damage in the Pathogenesis of Schizophrenia

The biochemical integrity of the brain is paramount to the function of the central nervous system, and oxidative stress is a key contributor to cerebral biochemical impairment. Oxidative stress, which occurs when an imbalance arises between the production of reactive oxygen species (ROS) and the efficacy of the antioxidant defense mechanism, is believed to play a role in the pathophysiology of various brain disorders. One such disorder, schizophrenia, not only causes lifelong disability but also induces severe emotional distress; however, because of its onset in early adolescence or adulthood and its progressive development, consuming natural antioxidant products may help regulate the pathogenesis of schizophrenia. Therefore, elucidating the functions of ROS and dietary antioxidants in the pathogenesis of schizophrenia could help formulate improved therapeutic strategies for its prevention and treatment. This review focuses specifically on the roles of ROS and oxidative damage in the pathophysiology of schizophrenia, as well as the effects of nutrition, antipsychotic use, cognitive therapies, and quality of life on patients with schizophrenia. By improving our understanding of the effects of various nutrients on schizophrenia, it may become possible to develop nutritional strategies and supplements to treat the disorder, alleviate its symptoms, and facilitate long-term recovery.

Healthcare Resource Utilization and Costs Among Patients With Schizophrenia Switching From Oral Risperidone/Paliperidone to Once-Monthly Paliperidone Palmitate: A Veterans Health Administration Claims Analysis

Background

Schizophrenia is associated with high health care resource utilization and treatment costs.

Objective

This study compared treatment patterns, health care resource utilization, and medical costs before and after a switch from oral antipsychotic drug (risperidone or paliperidone [RIS/PALI]) therapy to the long-acting injectable once-monthly paliperidone palmitate (PP1M) in patients with schizophrenia.

Methods

Data for adult patients (aged ≥18 years) with at least 1 diagnosis of schizophrenia who initiated treatment with oral RIS/PALI ≥6 months before switching and had continuous health plan enrollment during the study period before and after the switch were extracted from the Veterans Health Administration database. Treatment patterns, health care resource utilization, and costs were compared between the period 6 or 12 months before and after switching directly from oral RIS/PALI to PP1M.

Results

The analysis included 676 and 493 patients in the 6-month and 12-month cohorts, respectively. Adherence to oral RIS/PALI during the 12 months preswitch was 11.0% and 22.1% as measured by proportion of days covered and medication possession ratio ≥80%, respectively. During the 12 months postswitch, adherence to PP1M was 27.0% and 35.9%, respectively. Among patients treated with oral RIS/PALI, from 12 months pre- to 12 months post-PP1M switch, fewer all-cause inpatient stays (2.2 vs 1.1, respectively; P < 0.05) and a shorter mean length of inpatient stay (28.1 and 14.0 days, respectively; P < 0.05) were observed. This pattern was similar for both the number of mental health– and schizophrenia-related inpatient stays and length of stay. Compared with 12 months pre-PP1M switch, significantly higher mean numbers of all-cause outpatient visits and pharmacy visits were observed at 12 months postswitch. In line with health care resource utilization findings, at 12 months pre- versus 12 months post-PP1M switch we observed decreases in all-cause inpatient stay costs ($41,886 vs $20,489; P < 0.05) and increases in outpatient visit costs ($22,005 vs $29,069; P < 0.05). Findings for the 6-month cohort followed a similar pattern.

Conclusions

Post-PP1M switch, a decrease in total medical costs fully offset an increase in pharmacy costs, resulting in similar total costs. The findings suggest potential economic benefits of switching patients with schizophrenia from oral RIS/PALI to PP1M in the Veterans Health Administration.

Stable patients with schizophrenia switched to paliperidone palmitate 3-monthly formulation in a naturalistic setting: impact of patient age and disease duration on outcomes

BACKGROUND

Paliperidone palmitate 3-monthly (PP3M) is a second-generation, long-acting injectable antipsychotic formulation indicated for the maintenance treatment of adults with schizophrenia first stabilized with paliperidone palmitate 1-monthly (PP1M). This exploratory post hoc subgroup analysis of the 52-week, phase 3b REMISSIO study analysed outcomes according to patient age and disease duration in a naturalistic clinical setting.

