Long-acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations

Tolerability profile of paliperidone palmitate formulations: A pharmacovigilance analysis of the EUDRAVigilance database

Introduction

Long-acting injectable antipsychotics (LAIs) have proven to be effective in the maintenance treatment of patients suffering from schizophrenia, and their safety and tolerability profiles represent a key factor in their long-term use and choice in clinical practice. Paliperidone palmitate (PP) is the only second-generation LAI (SGA-LAI), available in both one- (PP1M) and 3-month (PP3M) formulations. However, real-world prospective studies on PP1M and PP3M are still few and mostly conducted on small samples. In this context, we aimed to better define the safety and tolerability profile of PP using real world pharmacovigilance data.

Methods

We retrospectively analyzed the publicly available data regarding Individual Case Safety Reports (ICSRs), presenting PP1M and/or PP3M as suspected drugs, reported on EUDRAVigilance between 2011 and June 30th, 2022. ICSRs relative to at least one SGA-LAI other than PP, reported between 2003 and June 30th, 2022, were also examined as reference group. Data were evaluated with a descriptive analysis, and then, as disproportionality measures, crude reporting odds ratio (ROR) and 95% confidence interval (CI) were calculated.

Results

A total of 8,152 ICSRs met the inclusion criteria, of those 77.7% (n = 6,332) presented as suspected drug PP1M, 21.2% (n = 1,731) PP3M, while 89 cases indicated both PP1M and PP3M. Significantly higher probabilities of reporting in PP-related reports were observed for the primary Standardized MedDRA Queries "Sexual Dysfunctions" (ROR = 1.45; 95% CI 1.23-1.70), "Haemodynamic oedema, effusions and fluid overload" (ROR = 1.42; 1.18-1.70), as well as "Fertility disorders" (ROR = 2.69; 1.51-4.80).

Discussion

Our analysis indicates that the tolerability and safety profiles of PP are in line with what is known for the other SGA-LAIs. However, differences regarding endocrine system ADRs have been noticed. The results presented in this work do not discourage the prescription of SGA-LAI formulations but aim to enhance their safety.

Prescribing patterns of long-acting injectable antipsychotics in a community setting in South Africa

Background

Long-acting injectable antipsychotics (LAI – APs) improve adherence to antipsychotics and decrease functional decline in schizophrenia. Yet they are prescribed late, in patients with established functional decline. Although LAI – APs are widely prescribed in South Africa, there is a paucity of research regarding the prescription profile for LAI – APs.

Aim

This study aimed to describe prescribing practices for LAI – APs at psychiatric clinics.

Setting

Community psychiatric clinics in South Africa.

Methods

A retrospective review of the psychiatric files of all patients on LAI – APs attending the clinics over the study period was conducted. Sociodemographic, clinical and pharmacological information regarding the LAI – AP prescribed was extracted from the files.

Results

A total of 206 charts were examined. The mean age of the study population was 46 (SD ± 12) years. Significantly more patients were male (n = 154; 74.8%), single (n = 184, 89.3%) and unemployed (n = 115; 55.8%) (p < 0.001). Approximately half had a comorbid substance use disorder (47.6%). The most common indication for the prescription of a LAI – AP was non-adherence (66%). Only 9.7% of the patients were prescribed a LAI – AP alone. No significant socio-demographic or clinical characteristic was associated with this prescribing habit. A LAI – AP was prescribed in combination with an oral antipsychotic, mood stabiliser or antidepressant in 53.9%, 44.7% and 7.8% of patients, respectively.

Conclusion

Long-acting injectable antipsychotics were prescribed mainly following noncompliance with oral antipsychotics and may represent a missed opportunity to prevent functional decline. The high prevalence of LAI – AP polypharmacy has been highlighted.

Predictors of long-acting injectable antipsychotic prescription at discharge in patients with schizophrenia and other psychotic disorders

Long-acting injectable antipsychotics (LAIs) increase drug compliance and offer a reliable treatment option with stable pharmacokinetics. The aim of our study is to examine the rate and predictors of LAIs' prescription at discharge in inpatients with schizophrenia and other psychotic disorders. This retrospective study included 400 inpatients. Sociodemographic and clinical characteristics of the patients, the treatments applied in the past and prescribed at discharge were obtained from the hospitalization files. We compared these characteristics of those who were given LAI treatment at discharge to the patients who were given oral treatments. Thirty-nine percent of the patients were prescribed a LAI at discharge. Duration of illness was longer, and number of previous hospitalizations was higher in the LAI group. Nonadherence to the antipsychotics before the hospitalization, the previous history of LAI use, lack of insight at the admission and no previous antidepressant use were found as independent contributors to LAI prescription as the treatment of discharge in logistic regression analysis. Our study showed that LAIs are used at a high rate in our clinic; however, they are still initiated at a later stage, mostly in chronic patients with a lack of insight and compliance at admission.

