Benefit-risk assessment of paliperidone oral extended-release tablet versus monthly injectable for maintenance treatment of schizophrenia

A randomized, prospective, active-controlled study comparing intramuscular long-acting paliperidone palmitate versus oral antipsychotics in patients with schizophrenia at risk of violent behavior

OBJECTIVE

Paliperidone palmitate (PP) is an effective long-acting antipsychotic injection, but its impact on the behavior of schizophrenia patients with dangerous tendencies requires further investigation. This study aims to explore the effects of long-term antipsychotic treatment on this population in the community.

METHODS

This 49-week, randomized controlled trial was conducted across 21 communities in Wuhan and enrolled 134 schizophrenia patients at risk for violent behavior. With a fixed block size of 10, participants were randomly assigned to receive either intramuscular PP 1-month formulation (PP1M) or oral antipsychotic medication (OAP) at a 1:1 ratio. Changes in patients' risk for violent/aggressive behavior, family burden, social, and cognitive functioning were measured using VRAPP, MOAS, PANSS, FBS, PSP, and RBANS scales from baseline to endpoint. Longitudinal data from multiple repeated measures were analyzed using linear mixed-effects models.

RESULTS

The study protocol was completed by 77.6% of the patients overall. Significant improvements were observed in the risk assessment scores, MOAS total score, PANSS total score, PSP total score, and FBS total score of patients in the PP1M group from baseline to the end of treatment (all P < 0.05). Importantly, compared to patients in the OAP group, the improvements in these measures were also significantly greater in the PP1M group. Commonly observed AEs, such as hyperprolactinemia (70.3% vs. 62.65%) and muscle tension (45.3% vs. 57.8%), were considered to be the PP-related AEs. Nonetheless, the differences between the two groups did not reach statistical significance, and no new safety concerns emerged.

CONCLUSIONS

Our study suggests that PP long-acting injection (LAI) is a safe and effective treatment option for community-dwelling schizophrenia patients with impulsive violence and risky behaviors.

The effect of long-acting injectable antipsychotic medications compared with oral antipsychotic medications among people with schizophrenia: A systematic review and meta-analysis

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.

Paliperidone to Treat Psychotic Disorders

PURPOSE OF REVIEW

This is a comprehensive review of the literature regarding the use of paliperidone in the treatment of schizophrenia and schizoaffective disorder. It covers the background and presentation of schizophrenia and schizoaffective disorder, as well as the mechanism of action and drug information for paliperidone. It covers the existing evidence of the use of paliperidone for the treatment of schizophrenia and schizoaffective disorder.

RECENT FINDINGS

Schizophrenia and schizoaffective disorder lead to significant cognitive impairment. It is thought that dopamine dysregulation is the culprit for the positive symptoms of schizophrenia and schizoaffective disorder. Similar to other second-generation antipsychotics, paliperidone has affinity for dopamine D₂ and serotonin 5-HT_2A receptors. Paliperidone was granted approval in the United States in 2006 to be used in the treatment of schizophrenia and in 2009 for schizoaffective disorder.

SUMMARY

Schizophrenia and schizoaffective disorder have a large impact on cognitive impairment, positive symptoms and negative symptoms. Patients with either of these mental illnesses suffer from impairments in everyday life. Paliperidone has been shown to reduce symptoms of schizophrenia and schizoaffective disorder.

Benefit-Risk Assessment of Esketamine Nasal Spray vs. Placebo in Treatment-Resistant Depression

This post hoc analysis assessed the benefit–risk profile of esketamine nasal spray + oral antidepressant (AD) induction and maintenance treatment in patients with treatment‐resistant depression (TRD). The Benefit–Risk Action Team framework was utilized to assess the benefit–risk profile using data from three induction studies and one maintenance study. Benefits were proportion of remitters or responders in induction studies and proportion of stable remitters or stable responders who remained relapse‐free in the maintenance study. Risks were death, suicidal ideation, most common adverse events (AEs), and potential long‐term risks. Per 100 patients on esketamine + AD vs. AD + placebo in induction therapy, 5–21 additional patients would remit and 14–17 additional patients would respond. In maintenance therapy, 19–32 fewer relapses would occur with esketamine. In both cases, there was little difference in serious or severe common AEs (primarily dissociation, vertigo, and dizziness). These findings support a positive benefit–risk balance for esketamine + AD as induction and maintenance treatment in patients with TRD.