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O'Neill JR, Taylor DM, Horowitz MA. Using in silico methods to determine optimal tapering regimens for decanoate-based long-acting injectable psychosis drugs. Ther Adv Psychopharmacol 2024; 14:20451253241272790. [PMID: 39282238 PMCID: PMC11401015 DOI: 10.1177/20451253241272790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 07/15/2024] [Indexed: 09/18/2024] Open
Abstract
Background Reducing the dose of psychosis drugs in a gradual hyperbolic manner may minimise withdrawal effects and risk of relapse. There is presently limited guidance on tapering decanoate-based long-acting injectable dopamine antagonists (LIDAs). Objectives We aimed to apply hyperbolic principles of tapering to the decanoate-based LIDAs flupentixol, zuclopenthixol and haloperidol to develop withdrawal regimens. Design We used in silico methodology to predict plasma drug levels and D2 occupancy for different LIDA regimens. Methods Existing pharmacokinetic and receptor occupancy data from nuclear neuroimaging studies were used to power modelling. Abrupt discontinuation was examined as a potential strategy, and dose reduction was modelled with pre-defined constraints used in similar work of 10 (fast regimens), 5 (moderate) and 2.5 (slow) percentage points of D2 occupancy change per month. Results Abrupt discontinuation of decanoate-based LIDAs leads to excessive change in D2 occupancy which violated our pre-defined constraints, potentially resulting in withdrawal symptoms and increased risk of relapse. Reduction of LIDA dose allowed hyperbolic reduction in plasma level consistent with imposed constraints on receptor occupancy reduction rate. For equivalent per-weekly LIDA dosing, more frequent administration allowed a more gradual reduction of D2 occupancy. However, switching to oral forms is required to continue hyperbolic tapering to full discontinuation; reduction to zero using only LIDA produces too large a reduction in D2 occupancy. Guidance for reduction and cessation of LIDAs according to slow, moderate and fast criteria is provided. Conclusion Abrupt cessation of decanoate LIDAs is not consistent with gradual hyperbolic tapering, despite their longer half-lives compared with oral formulations. Reduction to the point of full discontinuation can only be achieved by switching to oral therapy to complete the taper. These results are limited by the in silico and theoretical nature of the study, and there is a need to confirm these findings through real-world observational and interventional studies.
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Affiliation(s)
- James R O'Neill
- Faculty of Medicine and Health, University of Leeds, LS2 9JT, UK
| | | | - Mark A Horowitz
- Division of Psychiatry, University College London, London, UK
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Horowitz MA, Moncrieff J. Gradually tapering off antipsychotics: lessons for practice from case studies and neurobiological principles. Curr Opin Psychiatry 2024; 37:320-330. [PMID: 38726815 PMCID: PMC11139239 DOI: 10.1097/yco.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
PURPOSE OF REVIEW There has been an increasing focus on deprescribing in psychiatry recently, particularly of antipsychotic medication, with recognition that not all patients with psychotic disorders require lifelong medication. We summarize some empirical and theoretical papers, and examine case studies to provide instruction on this topic. RECENT FINDINGS Recent studies have found that slower tapering (over months or longer) of antipsychotics is associated with a lower relapse rate than quicker tapering (weeks). Case studies presented suggest that the process of reduction is associated with the precipitation or exacerbation of psychotic symptoms and that a slower process of reduction may minimize this effect. This may be because faster reductions cause greater disruption of homeostatic equilibria, provoking psychotic symptoms either as direct withdrawal symptoms or consequences of nonpsychotic withdrawal symptoms (e.g. insomnia) - although not all patients will experience withdrawal symptoms. This suggests that smaller dose reductions, especially at lower doses, made very gradually, may minimize the risk of psychotic symptoms. SUMMARY Slower tapering of antipsychotics may provide time for adaptations made to the presence of the medications to resolve, thus reducing the disruption to homeostatic equilibrium caused by dose reduction, potentially reducing the risk of relapse. Exacerbation of psychotic symptoms on antipsychotic reduction may not represent evidence of the need for a higher dose of antipsychotic on a long-term basis but may indicate the need for more gradual reduction. Gradual reduction of antipsychotics, especially after long-term use in clinical practice is prudent.
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Affiliation(s)
- Mark A. Horowitz
- Division of Psychiatry, University College London, Maple House, Fitzrovia, London
- North East London Foundation Trust, Goodmayes Hospital, Goodmayes, Ilford, UK
| | - Joanna Moncrieff
- Division of Psychiatry, University College London, Maple House, Fitzrovia, London
- North East London Foundation Trust, Goodmayes Hospital, Goodmayes, Ilford, UK
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McCutcheon RA, Taylor D, Rubio J, Nour J, Pillinger T, Murray RM, Jauhar S. Does Slow and Steady Win the Race? Rates of Antipsychotic Discontinuation, Antipsychotic Dose, and Risk of Psychotic Relapse. Schizophr Bull 2024; 50:513-520. [PMID: 37797288 PMCID: PMC11059789 DOI: 10.1093/schbul/sbad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
BACKGROUND Antipsychotics are recommended for prevention of relapse in schizophrenia. It is unclear whether increased risk of relapse following antipsychotic discontinuation is predominantly associated with an absolute magnitude of dose reduction or rate of antipsychotic reduction. Establishing the responsible mechanism is important because prolonged withdrawal schedules have been suggested to reduce risk of relapse. STUDY DESIGN Individual patient data from antipsychotic discontinuation studies were obtained. We estimated the occupancy of receptors over time using half-lives and median effective dose ED50 values obtained from pharmacokinetic and receptor occupancy studies. Hazard ratios for relapse events were calculated using Cox proportional hazards models to assess the influence of formulation (oral, 1-monthly, and 3-monthly injections). The change in hazard ratio over time was estimated, and the effect of time-varying covariates was calculated, including rate of occupancy reduction and absolute receptor occupancy. STUDY RESULTS Five studies including 1388 participants with schizophrenia were identified (k = 2: oral, k = 2: 1-monthly injection, k = 1: 3-monthly injection). Withdrawal of long-acting injectable medication did not lead to a lower hazard ratio compared with withdrawal of oral medication, and this included the period immediately following randomization. Hazard ratios were not associated with the rate of decline of receptor occupancy; however, they were associated with reduced absolute occupancy in trials of long-acting injections (P = .038). CONCLUSIONS Antipsychotic discontinuation is associated with an increased risk of psychotic relapse, related to receptor occupancy. Although relapse does not appear to be related to the rate of discontinuation, gradual discontinuation strategies may allow for easier antipsychotic reinstatement in case of symptomatic worsening.