The Impact of Once-Monthly Paliperidone Palmitate on Healthcare Utilization Among Patients With Schizophrenia Treated in an Integrated Healthcare System: A Retrospective Mirror-Image Study

INTRODUCTION

Previous evidence demonstrated that patients with schizophrenia consumed substantial healthcare resources in an integrated healthcare system. This study evaluated the impact of initiating once-monthly paliperidone palmitate (PP1M) on healthcare resource utilization (HRU) among patients with schizophrenia treated in a US integrated healthcare system.

METHODS

This retrospective study used electronic medical records from Atrium Health. Adults with at least two diagnoses of schizophrenia who received an initial PP1M dose between September 2009 and April 2019 (the corresponding date defined the index date) and at least one subsequent dose within 90 days were included. Additionally, patients were required to have received active care (at least one healthcare visit every 6 months) during 12-month pre- and post-index periods and at least one oral antipsychotic prescription during the 12-month pre-index period. Inpatient, emergency room (ER), and outpatient visits were compared over 12-month pre- versus post-index periods within the same cohort using McNemar's and Wilcoxon signed rank tests. Findings were reported for all patients and separately in patients with at least one schizophrenia relapse (schizophrenia-related inpatient or ER visit) during the 12-month pre-index period.

RESULTS

The study cohort included 210 patients (mean age 34.2 years, 69.5% male, 39.1% had Medicaid). From the 12-month pre- to post-index period, the proportion of patients with visits and mean number of visits reduced for all-cause inpatient (67.6% to 22.4%, 1.2 to 0.4), 30-day readmission (12.4% to 2.4%, 0.2 to 0.1), and ER (68.6% to 45.7%, 2.3 to 1.2) visits, whereas the mean number of outpatient visits increased (8.7 to 11.6) (all P < 0.05). Similar trends were observed for mental health- and schizophrenia-related HRU. The trends in HRU in patients with prior relapse were similar with a higher extent of reduction in inpatient and ER use compared to the overall cohort.

CONCLUSION

Initiation of PP1M was associated with reduced acute HRU in patients with schizophrenia, indicating potential clinical and economic benefits, especially in patients with prior relapse.

Evaluation of Prescribing Patterns of Long-Acting Injectable Antipsychotics Within a Community Health System

PURPOSE/BACKGROUND

Long-acting injectable antipsychotics (LAIAs) are used in the management of schizophrenia, bipolar disorder, and related psychiatric conditions. The efficacy of LAIAs has been established in randomized controlled trials; however, usage of LAIAs outside of randomized controlled trials may not correlate to naturalistic prescribing habits. The purpose of this analysis was to evaluate the prescribing patterns of LAIAs within our health system and identify any inconsistencies between medications' published labeling information and clinical practice.

METHODS/PROCEDURES

All patients who received a LAIA at the time of the analysis were included for review. Areas of inconsistency between the prescribed LAIA and each medication's published labeling information were targeted and assessed. Frequency statistics were used to review the following areas for inconsistencies: indication, trial of oral therapy, dose, frequency, and titration method.

FINDINGS/RESULTS

This analysis included 427 patient cases who received a combined 1480 injections during the analysis period. Overall consistency rates between labeling information and prescribed LAIAs within the analysis period were as follows: 71.2% for indication, 67.4% for trial of oral therapy, 94.4% for dose of LAIA, 84.5% for injection frequency, and 93.9% for titration method.

IMPLICATIONS/CONCLUSIONS

Inconsistencies were observed between labeling information and clinical practice for LAIAs prescribed within the community health system. Patients who are more symptomatic and have additional psychological comorbidities are commonly excluded from clinical trials. Alternative dosing may be clinically necessary to obtain an adequate response, and this may have been captured in this review. This analysis may be hypothesis generating for future studies on LAIAs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL TRIALSGOV

NCT02713282.

Long-acting injectable antipsychotics for the treatment of schizophrenia in Spain

Antipsychotics are an essential component in the treatment of schizophrenia. Long-acting injectable formulations (LAI) arose to improve adherence with the associated potential of reducing the risk of relapse. The objective of this article is to analyze the use of LAI antipsychotics in Spain, which is similar to other European countries but with a predominance of the use of second generation LAI, to discuss the possible causes of prescribing differences with respect to other countries (including organizational aspects, attitudes of psychiatrists, patients and family members, and clinical practice guidelines), and to discuss their use in acute psychiatric units, first episode, and in children and adolescents. In our view, while it is necessary to increase existing evidence regarding the advantages of LAI antipsychotics and the differentiation between LAI antipsychotics currently available, their use will likely continue to grow driven by clinical experience.

