Speaker: Include LAI antipsychotics in treatment of schizophrenia

Long-acting injectable antipsychotics benefit certain patients and should be included in the treatment of schizophrenia, according to a presenter at the NEI Max virtual conference.

“Irreversible functional decline occurs with each relapse, so we want to minimize the number of relapses that a person experiences in their lifetime,” Leslie Citrome, MD, MPH, clinical professor of psychiatry and behavioral sciences at New York Medical College, said in a presentation. “Preventing relapse is a key goal in our treatment of patients with schizophrenia and is reflected in many international clinical guidelines for schizophrenia. Unfortunately, most of our patients with schizophrenia will relapse.”

Approximately 80% of patients experiencing a first psychotic episode relapse within 5 years, according to study findings. Further results suggested that stopping medication is the most powerful predictor of first-episode relapse.

According to Citrome, consistent medication treatment is key in preventing relapse. He noted that he tells his patients and their families that within 2 years, approximately 75% relapse when off medications compared with 25% when on medications, meaning medications are not perfect but can offer a significant benefit.

Clinicians may overestimate adherence for several reasons, including potential bias to overestimate adherence because of nonadherence being viewed as failure and assumptions that lack of adequate response may be treatment resistance. Risk factors for nonadherence differ for each patient and can change over time but may include prior nonadherence, cognitive impairment, lack of family/social support, financial problems, adverse events and stigma attached to illness, according to Citrome.

Use of long-acting injectable (LAI) antipsychotics is associated with several potential advantages:

• reduces dosage deviations;

• eliminates uncertainty regarding adherence status;

• helps increase focus on reasons for poor response to medication;

• eliminates requirement for daily pill; and

• eliminates abrupt loss of efficacy if a doss is missed.

Citrome noted several potential obstacles related to LAI antipsychotics, such as anti-shot sentiment and stigma, lack of infrastructure in outpatient settings, overburdened public agencies and acquisition cost. Earlier use of LAI antipsychotics can potentially decrease the time spent experiencing antipsychotic symptoms and number of psychotic episodes, and it allows for rapid identification of overt nonadherence and elimination of covert nonadherence.

One study found that LAI antipsychotics reduce risk for rehospitalization after first hospitalization for schizophrenia. Further, a survey of patients with more than 3 months of LAI antipsychotic experience preferred the injectable formulation and 70% felt better supported in their illness because of regular contact with the doctor or nurse who administered the injection.

According to Citrome, although the COVID-19 pandemic has incurred some changes that affect LAI antipsychotics, such as reduced office visits and the closing of some clinics, LAI antipsychotics remain superior vs. their oral equivalent in helping patients stay out of the hospital and relapse-free.

“We think about adherence as probably one of the most common reasons why someone is not doing well,” Citrome said. “LAI antipsychotics use is one way of addressing this, and it certainly addresses the guesswork about adherence status. Patients ultimately will often prefer them, provided they're offered as a non-punitive, elective choice, and they certainly can still be given today during the public health emergency.”