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Affiliation(s)
- Robert A McCutcheon
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Jose Rubio
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, NY, USA
| | - Joseph Nour
- East London NHS Foundation Trust, London, UK
| | - Toby Pillinger
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Sameer Jauhar
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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Béchard L, Desmeules C, Bachand L, Huot-Lavoie M, Corbeil O, Anderson E, Brodeur S, LeBlanc A, Demers MF, Lauzier S, Roy MA. The effects of antipsychotic discontinuation or maintenance on the process of recovery in remitted first-episode psychosis patients - A systematic review and meta-analysis of randomized controlled trials. Eur Psychiatry 2024; 67:e13. [PMID: 38250810 PMCID: PMC10897830 DOI: 10.1192/j.eurpsy.2024.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/02/2024] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND The optimal duration of antipsychotic treatment following remission of first-episode psychosis (FEP) is uncertain, considering potential adverse effects and individual variability in relapse rates. This study aimed to investigate the effect of antipsychotic discontinuation compared to continuation on recovery in remitted FEP patients. METHODS CENTRAL, MEDLINE (Ovid), Embase, and PsycINFO databases were searched on November 2, 2023, with no language restrictions. RCTs evaluating antipsychotic discontinuation in remitted FEP patients were selected. The primary outcome was personal recovery, and secondary outcomes included functional recovery, global functioning, hospital admission, symptom severity, quality of life, side effects, and employment. Risk of bias was assessed using the Cochrane risk-of-bias tool 2, and the certainty of evidence was evaluated with GRADE. Meta-analysis used a random-effect model with an inverse-variance approach. RESULTS Among 2185 screened studies, 8 RCTs (560 participants) were included. No RCTs reported personal recovery as an outcome. Two studies measured functional recovery, and discontinuation group patients were more likely to achieve functional recovery (RR 2.19; 95% CIs: 1.13, 4.22; I2 = 0%; n = 128), although evidence certainty was very low. No significant differences were found in hospital admission, symptom severity, quality of life, global functioning, or employment between the discontinuation and continuation groups. CONCLUSIONS Personal recovery was not reported in any antipsychotic discontinuation trial in remitted FEP. The observed positive effect of discontinuation on functional recovery came from an early terminated trial and an RCT followed by an uncontrolled period. These findings should be interpreted cautiously due to very low certainty of evidence.
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Affiliation(s)
- Laurent Béchard
- Faculty of Pharmacy, University Laval, Quebec, Canada
- University Institute of Mental Health of Quebec, CIUSSS-CN, Quebec, Canada
- CERVO Research Center, Quebec, Canada
| | - Charles Desmeules
- CERVO Research Center, Quebec, Canada
- Faculty of Medicine, Laval University, Quebec, Canada
| | | | - Maxime Huot-Lavoie
- CERVO Research Center, Quebec, Canada
- Faculty of Medicine, Laval University, Quebec, Canada
| | - Olivier Corbeil
- Faculty of Pharmacy, University Laval, Quebec, Canada
- University Institute of Mental Health of Quebec, CIUSSS-CN, Quebec, Canada
- CERVO Research Center, Quebec, Canada
| | | | - Sébastien Brodeur
- University Institute of Mental Health of Quebec, CIUSSS-CN, Quebec, Canada
- CERVO Research Center, Quebec, Canada
- Faculty of Medicine, Laval University, Quebec, Canada
- King’s College London, London, UK
| | - Annie LeBlanc
- Faculty of Medicine, Laval University, Quebec, Canada
- VITAM - Centre de recherche en santé durable, Quebec, Canada
| | - Marie-France Demers
- Faculty of Pharmacy, University Laval, Quebec, Canada
- University Institute of Mental Health of Quebec, CIUSSS-CN, Quebec, Canada
- CERVO Research Center, Quebec, Canada
| | - Sophie Lauzier
- Faculty of Pharmacy, University Laval, Quebec, Canada
- CHU de Québec-Université Laval Research Centre, Quebec, Canada
| | - Marc-André Roy
- University Institute of Mental Health of Quebec, CIUSSS-CN, Quebec, Canada
- CERVO Research Center, Quebec, Canada
- Faculty of Medicine, Laval University, Quebec, Canada
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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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Correll CU, Brieden A, Janetzky W. Symptomatic, functional and quality of life measures of remission in 194 outpatients with schizophrenia followed naturalistically in a 6-month, non-interventional study of aripiprazole once-monthly. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2023; 9:80. [PMID: 37935711 PMCID: PMC10630463 DOI: 10.1038/s41537-023-00405-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
An important goal in the treatment of patients with schizophrenia is remission in various domains, i.e., of symptoms, psychosocial functioning and subjective well-being. We undertook a post hoc analysis of pre-stabilized outpatients with schizophrenia and complete outcome data who had been enrolled in a 6-month non-interventional study of aripiprazole once-monthly (AOM) at 75 German sites. Key outcomes were (i) symptomatic remission (cross-sectional Andreasen et al. criteria (≤mild positive and negative key symptoms on the Brief Psychiatric Rating Scale (BPRS))); (ii) functional remission (Global Assessment of Functioning (GAF) scale score >70), and (iii) subjective well-being remission (WHO-5 scale score ≥13) at week 24. Of 242 enrolled patients, 194 (80.2%) (age = 43.9 ± 15.3 years; 51.5% male, illness duration = 14.0 ± 12.0 years) with complete data were analyzed. While 61.3% of the patients achieved symptomatic remission and 76.8% achieved remission regarding subjective well-being, only 24.7% achieved psychosocial functioning remission at 6 months. Remission rates were similar for men and women and across strata of disease duration with, on average, less remission in patients with longer illness duration. Correlations of improvements on the BPRS and GAF were weak, with the weakest correlation between the BPRS depressive mood item and the GAF scale, but similarly high correlation between BPRS subscales or the BPRS depressive mood item and subjective well-being. These findings suggest that while treatment with AOM can lead to symptomatic remission and remission regarding subjective well-being, additional interventions such as psychosocial therapy or supported employment and education may be necessary to achieve functional remission.