Three-Year Naturalistic Study On Early Use Of Long-Acting Injectable Antipsychotics In First Episode Psychosis

ABSTRACT

Poor adherence to antipsychotics, which affects outcome, is frequent in first episode psychosis (FEP). Most randomized studies demonstrate no superiority of long-acting injectable antipsychotics (LAI-AP) over oral antipsychotics (OAP). However, participants in these studies represent a minority of patients who may benefit from LAI-AP. Mirror and naturalistic studies generally demonstrate efficacy of LAI-AP on more representative samples, but studies on FEP are scarce.

AIM

To describe LAI-AP's utilization and impact on FEP outcome in a naturalistic setting.

METHODS

A 3-year longitudinal prospective and retrospective descriptive study of all consecutive admissions from two Early Intervention Services for psychosis (EIS) in Montréal, Canada, compared the characteristics and evolution of patients who received LAI-AP for at least 12 months to those who received OAP only.

RESULTS

From 375 FEP patients included, 26,7% received LAI-AP during their follow-up. They were more likely to have poor prognostic factors (male gender, lower premorbid functioning, homelessness, substance use disorder and schizophrenia spectrum diagnoses). Despite a more severe illness and lower functioning in the LAI-AP group, at admission and study endpoint, clinical and functional improvements were observed.

CONCLUSION

Early prescription of LAI-AP seems beneficial in FEP with poor prognostic factors.

Baseline results from the European non-interventional Antipsychotic Long acTing injection in schizOphrenia (ALTO) study

BACKGROUND

The Antipsychotic Long-acTing injection in schizOphrenia (ALTO) study was a non-interventional study across several European countries examining prescription of long-acting injectable (LAI) antipsychotics to identify sociodemographic and clinical characteristics of patients receiving and physicians prescribing LAIs. ALTO was also the first large-scale study in Europe to report on the use of both first- or second-generation antipsychotic (FGA- or SGA-) LAIs.

METHODS

Patients with schizophrenia receiving a FGA- or SGA-LAI were enrolled between June 2013 and July 2014 and categorized as incident or prevalent users. Assessments included measures of disease severity, functioning, insight, well-being, attitudes towards antipsychotics, and quality of life.

RESULTS

For the 572 patients, disease severity was generally mild-to-moderate and the majority were unemployed and/or socially withdrawn. 331/572 were prevalent LAI antipsychotic users; of whom 209 were prescribed FGA-LAI. Paliperidone was the most commonly prescribed SGA-LAI (56% of incident users, 21% of prevalent users). 337/572 (58.9%) were considered at risk of non-adherence. Prevalent LAI users had a tendency towards better insight levels (PANSS G12 item). Incident FGA-LAI users had more severe disease, poorer global functioning, lower quality of life, higher rates of non-adherence, and were more likely to have physician-reported lack of insight.

CONCLUSIONS

These results indicate a lower pattern of FGA-LAI usage, reserved by prescribers for seemingly more difficult-to-treat patients and those least likely to adhere to oral medication.

Comparison of the G and V methods for ventrogluteal site identification: Muscle and subcutaneous fat thicknesses and considerations for successful intramuscular injection

The ventrogluteal site is increasingly recommended for long-acting antipsychotic intramuscular injections; however, it remains infrequently utilized due to nurses' lack of confidence in site identification. The more recent G (geometric) method of ventrogluteal site identification is less subjective and likely more reliable than the V method for successful intramuscular injection outcomes. Knowledge of muscle and subcutaneous fat thicknesses, and the influence of sex and anthropometry on theoretical injection outcome, is necessary to support evidence-based use of the ventrogluteal site. In the presents study, we compared the V and G methods for injection site subcutaneous fat, muscle, and total tissue thicknesses, and theoretical injection outcome (bone injury, intramuscular or subcutaneous), and determined anthropometric predictors of injection outcome. Subcutaneous fat and muscle thicknesses were measured via ultrasound, bilaterally at V and G method sites (28 males, 32 females). Muscle and total tissue were significantly thicker, and successful intramuscular injection significantly more likely, using the G versus V method (75% versus 57%). Females had significantly thicker subcutaneous fat than males at both sites. Even using the G method, 92% of males but only 59% of females, would have a successful intramuscular injection, with remaining females at risk of bone injury (16%) or subcutaneous injection (25%). The G method site is more reliable for successful intramuscular injection, with less risk of bone injury than the V method site. Appropriate needle-length selection is essential for females with a body mass index (BMI) <23 kg m^-2 and weight <60 kg (to avoid bone injury), and BMI >30 kg m^-2 and hip >90 cm (to avoid subcutaneous injection).

