Long-Acting Injectable Atypical Antipsychotic Use in Adolescents: An Observational Study

Safety and Efficacy of Paliperidone Palmitate in Pediatric Patients with Autism and Intellectual Disability

This retrospective chart review examines the safety, tolerability and effectiveness of long acting injectable paliperidone palmitate (P-LAI) targeting irritability in twenty-six youth and transition-aged individuals with autism spectrum disorder (ASD) and/or intellectual disability (ID) over a 3-year window. Clinical response was evaluated via prospectively assigned Clinical Global Impressions Severity (CGI-S) and Improvement (CGI-I) scales as well as number of hospital presentations. P-LAI was well tolerated with only 3 patients stopping P-LAI due to side effects. The average duration of P-LAI treatment was 21.1 months. Difficulty with medication compliance was the most common reason for initiating P-LAI. There was a statistically significant improvement in CGI-I, CGI-S and hospital visits and no change in BMI noted. Given the potential difficulty of medication administration in this population, this evidence of safety, tolerability as well as preliminary data supporting effectiveness is an important addition to the literature regarding psychopharmacologic management of irritability in youth with ASD and ID.

Initiation of Aripiprazole Lauroxil Long-Acting Injectable in Adolescents During Hospitalization: A Case Series

Objective: The efficacy and safety of long-acting injectable (LAI) antipsychotics in the pediatric population is not well established due to limited evidence. This case series aims to describe off-label use of aripiprazole lauroxil (AL) LAI in adolescent inpatients, including findings on safety and readmission trends. Methods: This was a retrospective chart review of patients who were initiated on AL LAI while admitted at a county-based adolescent psychiatric unit between March 2021 and March 2023. Data comprised sociodemographic and clinical characteristics, such as psychiatric diagnoses, prior antipsychotic trials, and history of nonadherence. Other observations of interest included tolerability of AL LAI and time to readmission. Results: This analysis identified 12 adolescents who received AL LAI within a 2-year period. The mean age was 16 ± 1 years, and seven (58%) patients were female. There were varying primary psychiatric diagnoses, with the most common being bipolar disorder (25%), schizophrenia (17%), major depressive disorder with psychotic features (17%), and unspecified mood disorder (17%). Eleven (92%) patients had previously trialed at least one antipsychotic, with seven (58%) having exposure to oral aripiprazole before admission. Nonadherence was the driving factor for LAI consideration in all but one patient. AL LAI was well tolerated short term; one patient reported experiencing injection site pain, and one patient discontinued the LAI after discharge due to anxiety. Time to readmission ranged from 15 to 658 days for seven patients who were hospitalized again; two of the readmissions occurred within 1 month. Conclusion: This is the first case series to describe initiation of AL LAI at an inpatient adolescent psychiatric unit. Our study illustrates that AL LAI may hold potential as an acceptably tolerated treatment in adolescents with varying psychiatric diagnoses. Further studies are needed to evaluate long-term safety and effectiveness of AL LAI in youth.

What Role for Long-Acting Injectable Antipsychotics in Managing Schizophrenia Spectrum Disorders in Children and Adolescents? A Systematic Review

BACKGROUND

Long-acting injectable antipsychotics (LAIAs) are an efficacious and well-tolerated treatment in adults with schizophrenia spectrum disorders (SSD). However, there is less evidence for their use in children and adolescents.

OBJECTIVES

The aim of this systematic review was to summarize findings regarding the effectiveness and side effects of LAIA in children and adolescents with SSD.

METHODS

Four databases (Web of Science, PubMed, MEDES, and Dialnet) were systematically searched for articles published between inception and 12 March, 2022, with the following inclusion criteria: (1) original articles or case reports; (2) providing data on efficacy/effectiveness or safety/tolerability of LAIA treatment in children and adolescents diagnosed with SSD (schizophrenia, schizoaffective disorder, schizophreniform disorder, non-affective psychotic disorder); (3) mean age of samples ≤ 18 years; and (4) written in English or Spanish. Exclusion criteria were review articles, clinical guides, expert consensus as well as posters or oral communication in conferences. The risk of bias was assessed using the ROBIS tool.