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Affiliation(s)
- Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA.
- Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany.
| | - Andreas Brieden
- Universität der Bundeswehr München, Werner-Heisenberg-Weg 39, D-85577, Neubiberg, Germany
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7
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Turkoz I, Wong J, Chee B, Siddiqui U, Knight RK, Richarz U, Correll CU. Comparative effectiveness study of paliperidone palmitate 6-month with a real-world external comparator arm of paliperidone palmitate 1-month or 3-month in patients with schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231200258. [PMID: 37786804 PMCID: PMC10541743 DOI: 10.1177/20451253231200258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/21/2023] [Indexed: 10/04/2023] Open
Abstract
Background The paliperidone palmitate 6-month (PP6M) long-acting injectable formulation is currently the longest dosing interval available for schizophrenia treatment. Objective To compare treatment outcomes between a real-world external comparator arm (ECA; NeuroBlu database) and the PP6M open-label extension (OLE) clinical trial arm. Methods The ECA comprised patients receiving PP 1-month (PP1M) or PP 3-month (PP3M) for ⩾12 months without a relapse. The PP6M OLE arm included patients with PP1M treatment prior to randomization who completed the 12-month double-blind PP6M study on either PP3M or PP6M relapse-free. Inverse probability treatment weighting (IPTW) was used to study time-to-relapse (primary outcome) and change in Clinical Global Impressions-Severity (CGI-S) score (secondary outcome). Results At 24 months, 3.9% (7/178) of patients in the PP6M cohort experienced a relapse versus 15.6% (26/167) in the ECA. Time-to-relapse was longer in the PP6M cohort versus the ECA at 12-, 18-, and 24-months across the different weighting methods; median time-to-relapse was not reached in both cohorts. Hazard ratio (HR) for relapse was significantly lower for the PP6M cohort versus the ECA throughout the duration of the study [HR at 24 months: 0.18 (95% CI: 0.08-0.42), p < 0.001]. At 24 months, change in CGI-S score for the PP6M cohort was 0.76 points lower than the ECA (p < 0.001). Results were similar in a sensitivity analysis using propensity score matching (PSM); IPTW resulted in larger sample sizes in balanced dataset than PSM. Conclusion Consistent findings across weighting and matching methods suggest PP6M efficacy in reducing and delaying relapses and long-term symptom control compared to PP1M/PP3M in usual-care settings. Additional confounds, such as greater illness severity and more frequent comorbidities and comedications in the ECA, were not fully controlled by the applied statistical methods. Future real-world studies directly comparing PP6M with PP3M/PP1M and adjusting for these confounders are warranted.
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Affiliation(s)
- Ibrahim Turkoz
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560-0200, USA
| | | | | | - Uzma Siddiqui
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - R. Karl Knight
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Ute Richarz
- Janssen Research & Development, Cilag Int., Zurich, Switzerland
| | - Christoph U. Correll
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, NY, USA
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
- Charité – Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
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O’Neill JR, Taylor DM, Horowitz MA. Implementing gradual, hyperbolic tapering of long-acting injectable antipsychotics by prolonging the inter-dose interval: an in silico modelling study. Ther Adv Psychopharmacol 2023; 13:20451253231198463. [PMID: 37719449 PMCID: PMC10501077 DOI: 10.1177/20451253231198463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/08/2023] [Indexed: 09/19/2023] Open
Abstract
Gradual, hyperbolic tapering has been proposed as a method to reduce the risk of withdrawal effects and potential relapse of an underlying condition by minimising disruption of existing equilibria. We applied hyperbolic tapering principles in silico to long-acting aripiprazole to generate regimens for withdrawal in clinical practice. We derived thresholds for taper rates using existing studies and consensus. Using pharmacokinetic data for aripiprazole long-acting injectable antipsychotic (ALAI), we conducted in silico modelling to examine the impact of abrupt cessation of long-acting injectable antipsychotic (LAI) medication and the effect of prolonging inter-dose interval on plasma aripiprazole levels and consequent D2 occupancy. We also modelled transitions from LAI medication to oral medication. Regimens were designed to afford a rate of reduction between 5 and 12.5 percentage points of D2 occupancy per month. Abrupt discontinuation of ALAI was shown to lead to a maximal D2 occupancy reduction of 16.8 percentage points per month; prolongation of the inter-dose interval of ALAI produced a slower reduction. Specifically, hyperbolic tapering was afforded by prolongation of a 400 mg ALAI inter-dose interval from 4 to 7 weeks, before reducing the dose to 300 mg ALAI. This could then be administered at up to 4-week (for 6% maximal D2 occupancy change), 6-week (9% change) or 7-week (11% change) intervals. Switching to oral medication - 5, 2.5 and 1.25 mg for the three regimens, respectively - is required for ALAI to complete full cessation to prevent too rapid a reduction in D2 occupancy. Oral medication should probably be maintained at a consistent dose for 3-6 months before further reductions to account for residual LAI being concurrently eliminated. Hyperbolic dose tapering is possible with ALAI through prolongation of the inter-dose interval and may reduce the risk of relapse compared to abrupt discontinuation of LAI medication.