Adherence, persistence, and inpatient utilization among adult schizophrenia patients using once-monthly versus twice-monthly long-acting atypical antipsychotics

AIMS

This study compared healthcare resource utilization (HRU), healthcare costs, adherence, and persistence among adult patients with schizophrenia using once-monthly (OM) vs twice-monthly (TM) atypical long-acting injectable (LAI) antipsychotic (AP) therapy.

MATERIALS AND METHODS

A longitudinal retrospective cohort study was conducted using Medicaid claims data from six states. Patients initiated on aripiprazole or paliperidone palmitate were assigned to the OM cohort; risperidone-treated patients were assigned to the TM cohort. HRU and healthcare costs were assessed during the first 12 months following stabilization on the medication. Adherence was measured using the proportion of days covered (PDC) during the first year of follow-up. Persistence to the index medication was measured during the first 2 years following the index date. Comparison between the cohorts was achieved using multivariable generalized linear models, adjusting for demographic and clinical characteristics.

RESULTS

Patients in the OM LAI cohort had lower inpatient HRU and medical costs when compared with patients in the TM cohort. Higher medical costs in the TM LAI cohort offset the higher pharmacy costs in the OM LAI cohort. Mean PDC during the first 12 months of follow-up was higher in the OM cohort than in the TM cohort (0.56 vs 0.50, p < .01). Median persistence was longer in the OM cohort than in the TM cohort (7.5 months vs 5.5 months), as was the hazard of discontinuing the index medication (hazard ratio = 0.83, p = .01). Kaplan-Meier rates of persistence at 1 year were higher for OM patients than for TM patients (37.6% vs 29.6%, p < .01).

LIMITATIONS

This was a Medicaid sample with few aripiprazole LAI patients (5.4% of OM cohort). Medication use was inferred from pharmacy claims.

CONCLUSIONS

Among Medicaid patients in these six states, OM AP treatment was associated with lower HRU, better adherence and persistence, and similar total costs compared to patients on TM treatment.

Real-world data on paliperidone palmitate for the treatment of schizophrenia and other psychotic disorders: a systematic review of randomized and nonrandomized studies

The aim of this study was to perform a systematic review of the effects of 1-month paliperidone palmitate (PP1M) for the treatment of schizophrenia and related psychotic disorders in terms of outcomes reported in real-world evidence studies. A systematic review of real-world randomized and nonrandomized studies with PP1M was performed and is reported according to PRISMA guidelines. Comparative effectiveness data with oral antipsychotics indicate that PP1M has a lower likelihood of relapse-related events, including rehospitalization, and these differences are clinically relevant. A randomized, double-blind study showed that PP1M has no advantage over haloperidol decanoate in the time to treatment failure. Although there was a marked variability across studies, PP1M was not superior to other antipsychotics in terms of study completion rates. Pharmacoeconomic data show that, during a follow-up period of 12 months, the mean total healthcare cost was not significantly different in patients treated with PP1M compared with those receiving oral antipsychotics. The mean maximum prolactin levels were significantly higher with PP1M than with haloperidol decanoate; however, neither drug differs in the frequency of prolactin-related adverse events. Results on prolactin-related adverse events were inconsistent in two randomized comparisons with oral antipsychotics and were not reported in a randomized comparison with aripiprazole. There were no significant differences between haloperidol decanoate and PP1M in the severity of abnormal involuntary movements and parkinsonism, or in the incidence of tardive dyskinesia; however, patients treated with haloperidol decanoate showed greater worsening of akathisia and required treatment for parkinsonism and akathisia significantly more frequently than patients who received PP1M. In conclusion, real-world data that originate from both pragmatic randomized clinical trials and observational studies indicate that PP1M is superior to oral antipsychotics in delaying the time to relapse or treatment failure. Furthermore, the pharmacoeconomic data reviewed for this article suggest that the advantages of PP1M compared with oral antipsychotics are not associated with an increased total cost for healthcare providers.

All-cause hospitalization and associated costs in patients with schizophrenia or bipolar disorder initiating long-acting injectable antipsychotics

OBJECTIVE

To compare all-cause hospitalization and associated costs among patients with schizophrenia or bipolar disorder (BD) treated with long-acting injectable antipsychotics (LAIs).