RESULTS

From 847 articles found, 13 met the inclusion criteria. These included seven single case reports or case series, four retrospective chart reviews, a 24-week open-label trial, and one observational prospective study, covering a total of 119 adolescents (aged 12-17 years) with SSD. Almost all the articles described data on second-generation LAIA (53 patients on risperidone [once every other week], 33 on paliperidone palmitate [once monthly], 10 on aripiprazole [once monthly], and two on olanzapine pamoate [once monthly]). Twenty-one patients were reported to be only on first-generation LAIAs. Non-adherence was the main reason for starting an LAIA. In all of the studies, the use of LAIAs was associated with improvement in the patients' symptoms.

CONCLUSIONS

There are few studies assessing the use of LAIAs in adolescents with SSD. Overall, these treatments have suggested good effectiveness and acceptable safety and tolerability. However, we found no studies examining their use in children aged < 12 years. The problems and benefits linked to this type of antipsychotic formulation in the child and adolescent population require further study, ideally with prospective, controlled designs.

Efficacy, Tolerability, and Acceptance of Long-Lasting Antipsychotics in Children and Adolescents: A Systematic Review

Objectives: While long-lasting antipsychotics (LLA) were specifically developed to address the problem of adherence in patients with chronic psychiatric disorders, their role in pediatric populations is not clear. Methods: To document the efficacy, tolerance, and acceptance of LLAs in children and adolescents, a literature search was conducted using several databases for published studies (PubMed, PsycINFO) from January 1965 to December 2020. Twenty-two studies were identified (16 case reports/series, 3 open label studies, 2 controlled studies, and 1 retrospective analysis of national database). Results: Demographic features were widely heterogeneous across studies (total N = 480, 58% male, mean age = 15.0 ± 1.8). Case reports/series presented positive therapeutic outcomes in noncompliant youths with severe mental illness. Three open-label one-arm studies supported the clinical efficacy of risperidone long-acting injection in patients previously stabilized with oral risperidone. One study showed lower clinical symptoms and higher functioning at 12 months in youths treated for an acute psychotic episode with paliperidone palmitate compared to oral risperidone. The types and rates of side effects of LLA were comparable to those observed for oral antipsychotics. Two studies suggested better metabolic and neurological tolerance of LLA compared to an oral form. Preliminary evidence supported a satisfactory level of treatment satisfaction in patients treated with LLA and their families, while concerns were raised regarding practical administration in outpatient services. However, the average quality of the evidence based on the RoB2 tool was low. Conclusions: The level of evidence was low for the efficacy of LLA in pediatric populations and very low for the tolerance and acceptance. It concerned mostly the effect of risperidone long-acting injection in adolescents with psychotic disorders. Randomized maintenance clinical trials using noninferiority analysis would be more appropriate for further research.

Aripiprazole LAI two-injection start in a 16 year-old adolescent with schizophrenia

Background

Aripiprazole long‐acting injection (LAI) is approved for the treatment of schizophrenia in adults. Recently, Europe and Canada approved the use of the two‐injection start regimen: two separate injections of 400‐mg long‐acting aripiprazole along with a single 20‐mg dose of oral aripiprazole. Aripiprazole showed efficacy in the treatment of adolescents with acute schizophrenia in several controlled trials, leading to its approval for 13‐ to 17‐year‐old adolescents with schizophrenia by the EMA. However, the LAI formulation still remains off‐label in adolescents.

Case presentation

The patient was admitted to the General Psychiatry inpatient unit with a Positive and Negative Syndrome Scale (PANSS) total score of 136 and the Clinical Global Impression (CGI) score of 7. Aripiprazole was started and up‐titrated to 30 mg/d. After 3 weeks, the positive symptoms were significantly reduced; however, he still showed prominent negative symptoms. Clozapine 100 mg/d was added, and in the following 2 weeks, the patient appeared slightly more communicative and generally more aware of himself and the others. The PANSS total score decreased to 81. Due to poor insight, the patient was at‐risk not to take medications upon returning home; therefore, aripiprazole LAI was proposed. Since he urged to be discharged from the hospital, we opted for the two‐injection start. The medication was optimally tolerated, with no evidence of akathisia or other side effects. One month later, global functioning and illness insight improved; Positive and Negative Syndrome Scale score was 43 and CGI score 2.

Conclusions

Aripiprazole LAI showed good efficacy and tolerability in an adolescent with schizophrenia. The two‐injection start regimen was a safe and effective option.

Although adherence to treatment is an issue in adolescents with schizophrenia, long‐acting injection (LAI) antipsychotics are not approved for use in this patient population. The article reports a case of a 16‐year‐old adolescent with schizophrenia treated with LAI aripiprazole two‐injection start regimen. The treatment was effective and well tolerated.