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Affiliation(s)
- James R. O’Neill
- South West Yorkshire Partnership NHS Foundation Trust, Newton Lodge, Ouchthorpe Lane, Wakefield WF1 3SP, UK
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Højlund M, Correll CU. Switching to long-acting injectable antipsychotics: pharmacological considerations and practical approaches. Expert Opin Pharmacother 2023; 24:1463-1489. [PMID: 37345508 DOI: 10.1080/14656566.2023.2228686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/20/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Long-acting injectable antipsychotics (LAIs) are an effective, but potentially underutilized treatment option in schizophrenia and other severe mental illnesses. Prescribing information typically focuses on how to initiate treatment from the corresponding oral formulations. However, in clinical practice other scenarios, such as switching from other oral antipsychotics or other LAIs, occur frequently, requiring guidance. AREAS COVERED Pharmacodynamic properties of antipsychotics and their relation to rebound symptoms. Pharmacokinetic properties of LAIs and their implications for switching approaches. Specific approaches to switching to LAIs. EXPERT OPINION The LAI landscape has evolved significantly in the last decade with more formulations available, longer dosing intervals, and extended indications. However, currently available LAIs have various shortcomings, e.g. short dosing intervals, need for oral supplementation, loading regimens, deep intramuscular injection and/or restricted indications. Recent improvements include a one-day initiation option for aripiprazole lauroxil, aripiprazole monohydrate once-monthly, risperidone in situ microparticles and subcutaneous risperidone. Future LAI developments should focus on longer dosing intervals, subcutaneous administration, expansion of LAIs beyond currently available antipsychotic agents and indications beyond schizophrenia and bipolar disorder. In the future, LAIs might become a first-line treatment after initial oral stabilization for chronic mental disorders with need for maintenance treatment and presence of significant non-adherence.
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Affiliation(s)
- Mikkel Højlund
- Department of Psychiatry Aabenraa, Mental Health Services Region of Southern Denmark, Aabenraa, Denmark
- Department of Public Health, Clinical Pharmacology, Pharmacy, and Environmental Medicine, University of Southern Denmark, Odense, Denmark
- Child and Adolescent Mental Health Centre, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark
| | - Christoph U Correll
- Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, NY, USA
- Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
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Haddad PM, Correll CU. Long-acting antipsychotics in the treatment of schizophrenia: opportunities and challenges. Expert Opin Pharmacother 2023; 24:473-493. [PMID: 36919576 DOI: 10.1080/14656566.2023.2181073] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Maintenance antipsychotic treatment improves multiple outcomes in people with schizophrenia. These benefits are challenged by medication nonadherence, which is a common occurrence. Long-acting injectable antipsychotic (LAI) formulations were developed to reduce nonadherence and thereby improve outcomes. This narrative review is based on a PubMed search (January 2000 - August 2022) for studies on LAI antipsychotics. AREAS COVERED Opportunities and challenges associated with LAIs are reviewed. Advantages, compared to oral antipsychotics (OAs), include improved adherence, reduced relapse and hospitalization risk, delayed and lower relapse risk after stopping treatment, and the ability to differentiate true treatment resistance from 'pseudo'-resistance. Additionally, LAIs are associated with lower all-cause mortality than OAs. LAIs are under-used in many services, partly reflecting negative attitudes, misconceptions, and lack of knowledge among clinicians, patients, and carers. Practical barriers to LAI use include acquisition costs and inadequate service structures to administer/monitor LAI treatment. EXPERT OPINION The education and engagement of clinicians, patients and caregivers can assist more informed decision-making regarding LAIs. Future research regarding LAIs should encompass multiple complementary designs, focus on functionality and recovery outcomes, and include groups at high risk of relapse, including those with comorbid substance use disorders and early in the course of schizophrenia.
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Affiliation(s)
- Peter M Haddad
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK.,Mental Health, Drugs and Alcohol Services (MHDAS), Barwon Health, Geelong, Australia
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
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Brandt L, Ritter K, Schneider-Thoma J, Siafis S, Montag C, Ayrilmaz H, Bermpohl F, Hasan A, Heinz A, Leucht S, Gutwinski S, Stuke H. Predicting psychotic relapse following randomised discontinuation of paliperidone in individuals with schizophrenia or schizoaffective disorder: an individual participant data analysis. Lancet Psychiatry 2023; 10:184-196. [PMID: 36804071 DOI: 10.1016/s2215-0366(23)00008-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Predicting relapse for individuals with psychotic disorders is not well established, especially after discontinuation of antipsychotic treatment. We aimed to identify general prognostic factors of relapse for all participants (irrespective of treatment continuation or discontinuation) and specific predictors of relapse for treatment discontinuation, using machine learning. METHODS For this individual participant data analysis, we searched the Yale University Open Data Access Project's database for placebo-controlled, randomised antipsychotic discontinuation trials with participants with schizophrenia or schizoaffective disorder (aged ≥18 years). We included studies in which participants were treated with any antipsychotic study drug and randomly assigned to continue the same antipsychotic drug or to discontinue it and receive placebo. We assessed 36 prespecified baseline variables at randomisation to predict time to relapse, using univariate and multivariate proportional hazard regression models (including multivariate treatment group by variable interactions) with machine learning to categorise the variables as general prognostic factors of relapse, specific predictors of relapse, or both. FINDINGS We identified 414 trials, of which five trials with 700 participants (304 [43%] women and 396 [57%] men) were eligible for the continuation group and 692 participants (292 [42%] women and 400 [58%] men) were eligible for the discontinuation group (median age 37 [IQR 28-47] years for continuation group and 38 [28-47] years for discontinuation group). Out of the 36 baseline variables, general prognostic factors of increased risk of relapse for all participants were drug-positive urine; paranoid, disorganised, and undifferentiated types of schizophrenia (lower risk for schizoaffective disorder); psychiatric and neurological adverse events; higher severity of akathisia (ie, difficulty or inability to sit still); antipsychotic discontinuation; lower social performance; younger age; lower glomerular filtration rate; benzodiazepine comedication (lower risk for anti-epileptic comedication). Out of the 36 baseline variables, predictors of increased risk specifically after antipsychotic discontinuation were increased prolactin concentration, higher number of hospitalisations, and smoking. Both prognostic factors and predictors with increased risk after discontinuation were oral antipsychotic treatment (lower risk for long-acting injectables), higher last dosage of the antipsychotic study drug, shorter duration of antipsychotic treatment, and higher score on the Clinical Global Impression (CGI) severity scale The predictive performance (concordance index) for participants who were not used to train the model was 0·707 (chance level is 0·5). INTERPRETATION Routinely available general prognostic factors of psychotic relapse and predictors specific for treatment discontinuation could be used to support personalised treatment. Abrupt discontinuation of higher dosages of oral antipsychotics, especially for individuals with recurring hospitalisations, higher scores on the CGI severity scale, and increased prolactin concentrations, should be avoided to reduce the risk of relapse. FUNDING German Research Foundation and Berlin Institute of Health.