METHODS

The Truven MarketScan Medicaid claims database was used to identify patients with schizophrenia; MarketScan Medicaid and commercial claims databases were used to identify BD. Adult patients with ≥1 LAI claim from January 1, 2013-June 30, 2014 (ID period) were identified. The first day of LAI initiation was the index date; patients were followed for ≥1 year. Logistic and general linear regression models were used to estimate the risk of hospitalization and associated costs.

RESULTS

Adjusted analyses showed that, in the schizophrenia cohort, risks of hospitalization were statistically significantly higher in the haloperidol [OR (95% CI) = 1.51 (1.05-2.16); HR (95% CI) = 1.35 (1.05-1.73)] and risperidone [OR (95% CI) = 1.58 (1.07-2.33); HR (95% CI) = 1.33 (1.01-1.74)] cohorts than in the aripiprazole once monthly extended release (AOM 400) cohort. Similarly, in patients with BD, risks of hospitalization were significantly higher in haloperidol [OR (95% CI) = 1.49 (1.01-2.19); HR (95% CI) = 1.33 (1.03-1.73)] and risperidone [OR (95% CI) = 1.78 (1.19-2.66); HR (95% CI) = 1.33 (1.01-1.75)] than in AOM400. No statistically significant differences in hospitalization costs were observed in either disease group.

CONCLUSIONS

Although the study results may be subject to confounding variables that are not contained in claims databases, such as disease severity, it appears that AOM400 may be more effective than haloperidol and risperidone LAIs among patients with schizophrenia or BD.

Drug Utilization of Japanese Patients Diagnosed with Schizophrenia: An Administrative Database Analysis

Background and objective

Patient characteristics require consideration for optimal treatment in order to achieve clinical remission for an improved quality of life and social functioning. Prior evidence supports long-acting injectable antipsychotics (LAIs) in the relapse prevention of schizophrenia. This study aimed to characterize Japanese patients diagnosed with schizophrenia and to compare the outcomes of LAIs and oral antipsychotics (AP) in re-hospitalization or emergency room visit rates.

Methods

Diagnostic Procedure Combination (DPC) designated hospital data in Japan with ICD-10 code F20x between July 2013 and June 2015 were obtained from the Medical Data Vision Co. Ltd. Patients were divided into sub-groups in order to filter co-diagnostic conditions. Differences across sub-groups were assessed using a Chi square test or ANOVA. The incidence rate ratio (IRR) was calculated to compare the re-hospitalization (30 days post discharge) or emergency room visit rates between pharmacotherapy groups of oral versus LAI or typical versus atypical within LAI patients. Adjusted estimates were provided by propensity scores that were assigned for age, gender, and Charlson co-morbidity index (CCI) scores.

Results

A quarter of the data sourced were attributed to co-diagnosis with dementia/delirium with antipsychotic prescriptions despite reported risks of antipsychotic use. After adjusting for age, gender, and co-morbidity, LAI reduced re-hospitalization and emergency (ER) visit rates more than oral APs (LAI vs. oral IRR = 0.38 (95% CI 0.17–0.74), IRR = 0.56 (95% CI 0.34–0.91), respectively).

Conclusion

The study findings demonstrate usage of DPC hospital data in schizophrenia pharmacotherapy based on classification of co-diagnoses. In comparison with oral APs only, LAI utilization can provide an opportunity for reduced re-hospitalization and ER visit rates among patients with schizophrenia.

Dual-stimuli responsive injectable microgel/solid drug nanoparticle nanocomposites for release of poorly soluble drugs

An in situ forming implant (ISFI) for drug delivery combines the potential to improve therapeutic adherence for patients with simple administration by injection. Herein, we describe the preparation of an injectable nanocomposite ISFI composed of thermoresponsive poly(N-isopropylacrylamide) based microgels and solid drug nanoparticles. Monodisperse poly(N-isopropylacrylamide) or poly(N-isopropylacrylamide-co-allylamine) microgels were prepared by precipitation polymerisation with mean diameters of approximately 550 nm at 25 °C. Concentrated dispersions of these microgels displayed dual-stimuli responsive behaviour, forming shape persistent bulk aggregates in the presence of both salt (at physiological ionic strength) and at body temperature (above the lower critical solution temperature of the polymer). These dual-stimuli responsive microgels could be injected into an agarose gel tissue mimic leading to rapid aggregation of the particles to form a drug depot. Additionally, the microgel particles aggregated in the presence of other payload nanoparticles (such as dye-containing polystyrene nanoparticles or lopinavir solid drug nanoparticles) to form nanocomposites with high entrapment efficiency of the payload. The resulting microgel and solid drug nanoparticle nanocomposites displayed sustained drug release for at least 120 days, with the rate of release tuned by blending microgels of poly(N-isopropylacrylamide) with poly(N-isopropylacrylamide-co-allylamine) microgels. Cytotoxicity studies revealed that the microgels were not toxic to MDCK-II cells even at high concentrations. Collectively, these results demonstrate a novel, easily injectable, nanocomposite ISFI that provides long-term sustained release for poorly water-soluble drugs without a burst release.