METHODS

Outcomes of patients with schizophrenia were analysed according to age [<35 years (n = 123) versus ⩾35 years (n = 182)] and disease duration [⩽3 years (n = 72) versus >3 years (n = 233)]. The primary efficacy outcome was the proportion of patients achieving symptomatic remission according to the Andreasen criteria. Adverse events were monitored throughout the study.

RESULTS

At endpoint (last observation carried forward), 60.7% (95% CI: 51.4%, 69.4%) of younger patients and 54.1% of older patients (95% CI: 46.6%, 61.6%) achieved symptomatic remission. The proportions for patients with disease duration ⩽3 years and >3 years were similar: 57.8% (45.4%, 69.4%) versus 56.5% (49.8%, 62.9%). Functional remission was reached by 45.4% (36.2%, 54.8%) of patients aged <35 years and 36% (28.9%, 43.6%) of patients aged ⩾35 years with a similar pattern when analysed by disease duration. PP3M had a favourable safety profile and was generally well tolerated in both age groups.

CONCLUSION

Patients with schizophrenia, previously stabilized on PP1M, may benefit from PP3M treatment with some additional potential improvements if started early in the disease course.

CLINICAL TRIALSGOV

NCT02713282.

Oral Antipsychotic Versus Long-Acting Injections Antipsychotic in Schizophrenia Spectrum Disorder: a Mirror Analysis in a Real-World Clinical Setting

Despite mixed results found in literature, long-acting injectable antipsychotics (LAIs) should offer better efficacy and tolerability, compared to oral antipsychotics due to improved adherence and more stable pharmacokinetics. From this perspective, authors evaluated 153 patients, diagnosed with Schizophrenia Spectrum Disorder and residing in the province of Varese (Italy), in order to compare oral antipsychotics' and LAIs' efficacy in terms of accesses to emergency room, number and length of hospitalizations. Data analysis showed a substantial reduction in all considered variables after the introduction of long-acting therapy, especially for those who received LAI treatment from disease's onset. Authors emphasised the use of long-acting antipsychotic as first-line treatment in the early stage of disease, since available data seem to confirm the hypothesis of a better prognosis for patients who received antipsychotic depot from illness's onset.

Clinical relevance of paliperidone palmitate 3-monthly in treating schizophrenia

Antipsychotics are the mainstay in schizophrenia management, and long-acting injectable (LAI) antipsychotics contribute to the successful maintenance of treatment by improving non-adherence and preventing relapses. Paliperidone palmitate 3-monthly (PP3M) formulation is the only available LAI antipsychotic that offers an extended 3-month window of stable plasma drug concentration, enabling only four injections per year. This paper summarizes clinically relevant endpoints from available evidence for PP3M to bridge translational research gaps and provide measurable outcomes that can be interpreted in clinical practice. Low number-needed-to-treat (NNT) for relapse prevention (NNT [95% CI] 6-month estimate: 4.8 [3.2; 10.0]; 12-month estimate: 3.4 [2.2; 7.0]), and high number-needed-to-harm (NNH [95% CI] akathisia, 27.1 [12.3; -667.1]; tremor, 80.0 [22.5; 67.3]; dyskinesia, -132.6 [44.5; -23.2]; parkinsonism, 160.0 [28.9; -49.8]) quantify the relative benefits and low propensity for adverse events with PP3M. Symptom remission and reductions in positive and negative symptoms indicate treatment stability. Additionally, meaningful functional remission, reduced dosing frequency, and freedom from daily negotiations favorably impact patient preference and attenuate burdensome aspects of caregiving, representing important healthcare determinants that enhance prospects of treatment continuity in schizophrenia. This information can potentially improve clinicians' judgment of treatment choices, clinical response, and patient selection in routine care. Taken together, PP3M is a valuable antipsychotic treatment option, meriting consideration for a broader role in the long-term management of schizophrenia; its utility should not be limited to patients with poor adherence or when oral antipsychotics have failed.