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Affiliation(s)
- Lasse Brandt
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Kerstin Ritter
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Bernstein Center of Computational Neuroscience Berlin, Berlin, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Christiane Montag
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Hakan Ayrilmaz
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Bermpohl
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Berlin School of Mind and Brain, Berlin, Germany
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, University of Augsburg, Medical Faculty, Bezirkskrankenhaus Augsburg, Augsburg, Germany
| | - Andreas Heinz
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Bernstein Center of Computational Neuroscience Berlin, Berlin, Germany; Berlin School of Mind and Brain, Berlin, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Heiner Stuke
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
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12
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Groenendaal E, Lynch S, Dornbush R, Klepacz L, Ferrando S. Clinical determinants, patterns and outcomes of antipsychotic medication prescribing in the treatment of schizophrenia and schizoaffective disorder: A naturalistic cohort study. J Psychiatr Res 2023; 158:273-280. [PMID: 36623361 DOI: 10.1016/j.jpsychires.2022.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/18/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Schizophrenia affects individuals, families, and systems, with treatment primarily being antipsychotic medications. Long-acting injectable (LAI) antipsychotics are increasingly being used. This study sought to identify predictors of antipsychotic choice, in terms of formulation (LAI vs oral) and class (FGA vs SGA), and clinical outcomes. METHODS 123 patients who received LAI antipsychotics were diagnosis-matched to patients who received oral antipsychotics. Sociodemographic and clinical factors were extracted from the medical record, including indicators of illness severity. Groups were compared with Chi-Square and t-tests, and logistic regression models were used to identify independent predictors of antipsychotic choice. RESULTS Patients that received LAIs had longer admissions, more complex discharges, and greater illness severity; however, there were no differences in readmission rates. Independent predictors of LAIs included younger age, being single, and longer admission. Patients who received FGA LAIs were more likely to use substances and be undomiciled compared to SGA LAIs, with the only predictor being older age. Oral FGAs were more likely than Oral SGAs to be prescribed to older and female patients, as well as those with co-occurring substance use, complex discharges, and longer admissions. CONCLUSIONS Illness severity and duration of illness appear to drive choice of LAI vs. oral antipsychotic medication and FGA vs. SGA. While LAIs were prescribed to patients with greater illness severity, readmission rates were equivalent to those receiving oral medication, supporting the use of LAI in patients with greater illness severity. Rationales for prescribing LAIs to younger patients and FGAs to older patients are discussed.
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Affiliation(s)
| | - Sean Lynch
- New York Medical College, USA; Mount Sinai Beth Israel, USA
| | - Rhea Dornbush
- New York Medical College, USA; Westchester Medical Center, USA
| | - Lidia Klepacz
- New York Medical College, USA; Westchester Medical Center, USA
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13
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Therapeutic Drug Monitoring of Long-Acting Injectable Antipsychotics as a Predictor of Relapse in Schizophrenia Spectrum Disorders: A 1-Year Pilot Study. Ther Drug Monit 2022; 44:805-810. [PMID: 35442940 DOI: 10.1097/ftd.0000000000000990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/21/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Long-acting injectable antipsychotics (LAIs) have been shown to reduce acute episodes of schizophrenia spectrum disorders (SSDs). However, breakthrough relapses are frequent, possibly because of underdosing in clinical practice. In this framework, the advantages of therapeutic drug monitoring (TDM) may be overlooked. This study explored the association of low steady-state LAI levels with a higher risk of relapse in SSDs, despite the use of a licensed posology. METHODS Forty-eight clinically stable outpatients with SSD underwent LAI-TDM using liquid chromatography-mass spectrometry for routine observational purposes. Baseline anamnestic, pharmacological, and psychometric evaluations compared subjects with "under-range" versus "in-range" LAI serum levels; between-group comparisons for different LAI treatments were also performed. A binary logistic regression explored which baseline factors (age, sex, previous hospitalizations, psychopathology, specific LAI treatment, and underrange serum levels) predicted relapse during the next 12 months. RESULTS Baseline comparisons did not show significant between-group differences, except for a higher percentage of underrange values in individuals receiving olanzapine pamoate. A total of 10 patients (20.8%) relapsed during the follow-up; only underrange LAI levels predicted the event (odds ratio 0.03, 95% confidence interval 0.01-0.36; P = 0.005). CONCLUSIONS Even if relapse remains as a multifactorial event, LAI-TDM may identify subjects at risk for this negative outcome, thus optimizing antipsychotic maintenance treatment in the context of precision medicine. The finding of underrange LAI plasma levels in real-world practice should prompt adequate monitoring of clinically stable outpatients to identify the early signs of psychopathological deterioration.