Decades of Progress in the Psychopharmacology of Autism Spectrum Disorder

Recent decades have been marked by a wave drug treatment research in autism spectrum disorder (ASD). This work has resulted in improved ability to treat commonly occurring behavioral challenges associated with ASD including most prominently irritability marked by aggression, self-injurious behavior, and severe tantrums. While treatment of interfering behavior has progressed in our field, there remain several areas of unmet medical need including most prominently a lack of any approved drug therapies for the core, defining symptoms of autism. We outline the progress to date in the field of autism drug treatment while taking a future look forward into how decades of work can inform better future steps in this field.

The use of first-generation long-acting injectable antipsychotics in children and adolescents-A retrospective audit from India

OBJECTIVES

There is a dearth of knowledge regarding the usage of first-generation long-acting injectable (LAI) antipsychotics in children and adolescents, despite their off-label use, in low and middle-income countries (LAMIC).

METHODS

Case records of subjects less than 18 years of age who received any first-generation LAI antipsychotics in the last 10 years(between 2010-19) were reviewed. Details documented for the study from the records included ICD-10 diagnoses, clinical profile, indication for use, medication details, severity of illness, improvement, and global functioning.

RESULTS

Forty-five subjects (55.3 % male) received first-generation LAI antipsychotics during the study period. All subjects were diagnosed to have serious mental illnesses, with Schizophrenia (52.6 %) and Bipolar Affective Disorder (31.6 %) being the most common diagnoses. At baseline, according to Clinical Global Impressions-Severity (CGI-S) scale, a majority (94.7 %) were severely or markedly ill. Fluphenazine decanoate (60.5 %), flupenthixol decanoate (34.2 %), and zuclopenthixol decanoate (18.4 %) were the first- generation LAI antipsychotics used. Nearly half the subjects (47.4 %) experienced at least one acute adverse event. The most common acute adverse events noted included tremors, rigidity, sialorrhea, and bradykinesia. 31/34 subjects showed improvement at follow-up.

CONCLUSIONS

The profile of patients for whom first-generation LAI antipsychotics were used included children and adolescents who had severe mental illnesses and were considerably ill. Acute adverse events were common. Short and- long-term follow-up studies are needed to evaluate the efficacy and safety of first-generation LAI antipsychotics in children and adolescents, especially in low and middle-income countries, given that they are reasonably priced and efficacious for severe mental illnesses.

Current and emerging long-acting antipsychotics for the treatment of schizophrenia

Introduction: In this review, the authors discuss the role of long-acting injectable antipsychotics (LAIs) for schizophrenia, focusing on the effectiveness and new perspectives introduced by such treatment strategy. Despite their promising pharmacokinetic features and their potential advantages in medication adherence, clinical outcomes, and medical costs, LAIs are not habitually presented as an option for patients, especially in the early phase of schizophrenia.Areas covered: This review explores the panorama of available LAIs for the treatment of schizophrenia, first-episode of psychosis, approved indications, medical costs, medication adherence, side effects, effectiveness and differences between first-generation (FGA)-LAIs and second-generation (SGA)-LAIs.Expert Opinion: LAIs differ in terms of specific indications, approved injection sites, needle size, injection volume, injection interval as well as potential drug-drug interactions, and commonly reported adverse reactions. The approved indications have expanded beyond schizophrenia to include bipolar and schizoaffective disorder. SGA-LAIs are often preferred to FGA-LAIs. FGA-LAIs although are less chosen in new patients due to the induction of cognitive and extrapyramidal side effects, even if, on the other hand, many SGA-LAIs are burden by hyperprolactinemia and weight gain. After a review of the available evidence, insight is provided into the potential and current therapeutic opportunities offered by LAI antipsychotic formulations.

What is autism?

The term "Autism spectrum disorder" (ASD), in vogue at present, has evolved after continual substantial developments taking place over more than a century. ASD is a heterogeneous, multi-factorial, developmental disability in which an unusual pattern of development takes place during infant and toddler years. As per DSM-5, Autism spectrum disorder is a combined phrase for a family of complex developmental disabilities inclusive of "Autistic Disorder, Pervasive Developmental Disorder not Otherwise Specified (PDD-NOS), and Asperger's Disorder". "ASD is characterized not only by persistent impairments in reciprocal social communication and social interactions, but is also manifested by restricted, repetitive patterns of behavior, interests, or activities". The classical clinical signs that exist in two major domains, viz. the 'social domain' and the 'behavioral domain' for the precise diagnosis of ASD have been tabulated and major differences between DSM-5 and DSM-4 are depicted with the help of a figure in this basic review article. A sharp rise in the incidence of ASD cases has been observed worldwide owing to various risk factors such as genetic predisposition coupled with adverse environmental conditions, gynecological interventions, etc. Two official manuals viz. the "Diagnostic and Statistical Manual of Mental Disorders" (DSM) (published by the American Psychiatric Association), and the "International Classification of Diseases" (ICD) (published by the World Health Organization) is being regularly updated to facilitate diagnosis of ASD. ICD-11 guidelines being prospectively implemented with effect from January 2022 have attracted global attention.