Real-life assessment of aripiprazole monthly (Abilify Maintena) in schizophrenia: a Canadian naturalistic non-interventional prospective cohort study

BACKGROUND

With previously established efficacy of aripiprazole once-monthly injectable formulation (AOM) in pre-registration randomized controlled trials, the current study was designed to evaluate its effectiveness in patients treated for schizophrenia in regular clinical settings in Canada.

METHODS

Following their clinicians' decision to prescribe AOM, 193 patients with a diagnosis of schizophrenia, were recruited from 17 Canadian community or hospital-based settings. The primary outcome of global functioning was assessed with the Global Assessment of Functioning Scale (GAF) at 3-month intervals for 1 year. Secondary outcomes (social and occupational functioning and illness severity) and adverse drug reactions (ADR) were also assessed.

RESULTS

A majority of the 169 evaluable patients were within the first 5 years of diagnosis (early phase). A linear mixed model analysis showed a significant main effect of time (Type III test p < 0.001) after adjusting for baseline GAF score, with a change in mean GAF scores from 49 at baseline to 61 at 12 months. No differences between early vs late phase were observed. Results on secondary outcome measures of function (Social and Occupational Functioning Scale) and illness severity (Clinical Global Impression-Severity Scale and Brief Psychiatric Rating Scale) were similar. Serious ADRs were observed in 29 (14.6%) patients and akathisia in 18 (9.1%) patients. At month-12, significant (≥7%) weight gain was observed in 25.7% (n = 27/105) of patients.

CONCLUSIONS

Treatment with AOM is effective in improving symptoms and functioning in schizophrenia patients treated in regular clinical settings. Akathisia was infrequent while one quarter of patients gained clinically significant weight.

TRIAL REGISTRATION

Unique identifier: NCT02131415 . First posted: 06 May 2014.

The modern perspective for long-acting injectables antipsychotics in the patient-centered care of schizophrenia

Schizophrenia is a chronic syndrome involving different clinical dimensions, and causes significant disability with a negative impact on the quality of life of patients and their caregivers. Current guidelines for the treatment of schizophrenia focus on maximizing a patient's adaptive functioning and quality of life in a recovery-oriented approach that encourages active collaboration among patients, caregivers, and mental health professionals to design and manage a customized and comprehensive care plan. In the present study, a panel of experts (psychiatrists, psychologists, nurse, and social worker) gathered to review and explore the need for contemporary use of second-generation antipsychotic long-acting injectables (SGA LAIs) in "recovery-oriented" and "patient-centered" care of schizophrenia. Starting from the available data and from sharing personal attitudes and experiences, the panel selected three clinical dimensions considered useful in characterizing each patient: phase of disease, adherence to treatment, and level of functioning. For each clinical dimension, perspectives of patients and caregivers with regard to needs, expectations, and personal experiences were reviewed and the role of SGA LAIs in achieving shared goals examined. The experts concluded that from today's modern perspectives, SGA-LAIs may play an important role in breaking the spiral of desocialization and functional decline in schizophrenia, thus favoring the recovery process.

Effectiveness of financial incentives for long-acting injectable antipsychotic adherence in patients with psychotic and bipolar disorders: a systematic review protocol

REVIEW QUESTION

The question of this review is: what is the effectiveness of financial compensation for receiving a dose of long-acting injectable antipsychotic medication on the rate of medication adherence in adult patients with psychotic and bipolar disorders in an outpatient/community setting?

Effectiveness of 1-year treatment with long-acting formulation of aripiprazole, haloperidol, or paliperidone in patients with schizophrenia: retrospective study in a real-world clinical setting

BACKGROUND

Schizophrenia is a chronic mental illness that requires lifelong antipsychotic treatment. Therapy discontinuation, often due to poor adherence, increases the risk of relapses after both first and subsequent psychotic episodes. Long-acting injectable (LAI) antipsychotic drugs (APDs) have been introduced to increase therapeutic adherence, reducing blood-level variability compared to corresponding oral preparations.

PURPOSE

To compare the effectiveness of three LAI-APDs: aripiprazole (Apr) prolonged release once monthly (OM) haloperidol decanoate (Hal-D) and paliperidone palmitate (PP-OM).