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Rubio JM, Perez-Rodriguez M. Chronic Use of Antipsychotics in Schizophrenia: Are We Asking the Right Question? SCHIZOPHRENIA BULLETIN OPEN 2022; 3:sgac059. [PMID: 36277256 PMCID: PMC9577501 DOI: 10.1093/schizbullopen/sgac059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There is an ongoing debate about the potential risks and benefits of long-term antipsychotic treatment in schizophrenia. The data for and against the chronic use of these medicines is mostly indirect, either from observational studies potentially exposed to reverse causation bias or randomized controlled studies that do not cover beyond 2–3 years. We propose that perseverating on the question of what positive or negative outcomes are causally associated with chronic antipsychotic treatment may not lead to better answers than the limited ones that we have, given the limited feasibility of more conclusive studies. Rather, we argue that addressing the research question of the risks and benefits of antipsychotic discontinuation from a perspective of personalized medicine, can be more productive and meaningful to people living with schizophrenia. To this end, research that can quantify the risk of relapse after treatment continuation for a given individual should be prioritized. We make the case that clinically feasible neuroimaging biomarkers have demonstrated promise in related paradigms, and that could be offering a way past this long debate on the risks and benefits of chronic antipsychotic use.
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Affiliation(s)
- Jose M Rubio
- To whom correspondence should be addressed; Donald and Barbara Zucker School of Medicine at Hofstra/Nortwhell, Hempstead, NY, USA; tel: 7184705912, e-mail:
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15
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Rubio JM, Kane JM. The pharmacological treatment of schizophrenia: How far have we come? PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2022; 1:e13. [PMID: 38868633 PMCID: PMC11114354 DOI: 10.1002/pcn5.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 06/14/2024]
Abstract
Schizophrenia is a chronic and often severe mental disorder for which antipsychotic drugs are the cornerstone of treatment. Although the essential mechanism of action of these drugs has not changed much since they were first discovered in the 1950s, there have been numerous advances in the context in which these drugs are prescribed, as well as in the considerations for their optimal use. In this review, we summarize five selected issues in which the psychopharmacological treatment of schizophrenia has most evolved. Namely, these are the shift of outcomes of interest from symptoms to recovery, the development of stratified approaches to select the most appropriate treatment for each individual, the recognition of treatment nonadherence as a critical factor determining outcomes, the recommendations for maintenance treatment, and, finally, the promise of new antipsychotic compounds that innovate in their mechanisms of action, improving efficacy/safety profiles. Finally, we discuss how some of these advances have already delivered to improved outcomes in the real world, whereas others have demonstrated efficacy under optimal circumstances yet have not been translated into better outcomes in the community. Thus, the road ahead includes both identifying novel treatments that engage the psychopathology of the illness and improve the efficacy/tolerability profile of currently available agents, as well as developing interventions that mitigate the barriers for the use of novel interventions, some of them already existing, in the real world.
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Affiliation(s)
- Jose M. Rubio
- Donald and Barbara Zucker School of Medicine at Hofstra—Northwell, Feinstein Institutes of Medical Research—Institute of Behavioral ScienceZucker Hillside Hospital—Northwell HealthGlen OaksNYUnited States
| | - John M. Kane
- Donald and Barbara Zucker School of Medicine at Hofstra—Northwell, Feinstein Institutes of Medical Research—Institute of Behavioral ScienceZucker Hillside Hospital—Northwell HealthGlen OaksNYUnited States
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16
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Okoli CTC, Kappi A, Wang T, Makowski A, Cooley AT. The effect of long-acting injectable antipsychotic medications compared with oral antipsychotic medications among people with schizophrenia: A systematic review and meta-analysis. Int J Ment Health Nurs 2022; 31:469-535. [PMID: 34931437 DOI: 10.1111/inm.12964] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
Long-acting injectable (LAI) antipsychotic medications may be an important modality of reducing costs, improving symptoms, and fostering quality of life outcomes for those with schizophrenia. Our objective was to systematically review and conduct a meta-analysis of the effectiveness of LAIs compared with oral antipsychotics on medication adherence, symptom remission/relapse, rehospitalization, outpatient visits, emergency department visits, healthcare costs, and social functioning. We performed a systematic search of PsycInfo, CINAHL, PubMed, and Scopus databases to examine studies meeting inclusion criteria prior to August 30th, 2020. Randomized controlled trials, retrospective studies, prospective studies among people with schizophrenia with at least 6-month follow-up data were obtained. Overall effect sizes and associated 95% confidence intervals (CI) were estimated with random-effects modeling. We found 75 articles meeting our inclusion criteria, including 341 730 individuals with schizophrenia. Systematic review results indicated that LAIs compared with orals improved medication adherence (25/29 studies), symptom remission/relapse (10/18 studies), rehospitalizations (26/49 studies), emergency department visits (9/17 studies), medical costs (11/15 studies), and social functioning (5/9 studies); however, LAIs also increased outpatient visits (7/16 studies) and pharmacy costs (10/10 studies). Meta-analytic results of studies with similar outcome measures did not find differences between LAIs and orals in respect to outcomes, except lowering emergency department visits and increasing pharmacy costs. The differences between the results of the narrative synthesis and the meta-analyses were possibly because of the low availability of studies with similar outcomes in the pooled analyses. Our overall results suggest that LAIs are at least comparable to orals in supporting important healthcare outcomes for those with schizophrenia. These findings support clinical practice in encouraging providers to prescribe LAIs when indicated.