Recent Advances in the Pharmacological Management of Behavioral Disturbances Associated with Autism Spectrum Disorder in Children and Adolescents

Autism spectrum disorder (ASD) is a heterogeneous neuropsychiatric condition affecting an estimated one in 36 children. Youth with ASD may have severe behavioral disturbances including irritability, aggression, and hyperactivity. Currently, there are only two medications (risperidone and aripiprazole) approved by the US Food and Drug Administration (FDA) for the treatment of irritability associated with ASD. Pharmacologic treatments are commonly used to target ASD-associated symptoms including irritability, mood lability, anxiety, and hyperactivity. However, evidence for the efficacy of many commonly used treatments is limited by the lack of large placebo-controlled trials of these medications in this population. Research into the pathophysiology of ASD has led to new targets for pharmacologic therapy including the neuroimmune system, the endocannabinoid system, and the glutamatergic neurotransmitter system. The goal of this review is to provide an overview of the current evidence base for commonly used treatments, as well as emerging treatment options for common behavioral disturbances seen in youth with ASD.

Long-acting antipsychotic medication as first-line treatment of first-episode psychosis with comorbid substance use disorder

AIM

Substance use disorder (SUD) is highly prevalent among patients with first-episode psychosis (FEP) and associated with poor adherence and worst treatment outcomes. Although relapses are frequent in FEP, current literature on long-acting injectable antipsychotics (LAI-AP) use in FEP is scarce and studies often exclude patients with SUD.

OBJECTIVES

To determine the impact of LAI-AP as first-line treatment on psychotic relapses or rehospitalizations in FEP patients with comorbid SUD (FEP-SUD).

METHODS

This is a naturalistic, longitudinal, 3-year prospective and retrospective study on 237 FEP-SUD admitted in two EIS in Montreal, between 2005 and 2012. The patients were divided on the basis of first-line medication introduced, either oral antipsychotics (OAP, n = 206) or LAI-AP (n = 31). Baseline characteristics were compared using χ² test and analysis of variance, and Kaplan-Meier survival analysis was performed on relapse and rehospitalization.

RESULTS

Compared to the OAP group, patients in the LAI-AP group presented worse prognostic factors (eg, history of homelessness). Despite this, the LAI-AP group presented a lower relapse rate (67.7% vs 76.7%), higher relapse-free survival time (694 vs 447 days, P = 0.008 in Kaplan-Meier analysis), and trends for reduced rehospitalization rates (48.4% vs 57.3%) and hospitalization-free survival time (813 vs 619 days, P = 0.065 Kaplan-Meier analysis). Of those receiving OAP as first-line, 41.3% were eventually switched to LAI-AP and displayed worst outcome in relapse and rehospitalization.

CONCLUSION

LAI-AP should be strongly considered as first-line treatment of FEP-SUD patients since this pharmacological option reduces the risk of relapse and rehospitalization even in the individuals with poor prognostic factors.

Long-Acting Injectable Antipsychotic Medications: Why Aren't They Used as Often as Oral Formulations?

Long-acting injectable (LAI) antipsychotic medications have been around since the 1960s as alternatives to oral formulations to improve medication adherence. LAIs are similar enough to their corresponding oral formulations to be used interchangeably and have convincing evidence of improving consistency in pharmacotherapy that reduces the rates of relapse and frequency of hospitalization for individuals with psychosis. So why are they not used as often? The current article presents an argument to initiate LAIs early in treatment as a way of establishing consistency in treatment, thereby, potentially improving client outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 57(3), 7-10.].

Retrospective Analysis of the Effectiveness and Tolerability of Long-Acting Paliperidone Palmitate Antipsychotic in Adolescent First-Episode Schizophrenia Patients

OBJECTIVE

The aim of this study was to explore the effectiveness and tolerability of long-acting paliperidone palmitate antipsychotic in adolescent first-episode schizophrenia patients while comparing the results with the oral antipsychotic risperidone.