METHODS

We retrospectively collected data for all patients with schizophrenia or other psychoses (n=217) treated with the three LAI-APDs for the first time from January 1, 2012 to October 31, 2016: n=48 with Apr-OM, n=55 with Hal-D, and n=114 with PP-OM. After 6 and 12 months of LAI treatments, we assessed clinical and functioning improvement, urgent consultations, psychiatric hospitalizations, adverse effects, and dropout. We compared urgent consultations and psychiatric hospitalizations required by the same patient 6 and 12 months before and after LAI implementation. Data were statistically analyzed.

RESULTS

The three LAI groups differed significantly only for "need for economic support from social service" (more frequent in the Hal-D group) and "schizoaffective disorder" (prevalent in the Apr-OM group). Apr-OM was prescribed at the maximum dose required by the official guidelines, whereas the other two LAIs were prescribed at lower doses. After 6 and 12 months' treatment with the three LAI-APDs, we registered similar and significant reductions in both urgent consultations and psychiatric hospitalizations (P<0.001) and overlapping clinical and functioning improvement-scale scores (P<0.001), and 14.28% of patients dropped out, with no difference among the three LAI-APDs. Different kinds of adverse effects, though similar for number and severity, were reported in the three LAI groups.

CONCLUSION

Our results suggest that both first- and second-generation LAI-APDs represent important therapeutic options, useful for improving schizophrenia's clinical course and its economic burden. Our study, which offers a wide and comprehensive observation of real-world clinical settings, combined an effectiveness evaluation through mirror analysis performed for each individual patient to a subsequent comparison among the three LAI-APDs, allowing us a more complete evaluation of clinical efficacy.

Heterogeneity of Treatment Effects of Long-Acting Injectable Antipsychotic Medications

OBJECTIVE

To investigate subgroup responses to long-acting injectable (LAI) medications haloperidol decanoate (HD) and paliperidone palmitate (PP) in a randomized controlled trial that found no difference between the treatments on the primary outcome of efficacy failure.

METHODS

A Comparison of Long-Acting Injectable Medications for Schizophrenia (ACLAIMS) enrolled 311 participants from March 2011 to July 2013 meeting DSM-IV-TR criteria for diagnoses of schizophrenia or schizoaffective disorder at risk of relapse due to medication nonadherence or substance abuse. Participants were randomly assigned to double-blinded treatment with HD or PP and followed for up to 2 years. A committee blinded to treatment assignment adjudicated efficacy failure on the basis of participants' meeting at least 1 of these criteria: psychiatric hospitalization, crisis stabilization, increased outpatient visits, could not discontinue oral antipsychotic, discontinued assigned LAI due to inadequate therapeutic benefit, or ongoing or repeated need for adjunctive oral antipsychotic medication. Survival analyses examined modification of treatment effects on efficacy failure by age, sex, race, substance abuse, baseline symptom severity, and baseline adherence. Mixed-effect linear models and analysis of covariance examined this modification on safety outcomes.

RESULTS

An interaction between age and treatment (P = .009) revealed younger participants assigned HD had longer time to efficacy failure than those assigned PP. Interactions were not significant between treatment group and sex, race, substance use disorder, baseline symptom severity, or baseline adherence. An interaction of treatment and age on akathisia (P = .047) found an advantage for PP that was larger among younger persons. An advantage for HD on serum prolactin levels was larger among younger women (P = .033).

CONCLUSIONS

Among younger persons, HD was associated with lower rates of efficacy failure than PP. Age effects on adverse effects were mixed. Age-related heterogeneity of antipsychotic treatment effects warrants further investigation and consideration in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01136772.

Understanding healthcare burden and treatment patterns among young adults with schizophrenia

BACKGROUND

Schizophrenia is a serious public health problem that affects ∼1% of the US population.

AIMS

To examine treatment patterns and evaluate healthcare resource utilization (HRU) and costs among young adults (18-35 years) with schizophrenia who were early in the disease.