Treatment Duration With Long-Acting Injectable Antipsychotics After In-hospital Initiation: A Retrospective Cohort Study

PURPOSE

Long-acting injectable (LAI) antipsychotics are recommended especially for patients with multiple admissions and poor adherence. The empirical basis of this strategy is a matter of debate.

METHODS

In a retrospective cohort study extending over 6 years, all patients admitted for inpatient treatment with a diagnosis of psychotic disorders according to International Statistical Classification of Diseases and Related Health Problems, 10th Revision (F2) were screened for treatment episodes with a new start of an LAI. Indication for LAI treatment was based primarily on previous medication default. All-cause discontinuation was used as a measure of treatment efficiency. Patients with early dropout (termination of LAI treatment within 6 months) were compared with patients with longer treatment (treatment >6 months) for sociodemographic and treatment variables using bivariate and multivariate analyses.

RESULTS

A total of 194 treatment episodes with new start of LAIs were identified. Almost one half dropped out within 6 months (early dropout: n = 95 [49%]; mean duration, 2.2 months). Termination of treatment was mainly due to patients' refusal to continue. However, almost a third of patients (61; 31.4%) had a treatment duration of more than 2 years. In a multivariate Cox regression model, longer treatment duration was associated with older age (P = 0.05), not being single (P = 0.04), fewer admissions during the year preceding the index episode (P = 0.02), and better ratings for adherence at the index episode (P = 0.03).

CONCLUSIONS

There are both more patients than expected leaving the treatment early and more patients than expected staying for long periods, even among patients with a history of poor adherence.

Productivity and deadweight losses due to relapses of schizophrenia in Japan

BACKGROUND

No study has examined the financial impact of relapses on schizophrenia from the perspective of Japanese society. This study aimed to estimate the societal costs in Japan caused by the relapses of schizophrenia.

METHODS

The societal costs in Japan in 2013 due to relapses of schizophrenia were estimated by summing the productivity loss and deadweight loss caused by schizophrenia relapses in 2013. Deterministic sensitivity analysis was conducted for deadweight loss rate, relapse rate, and patient income.

RESULTS

Japan incurred JPY 55,039 million societal costs because of relapses in 2013. This consists of JPY 3,990 million for productivity loss and JPY 51,049 million for deadweight loss. Rate of deadweight loss is the most significant cost driver in the sensitivity analysis.

CONCLUSION

Relapses of schizophrenia could generate huge amount of societal costs by reducing labor productivity and economic efficiency. To curb these costs, relapse prevention is desired in treating schizophrenia.

Clinical benefits and impact of early use of long-acting injectable antipsychotics for schizophrenia

AIM

Results from clinical trials support the use of oral antipsychotics for treatment of early or first-episode psychosis in patients with schizophrenia. This paper will review literature on the advantages of early initiation of treatment for schizophrenia and the clinical benefits of early use of long-acting injectable antipsychotics (LAIs).

METHOD

A comprehensive literature review was conducted to identify published literature on the use of LAIs early in the treatment of schizophrenia.

RESULTS

Although there is a higher response rate to initial antipsychotic treatment for a first-episode of schizophrenia than with subsequent antipsychotic treatment, we have not effectively addressed this issue. Poor adherence to treatment is a primary cause of relapse and rehospitalization in subsequent years and was associated with higher relapse rates resulting in devastating effects and substantial economic burden. The costs of nonadherence were estimated to be $1.48 billion. Thus, a major challenge with the treatment of schizophrenia is changing poor adherence to persistence with antipsychotic therapy. LAIs are known to be at least as effective as oral antipsychotics for treating schizophrenia, and yet are underutilized. Further, LAIs address many of the problems associated with adherence to oral therapy. Recent evidence suggests that LAIs are effective for treating first-episode psychosis and for early initiation of treatment for schizophrenia.

CONCLUSION

Although consistent antipsychotic treatment represents a critical part of treatment, a person-centred approach to treating schizophrenia is essential for all aspects of care, including establishing and maintaining a therapeutic alliance, strengthening shared decision-making and adherence, and achieving long-lasting recovery.