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Affiliation(s)
| | - Amani Kappi
- University of Kentucky College of Nursing, Lexington, Kentucky, USA
| | - Tianyi Wang
- Department of Statistics, University of Kentucky College of Arts and Sciences, Lexington, Kentucky, USA
| | - Andrew Makowski
- University of Kentucky College of Nursing, Lexington, Kentucky, USA
| | - Andrew T Cooley
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
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Calling for policy actions to increase access to long-acting antipsychotics in low-income and middle-income countries. Epidemiol Psychiatr Sci 2022; 31:e34. [PMID: 35543395 PMCID: PMC9121849 DOI: 10.1017/s2045796022000166] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Schizophrenia-spectrum disorders are associated with substantial impairment and disability. Lack of treatment adherence is a major issue, especially in low- and middle-income countries (LMICs). Despite growing evidence supporting second-generation long-acting antipsychotics (LAIs) as an effective strategy to ensure continued maintenance treatment in schizophrenia, access to these technologies has been very limited in constrained-resource settings. Including second-generation LAIs in national and international essential medicines lists and evidence-based guidelines, promoting public health-oriented patent pooling and extending their availability to primary health care settings, are key actions that should urgently be implemented to increase access to long-acting technologies. Implementing these policy actions can pragmatically improve treatment adherence, ultimately tackling schizophrenia-related impairment and disability in LMICs, which can be regarded as a global health priority.
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18
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Taipale H, Tanskanen A, Correll CU, Tiihonen J. Real-world effectiveness of antipsychotic doses for relapse prevention in patients with first-episode schizophrenia in Finland: a nationwide, register-based cohort study. Lancet Psychiatry 2022; 9:271-279. [PMID: 35182475 DOI: 10.1016/s2215-0366(22)00015-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antipsychotic doses for relapse prevention in patients with first-episode schizophrenia that have the highest likelihood of success are unknown. We aimed to study the evolution of antipsychotic dose and risk of severe relapse indicated by psychiatric rehospitalisation associated with antipsychotic use and specific dose categories. METHODS We did a nationwide, register-based cohort study in Finland. Patients were identified from the nationwide Hospital Discharge register, which records all inpatient hospital stays. Patients with first-episode schizophrenia diagnosed as inpatients and who were 45 years or younger were followed-up for 5 years of illness or until a fifth relapse episode. The primary measure was rehospitalisation due to psychosis, which was used as a marker of relapse and defined as inpatient hospital care with an ICD-10 code of F20-F29 diagnosis recorded as the main discharge diagnosis. Time between relapses was required to be at least 30 days to be considered a next relapse. Antipsychotic use was derived from the prescription register. Dose was summed from all concomitant antipsychotics. Antipsychotic effectiveness for preventing rehospitalisation was studied using within-individual analyses to eliminate selection bias, stratifying time to before and after the second relapse. FINDINGS In total, the study population comprised 5367 patients, of whom 3444 (64·2%) were men and 1923 (35·8%) were women, with a mean age of 29·5 years (SD 7·8) at the start of follow-up. Ethnicity data were not available. 3058 (57·0%) of 5367 patients required hospitalisations. In these patients, the mean dose increased gradually after each new relapse from 1·22 defined daily doses per day (95% CI 1·18-1·26) before the first relapse to 1·56 defined daily doses per day (1·48-1·64) before the fifth relapse. Adjusted hazard ratio (aHR) for rehospitalisation with antipsychotic use versus non-use increased from 0·42 (95% CI 0·35-0·51) before the second relapse to 0·78 (0·62-0·99) after the second relapse (p<0·0001), indicating markedly decreased effectiveness. Analysing specific dose categories revealed a U-shaped curve, showing the lowest rehospitalisation risk during use of the standard dose (0·9 to <1·1 defined daily doses per day) before but not after the second relapse. Low dose (<0·6 defined daily doses per day) was associated with substantially higher rehospitalisation risk (aHR 1·54 [95% CI 1·06-2·24]) versus standard dose before the second relapse, but not after the second relapse (1·11 [0·76-1·62]), owing to reduced effectiveness of all doses after the second relapse. INTERPRETATION The effectiveness of antipsychotics for relapse prevention decreased substantially after the second relapse. Therefore, prevention of the second relapse is essential, and all patients should receive sufficient antipsychotic doses and enhanced relapse prevention efforts after their first relapse. FUNDING Academy of Finland and Finnish Ministry of Social Affairs and Health.
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Affiliation(s)
- Heidi Taipale
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; School of Pharmacy, University of Eastern Finland, Kuopio, Finland; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden.
| | - Antti Tanskanen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden; Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden; Neuroscience Center, University of Helsinki, Helsinki, Finland
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Reymann S, Schoretsanitis G, Egger ST, Mohonko A, Kirschner M, Vetter S, Homan P, Seifritz E, Burrer A. Use of Long-Acting Injectable Antipsychotics in Inpatients with Schizophrenia Spectrum Disorder in an Academic Psychiatric Hospital in Switzerland. J Pers Med 2022; 12:jpm12030441. [PMID: 35330441 PMCID: PMC8955244 DOI: 10.3390/jpm12030441] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/05/2022] [Accepted: 03/09/2022] [Indexed: 01/13/2023] Open
Abstract
Long-acting injectable antipsychotics (LAIs) offer many benefits to patients with schizophrenia spectrum disorder (SSD). They are used with very different frequencies due to questions of eligibility or patients and prescribers’ attitudes towards LAI use. We assessed the prescribing rates of LAIs in a large academic psychiatric hospital with a public service mandate in Switzerland and compared them with other countries and health care systems. To our knowledge, this study is the first to investigate inpatient LAI use in Europe. Medical records of all patients diagnosed with SSD discharged from the Clinic of Adult Psychiatry of the University Hospital of Psychiatry Zurich over a 12 month period from January to December 2019 were evaluated regarding the prescribed antipsychotics at the time of discharge. The rates of use of LAIs among all patients and among patients receiving LAI-eligible antipsychotic substances were assessed retrospectively. We assessed records of 885 patients with SSD. Among all cases, 13.9% received an LAI. Among patients who received antipsychotic medication that was eligible for LAI use (n = 434), 28.1% received an agent as an LAI. LAI use included paliperidone palmitate (69.9%), aripiprazole monohydrate (14.6%), risperidone (4.9%) and first-generation LAIs (9.8%). Compared to international frequencies of LAI administration, the prescription rate of LAIs in SSD patients was low. Further studies will evaluate patient- and prescriber-related reasons for this low rate.