MATERIALS AND METHODS

Patients aged 18-64 years with ≥2 schizophrenia diagnoses in the identification period (January 1, 2012-September 30, 2015) and continuous enrollment for ≥12 months pre- and post-index date were identified from the OptumInsight Clinformatics DataMart. Demographics, clinical characteristics, HRU, costs, and treatment patterns were compared between schizophrenia and non-schizophrenia "controls" cohorts and between young (18-35 years) and older adults (36-64 years) with schizophrenia.

RESULTS

Among 9,889 schizophrenia patients, 23.70% were young adults (aged 18-35), had higher all-cause per-patient-per-year (PPPY) costs ($22,338 vs $7,332; p < .0001), higher inpatient costs ($8,857 vs $1,289; p < .0001), and longer inpatient length-of-stay (LOS) (5.0 vs 0.4 days, p < .0001; adjusted incidence rate ratio [aIRR] = 12.8; 95% confidence interval [CI] = 11.5-14.3) than controls. Among young adults with schizophrenia, there were more mental-health-related and fewer non-mental-health-related diagnoses compared to older adults with schizophrenia; 63.40% were male. Young adults with schizophrenia incurred higher inpatient costs ($15,692 vs $10,274; p < .0001) and longer inpatient LOS (9.6 vs 5.9 days, p < .0001; aIRR = 1.6; 95% CI = 1.4-1.8) compared to older adults with schizophrenia. A substantial proportion of patients were treated with oral antipsychotics vs long-acting injectables in both cohorts (young adults: 98.72% vs 9.71%; older adults: 98.10% vs 13.31%).

LIMITATIONS

Claims data are collected for payment and not research. The presence of a prescription claim does not indicate medication was consumed or taken as prescribed.

CONCLUSIONS

The economic burden for schizophrenia patients is substantial, especially among young adults. Based on this analysis, further research is warranted to better understand the association between adherent treatment patterns earlier in the disease and long-term health outcomes among patients with schizophrenia.

Medication Adherence and Discontinuation of Aripiprazole Once-Monthly 400 mg (AOM 400) Versus Oral Antipsychotics in Patients with Schizophrenia or Bipolar I Disorder: A Real-World Study Using US Claims Data

Introduction

Few studies have compared adherence between long-acting injectable antipsychotics, especially for newer agents like aripiprazole once-monthly 400 mg (AOM 400; aripiprazole monohydrate) and oral antipsychotics, in patients with schizophrenia or bipolar I disorder (BD-I) in a real-world setting.

Methods

Two separate retrospective cohort analyses using Truven MarketScan data from January 1, 2012 to June 30, 2016 were conducted to compare medication adherence and discontinuation in patients with schizophrenia or BD-I who initiated treatment with AOM 400 vs. patients changed from one oral antipsychotic monotherapy to another. Adherence was defined as proportion of days covered (PDC) ≥ 0.80 in the year following the index date. Linear regression models examined the association between AOM 400 and oral antipsychotic cohorts and medication adherence. Kaplan–Meier curves and Cox regression estimated time to and risk of discontinuation, while adjusting for baseline covariates. A sensitivity analysis was conducted using a combination of propensity score matching and exact matching to create matched cohorts.

Results

Final cohort sizes were as follows—Schizophrenia: AOM 400 n = 408, oral antipsychotic n = 3361; BD-I: AOM 400 n = 413, oral antipsychotic n = 15,534. In patients with schizophrenia, adjusted mean PDC was higher in patients in the AOM 400 cohort vs. the oral antipsychotic cohort (0.57 vs. 0.48 P < 0.001), and patients in the oral antipsychotic cohort had a higher risk of discontinuing treatment vs. the AOM 400 cohort (HR 1.45, 95% CI 1.29–1.64). For patients with BD-I, adjusted mean PDC was higher for the AOM 400 cohort (0.59 vs. 0.44, P < 0.001), and patients in the oral antipsychotic cohort had a higher risk of discontinuation (HR 1.71, 95% CI 1.53–1.92).

Conclusions

In a real-word setting, AOM 400 resulted in a significantly higher percentage of patients with a PDC ≥ 0.80 and significantly longer time to treatment discontinuation compared to patients with schizophrenia or BD-I who received treatment with an oral antipsychotic.