METHODS

This study is a retrospective, noninterventional study to assess the effectiveness and tolerability of long-acting injectable antipsychotic paliperidone palmitate in first-episode adolescent patients during the first 12 months of treatment compared with the oral antipsychotic risperidone. The data include general sociodemographic characteristics, number of hospitalizations, side effects, and the following clinical scales: Positive and Negative Syndrome Scale (PANSS), Personal and Social Performance Scale (PSP), Clinical Global Impression Improvement and Severity (CGI-I and CGI-S), and Treatment Satisfaction Questionnaire for Medication (TSQM).

RESULTS

During the 12-month study period significant improvement was registered in patients receiving both paliperidone palmitate and risperidone in the following scales: PANSS, PSP, CGI-I, and CGI-S. Patients receiving paliperidone palmitate had significantly greater improvement in PANSS, CGI-S, and PSP compared with the risperidone group. Patients receiving risperidone had significantly higher number of hospitalizations than the patients receiving paliperidone palmitate. The TSQM revealed that the patients who were receiving paliperidone palmitate achieved significantly higher scores on the convenience scale, global satisfaction, and on the overall result, whereas no difference was observed on the effectiveness scale. There were several side effects reported for paliperidone (5.5% hyperprolactinemia, 5.5% weight gain) and risperidone (5.5% hyperprolactinemia, 16.7% weight gain).

CONCLUSIONS

In conclusion, paliperidone palmitate seems to be safe and effective in adolescent patients. Furthermore, it compared favorably with risperidone in the clinical response, side effects, and hospitalizations.

Aripiprazole Long-Acting Injection During First Episode Schizophrenia-An Exploratory Analysis

Background: Long-acting injectable (LAI) aripiprazole was found to be efficacious in schizophrenia. In common clinical practice, the use of LAIs is often restricted to chronic patients with frequent relapses and poor adherence. Recently, some investigators advanced the idea of early LAI use also in young people with schizophrenia at their first psychotic episode (FEP). Objective: Our study aimed to assess the effect of LAI aripiprazole once monthly (AOM) in the treatment of FEP in patients aged 18-26 years. Methods: We included 50 patients with DSM-5 schizophrenia as assessed with SCID, and used the Clinical Global Impressions Scale-Severity of Illness (CGI-S) and the Positive and Negative Syndrome Scale (PANSS) to assess symptom severity and the World Health Organization Quality of Life (WHOQOL), the Short Form Health Survey (SF-36) and the Personal and Social Performance Scale (PSP) to assess quality of life (QoL) and global health perception at baseline and 3, 6, 9, and 12 months after the first AOM injection. Results: AOM was associated with a progressive improvement, compared to baseline, of both positive (p < 0.001) and negative (p < 0.001) symptoms and in general psychopathology (p < 0.001) and decrease in global severity (p < 0.001). We also observed progressive improvement in QoL and social and personal functioning. Treatment adherence was 78% at study endpoint. Our results support that AOM may improve psychotic symptoms, QoL and social functioning in young FEP patients. Further studies should compare AOM to its oral formulation in the treatment of young patients with schizophrenia at the outset of their illness.

Pharmacological management of behavioral disturbances in children and adolescents with autism spectrum disorders

Autism spectrum disorder (ASD) is a heterogeneous neuropsychiatric condition that, based on recent CDC estimates affects an estimated 1 in 59 American children. Behavioral treatments remain the mainstay of treatment for the core symptoms of ASD including communication deficits, social interaction deficits and repetitive behavior. However, youth with ASD may also have severe behavioral challenges including irritability, aggression, and hyperactivity. Currently there are only two medications (risperidone and aripiprazole) approved by the FDA for the treatment of irritability associated with ASD in children. Psychiatric comorbidities are common in youth with ASD, affecting up to 70% of affected children and adolescents. Given the burden of co-occurring disorders, medications are often employed to target symptoms such as irritability, anxiety, and hyperactivity. Other common co-occurring conditions including gastrointestinal disorders and sleep disorders may be improved with pharmacologic management. Evidence for the efficacy of many commonly used psychotropic medications in ASD is limited by the lack of large placebo-controlled trials in youth with ASD. This paper reviews the current literature regarding use of medications to address co-occurring conditions in children and adolescents with ASD as well as areas of emerging research.