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Affiliation(s)
- Stephan Reymann
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
| | - Stephan T. Egger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
| | - Alexey Mohonko
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
| | - Matthias Kirschner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
| | - Stefan Vetter
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
| | - Philipp Homan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
- Neuroscience Center Zurich, University of Zurich, 8057 Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
| | - Achim Burrer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, 8032 Zurich, Switzerland; (S.R.); (G.S.); (S.T.E.); (A.M.); (M.K.); (S.V.); (P.H.); (E.S.)
- Correspondence:
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Horowitz MA, Murray RM, Taylor D. Confounding of Antipsychotic Discontinuation Studies by Withdrawal-Related Relapse. Schizophr Bull 2022; 48:294-295. [PMID: 34964477 PMCID: PMC8886601 DOI: 10.1093/schbul/sbab146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mark Abie Horowitz
- Division of Psychiatry, University College London, London, UK
- Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, UK
| | - Robin M Murray
- NIHR Maudsley Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - David Taylor
- NIHR Maudsley Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, Pharmacy Department, London, UK
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21
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Olivares JM, Fagiolini A. Long-Term Real-World Effectiveness of Aripiprazole Once-Monthly. Treatment Persistence and Its Correlates in the Italian and Spanish Clinical Practice: A Pooled Analysis. Front Psychiatry 2022; 13:877867. [PMID: 35573364 PMCID: PMC9096029 DOI: 10.3389/fpsyt.2022.877867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND One of the most significant risk factors for relapse and hospitalization in schizophrenia is non-adherence to antipsychotic medications, very common in patients with schizophrenia. The aim of this analysis was to evaluate the treatment persistence to aripiprazole once-monthly (AOM) and the factors affecting it in the pooled population of two similar studies performed previously in two different European countries. METHODS Pooled analysis of two non-interventional, retrospective, patient record-based studies: DOMINO and PROSIGO. Both analyzed treatment persistence after starting AOM treatment in the real-world setting. The primary variable was persistence with AOM treatment during the first 6 months after treatment initiation. A multivariate Cox regression model was used to evaluate the influence of several baseline characteristics on the persistence. RESULTS The study population comprised 352 patients included in the two studies, DOMINO (n = 261) and PROSIGO (n = 91). The overall persistence with AOM treatment at the end of the 6-month observation period was 82.4%. The multivariate analysis showed that patients with "secondary school" level of education present a 67.4% lower risk of discontinuation within 6 months after AOM initiation when compared with "no/compulsory education patients" (p = 0.024). In addition, patients with an occupation present a 62.7% lower risk of discontinuation when compared with unemployed patients (p = 0.023). Regarding clinical history, patients with a Clinical Global Impression-Severity scale (CGI-S) score ≤3 present a 78.1% lower risk of discontinuation when compared with patients with a CGI-S score ≥6 (p = 0.044), while patients with a time since schizophrenia diagnosis ≤8.4 years present a 52.9% lower risk of discontinuation when compared with the rest of patients (p = 0.039). CONCLUSION The AOM persistence rate observed in this study was 82.4%, which was higher than that reported in clinical trials, aligned with other real-life studies and higher than reported for other long-acting injectable antipsychotics. The persistence rate was high in complex patients, although patients with higher level of education, active occupation, lower initial CGI-S score and shorter time since the diagnosis of schizophrenia appear to be more likely to remain persistent with AOM during the 6 months after initiation.
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Affiliation(s)
| | - Andrea Fagiolini
- School of Medicine, Department of Molecular Medicine, University of Siena, Siena, Italy
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Lin CH, Chan HY, Wang FC, Hsu CC. Time to rehospitalization in involuntarily hospitalized individuals suffering from schizophrenia discharged on long-acting injectable antipsychotics or oral antipsychotics. Ther Adv Psychopharmacol 2022; 12:20451253221079165. [PMID: 35340566 PMCID: PMC8949740 DOI: 10.1177/20451253221079165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/14/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Involuntarily hospitalized individuals suffering from schizophrenia often have a poorer prognosis after discharge. OBJECTIVE This study aimed to analyze time to rehospitalization within 6 months of discharge in involuntarily hospitalized individuals suffering from schizophrenia discharged on long-acting injectable antipsychotics (LAIs) or oral antipsychotics (OAPs). In addition, temporal trends in LAI use at discharge were explored. METHODS Involuntarily hospitalized individuals suffering from schizophrenia discharged from the study hospital between 2006 and 2019 (n = 806) were included in the analysis. Survival analysis was used to compare time to rehospitalization within 6 months of discharge between individuals discharged on LAIs and OAPs, and between first-generation antipsychotic (FGA) LAIs and second-generation antipsychotic (SGA) LAIs. The Cochran-Armitage trend test was used to test whether a temporal trend existed for LAIs use at discharge during the study period. RESULTS The LAIs group (n = 231) had a significantly lower rate of rehospitalization and a significantly longer time to rehospitalization than the OAPs group (n = 575). Rehospitalization rate and time to rehospitalization were not significantly different between individuals discharged on FGA-LAIs and SGA-LAIs. LAIs use at discharge grew significantly from 16.77% in 2006 to 50.00% in 2019 (Z = 6.81, p < 0.0001). Among all LAIs, only use of SGA-LAIs at discharge increased significantly (Z = 5.74, p < 0.0001), but not FGA-LAIs. CONCLUSIONS LAIs were superior to OAPs in preventing rehospitalization. However, SGA-LAIs were comparable with FGA-LAIs in reducing rehospitalization risk. Use of LAIs increased significantly in discharged involuntarily hospitalized individuals during the study period, especially SGA-LAIs.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung
| | - Hung-Yu Chan
- Department of General Psychiatry, Taoyuan Psychiatric Center, No. 71, Long-Show Street, Taoyuan City 33058
| | - Fu-Chiang Wang
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung
| | - Chun-Chi Hsu
- Department of General Psychiatry, Taoyuan Psychiatric Center, Taoyuan City
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