Funding

Otsuka Pharmaceutical Development and Commercialization, Inc. and Lundbeck.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0785-y) contains supplementary material, which is available to authorized users.

Medication adherence and discontinuation of long-acting injectable versus oral antipsychotics in patients with schizophrenia or bipolar disorder

AIMS

To examine medication adherence and discontinuation in two separate groups of patients with schizophrenia or bipolar disorder (BD), who began receiving a long-acting injectable antipsychotic (LAI) versus those who changed to a different oral antipsychotic monotherapy.

MATERIALS AND METHODS

The Truven Health Analytics MarketScan Multi-State Medicaid claims database was used to identify patients with schizophrenia; Truven Health Analytics MarketScan Commercial and Medicaid claims databases were used to identify patients with BD. The analyses included adult patients (≥18 years) who either began receiving an LAI (no prior LAI therapy) or changed to a different oral antipsychotic (monotherapy). The first day of initiating an LAI or changing to a new oral antipsychotic was the index date. Linear and Cox regression models were conducted to estimate medication adherence (proportion of days covered [PDC]) and time to medication discontinuation (continuous medication gap ≥60 days), respectively. Models adjusted for patient demographic and clinical characteristics, baseline medication use, and baseline ED or hospitalizations.

RESULTS

Patients with schizophrenia (N = 5638) who began receiving LAIs had better medication adherence (5% higher adjusted mean adherence) during the 1 year post-index period and were 20% less likely to discontinue their medication during the entire follow-up period than patients who changed to a different oral antipsychotic monotherapy, adjusting for differences between LAI users and oral users. Similarly, patients with BD (N = 11,344) who began receiving LAIs also had 5% better medication adherence and were 19% less likely to discontinue their medication than those using oral antipsychotics.

LIMITATIONS

Clinical differences unmeasurable in this database may have been responsible for the choice of LAI versus oral antipsychotics, and these differences may be responsible for some of the adherence advantages observed.

CONCLUSIONS

This real-world study suggests that patients with schizophrenia or BD who began receiving LAIs had better medication adherence and lower discontinuation risk than those who changed to a different oral antipsychotic monotherapy.

Role of 3-monthly long-acting injectable paliperidone in the maintenance of schizophrenia

AIMS

Paliperidone palmitate 3-month (PP3M) represents a new long-acting injectable antipsychotic therapeutic option. This review aims: 1) to summarize available data relating to efficacy, safety, tolerability and costs of PP3M; 2) to describe hospitalization rate, occupational status, treatment preference, satisfaction, adherence and caregiver burden of patients with schizophrenia who participate in PP3M clinical trials; 3) to examine ethical implications, pros and cons of PP3M use and 4) to propose study designs to further assess PP3M.

METHODS

On August 21, 2017, a search on PubMed about PPM3, without any filter restriction, was conducted and all available records were analyzed. Records written in a language other than English were excluded.

RESULTS

Twenty-two records were included in this review: 6 reviews, 1 report, 4 pharmacokinetic studies, 2 cost-effectiveness analyses, 1 open-label clinical trial, 2 randomized controlled trials (RCTs), 5 studies based on these 2 RCTs and 1 observational study.

DISCUSSION

According to these last 9 studies, when compared with placebo, PP3M showed a longer time to relapse and good safety and tolerability profiles. Furthermore, when compared with paliperidone palmitate 1 month (PP1M), PP3M treatment showed: 1) non-inferiority in terms of efficacy, safety, tolerability, rate of hospitalization, symptomatic and functional remission, treatment preference and variations of the occupational status; 2) a longer time to relapse after treatment discontinuation and 3) a similar reduction of the caregiver burden.

CONCLUSION

PP3M is the only 3-monthly long-acting injectable antipsychotic available on the market. This makes it a unique option of treatment, which could be chosen both in early and advanced phases of illness. Nonetheless, longer naturalistic follow-up studies, two-arm head-to-head superiority trials and mirror studies, based on real-world samples of patients, are needed to further assess long-term safety and advantages of this new option of treatment and to define patients' sub-populations that would most beneficiate from it.