A long-acting integrase inhibitor protects female macaques from repeated high-dose intravaginal SHIV challenge

Long-acting GSK1265744 (GSK744 LA) is a strand transfer inhibitor of the HIV/SIV (simian immunodeficiency virus) integrase and was shown to be an effective preexposure prophylaxis (PrEP) agent in a low-dose intrarectal SHIV (simian-human immunodeficiency virus) rhesus macaque challenge model. We examined the pharmacokinetics and efficacy of GSK744 LA as PrEP against repeat high-dose intravaginal SHIV challenge in female rhesus macaques treated with Depo-Provera (depot medroxyprogesterone acetate), which promotes viral transmission vaginally. When Depo-Provera-treated female rhesus macaques were dosed with GSK744 LA (50 mg/kg) monthly, systemic and tissue drug concentrations were lower than previously observed in male rhesus macaques. GSK744 concentrations were fivefold lower on average in cervical tissues than in rectal tissues. Eight female rhesus macaques were treated with GSK744 LA at week 0, and four female rhesus macaques served as controls. All animals received a high-dose challenge of SHIV162P3 at week 1. No infection was detected in GSK744 LA-treated rhesus macaques, whereas viremia was detected 1 to 2 weeks after SHIV challenge in all control animals. The GSK744 LA-treated rhesus macaques were given a second administration of drug at week 4 and further challenged at weeks 5 and 7. GSK744 LA treatment protected six of eight female rhesus macaques against three high-dose SHIV challenges, whereas all control animals became infected after the first challenge (P = 0.0003, log-rank test). These results support further clinical development of GSK744 LA for PrEP.

New approaches to antiretroviral drug delivery: challenges and opportunities associated with the use of long-acting injectable agents

Research on improved treatment of HIV infection and pre-exposure prophylaxis continues. Poor adherence to treatment is the critical risk factor for virological failure and resistance development, and long-acting formulations of anti-HIV medications that need only infrequent dosing may facilitate long-term therapeutic responses. Importantly, long-acting formulations of therapeutic agents have been used to avoid missing doses or treatment fatigue to prescribed lifelong medications in a number of different medical fields, with demonstrable success. However, such formulations are associated with challenges, such as the prolongation of adverse events with the persistence of drug concentrations and concerns over the development of resistance as a result of selective pressure as drug concentrations decline. Furthermore, long-acting injectable formulations of antiretroviral (ARV) agents with infrequent dosing may be advantageous over daily oral drug intake to prevent transmission of HIV. However, the knowledge on protective drug concentrations and frequency of dosing is poor to date and implementation globally is challenging. Importantly, if nanoformulations of ARVs requiring lower drug doses become available globally, the potential for treatment cost reductions is high, as, especially in resource-limited settings, the active pharmaceutical ingredient accounts for the greater proportion of the total cost of the medicine. In conclusion, different long-acting ARVs are being studied in phase I/II for both the treatment and prevention of HIV infection, and research on administering these agents in combination has started.

Adherence and rehospitalizations in patients with schizophrenia: evidence from Japanese claims data

BACKGROUND

The aim of this study is to analyze if there is a relationship between adherence to antipsychotic medication and rehospitalization for patients diagnosed with schizophrenia in Japan.

METHODS

Based on Japanese claims data, we constructed three patient groups based on their medication possession ratio (MPR). Controlling for potential confounders, a Cox proportional hazard model was employed to assess if medication adherence affects the risk of rehospitalization.

RESULTS

Patients with good adherence (MPRs from 0.8-1.1) had the lowest rates of admission. Both poor adherence (MPRs <0.8) and overadherence (MPRs >1.1) were associated with a significant higher risk of rehospitalization with hazard ratios of 4.7 and 2.0, respectively.

CONCLUSION

The results of this study support the notion that good adherence to antipsychotic medication reduces the risk of rehospitalization of schizophrenia patients. Appropriate measures should be taken to improve adherence of schizophrenia patients.

Medication adherence in patients with psychotic disorders: an observational survey involving patients before they switch to long-acting injectable risperidone

BACKGROUND

Maintaining antipsychotic therapy in psychosis is important in preventing relapse. Long-acting depot preparations can prevent covert non-adherence and thus potentially contribute to better patient outcomes. In this observational survey the main objective is to evaluate medication adherence and its determinants for oral treatment in a large sample of patients with psychosis.

METHODS

In this cross-sectional survey medication adherence for oral treatment was assessed by patients using the patient-rated Medication Adherence Questionnaire (MAQ). Data were collected by physicians on patients with a recent acute psychotic episode before switching to long-acting injectable risperidone. Other evaluations included disease severity (Clinical Global Impression - Severity), patients' insight (Positive and Negative Syndrome Scale item G12), treatment acceptance (clinician-rated Compliance Rating Scale), and therapeutic alliance (patient-rated 4-Point ordinal Alliance Scale).

RESULTS

A total of 399 psychiatrists enrolled 1,887 patients (mean age 36.8±11.9 years; 61.6% had schizophrenia). Adherence to oral medication was "low" in 53.2% of patients, "medium" in 29.5%, and "high" in 17.3%. Of patients with psychiatrist-rated active acceptance of treatment, 70% had "medium" or "high" MAQ scores (P<0.0001). Medication adherence was significantly associated with therapeutic alliance (4-Point ordinal Alliance Scale score; P<0.0001). Patient age was significantly associated with adherence: mean age increased with greater adherence (35.6, 36.7, and 38.6 years for patients with "low", "medium", and "high" levels of adherence, respectively; P=0.0007), while age <40 years was associated with "low" MAQ classification (P=0.0003). Poor adherence was also associated with a diagnosis of schizophrenia (P=0.0083), more severe disease (Clinical Global Impression - Severity ≥4; P<0.0001), and lower insight (Positive and Negative Syndrome Scale-G12 ≥4; P<0.0001).

CONCLUSION

Self-reported adherence was low in most patients, with a strong positive association between self-reported adherence and psychiatrists' assessment of treatment acceptance. Understanding factors associated with poor medication adherence may help physicians to better manage their patients, thereby improving outcomes.

Consensus statements on adherence issues in schizophrenia for Hong Kong

AIM

In view of the clinical importance of the adherence issues in schizophrenia management, a consensus group of experienced local psychiatrists and nurse specialists gathered to outline a number of consensus statements for clinicians to consider enhancing adherence in their patients.

PROCESS

Prior to the consensus group meeting, three core members drafted eight statements on the issue of adherence in schizophrenia. Using a modified Delphi method, published literature and published guidelines regarding the management of schizophrenia were reviewed by the full panel during the group meeting. After discussion and reflection from each individual member of the consensus group, the eight statements were reworded and electronically voted on anonymously in two steps: acceptance on quality of evidence and practicability in implementation.

RESULTS

After modifications of the original statements, there was very high overall level of agreement and acceptance (reaching international standard) on all the five areas of adherence within the eight statements of the finalised statement.

CONCLUSIONS

The present consensus statements are the first in Hong Kong to address systematically adherence issues in schizophrenia management. They include areas on adherence assessment and definition, treatment strategies in enhancing adherence, and treatment considerations at specific phases of schizophrenia. They are tailored to be of practical utility in the local Hong Kong setting.

Adherence challenges and long-acting injectable antipsychotic treatment in patients with schizophrenia

Medication nonadherence has been associated with persistence of psychotic symptoms, relapse, and hospitalization in patients with schizophrenia. Patients with untreated psychosis are significantly less likely to achieve remission, whereas antipsychotic drug adherence has been associated with recovery. As such, adherence to antipsychotic drug treatment is a key issue for nurses and treatment team members caring for patients who typically are on chronic, progressive disease course. Long-acting injectable (LAI) anti-psychotic drugs, developed to improve adherence and provide and alternative antipsychotic drug treatment fro schizophrenia, have been associated with improved treatment outcomes including reduction of relapse rates approximately 30% and reduction in hospitalizations. However, LAI antipsychotic drugs remain underutilized in the United States despite a growing body of literature supporting positive outcomes of LAI versus oral antipsychotic drugs. Mental health nurses are in a key position to support improved adherence inpatients with schizophrenia through use of practical educational strategies that help patients, family members, and health care providers better understand and manage treatment.

Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia

Schizophrenia is a debilitating chronic disease that requires lifelong medical care and supervision. Even with treatment, the majority of patients relapse within 5 years, and suicide may occur in up to 10% of patients. Poor adherence to oral antipsychotics is the most common cause of relapse. The discontinuation rate for oral antipsychotics in schizophrenia ranges from 26% to 44%, and as many as two-thirds of patients are at least partially nonadherent, resulting in increased risk of hospitalization. A very helpful approach to improve adherence in schizophrenia is the use of long-acting injectable (LAI) antipsychotics, although only a minority of patients receive these. Reasons for underutilization may include negative attitudes, perceptions, and beliefs of both patients and health care professionals. Research shows, however, significant improvements in adherence with LAIs compared with oral drugs, and this is accompanied by lower rates of discontinuation, relapse, and hospitalization. In addition, LAIs are associated with better functioning, quality of life, and patient satisfaction. A need exists to encourage broader LAI use, especially among patients with a history of nonadherence with oral antipsychotics. This paper reviews the impact of nonadherence with antipsychotic drug therapy overall, as well as specific outcomes of the schizophrenia patient, and highlights the potential benefits of LAIs.