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

Background: Schizophrenia and schizoaffective disorder are treated with antipsychotic drugs. Some patients show treatment-resistant forms of psychotic disorders and, in this case, they can be treated with clozapine. In these patients and based on previous reviews on novel antipsychotic drugs, it is important to know whether an add-on therapy with new drugs can ameliorate the positive and negative schizophrenic scale (PANSS) total score. Objective: The aim of this review is to suggest an appropriate treatment for patients with treatment-resistant forms of psychotic disorders. A combination of current available antipsychotic drugs with novel antipsychotic or modulating drugs might improve negative schizophrenic symptoms and cognitive function and thereby social functioning and quality of life. Results: The mechanisms of action, the therapeutic effects and the pharmacokinetic profiles of novel antipsychotic drugs such as cariprazine, brexipiprazole and lumateperone are up-dated. Published case reports of patients with treatmentresistant psychoses are also discussed. These patients were treated with clozapine but a high PANSS total score was observed. Only an add-on therapy with cariprazine improved the score and, above all, negative schizophrenic symptoms and cognitive functions. To ensure a constant antipsychotic drug concentration, long-acting injectable antipsychotic drugs may be a choice for a maintenance therapy in schizophrenia. New modulating drugs, such as receptor positive allosteric modulators (N-methyl-D-aspartate receptor; subtype 5 of the metabotropic glutamatergic receptor) and encenicline, an alpha7 nicotinic cholinergic receptor agonist, are being investigated in preclinical and clinical trials. Conclusion: In clinical trials, patients with treatment-resistant forms of psychosis should be examined to know whether a combination therapy with clozapine and a novel antipsychotic drug can ameliorate the PANSS total score. In schizophrenia, long-acting injectable antipsychotic drugs are a safe and tolerable maintenance therapy. In further clinical studies, it should be investigated whether patients with treatment-resistant forms of psychoses can improve negative schizophrenic symptoms and cognitive functions by an add-on therapy with cognition enhancing drugs.

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Effectiveness of long-acting injectables and clozapine in a real-world setting during the early-stages of psychotic illness

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.088 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S105-S105

Author(s):

E.G. Ostinelli ◽

E. Guanella ◽

S. Cavallotti ◽

C. Casetta ◽

A. D’Agostino

Keyword(s):

Psychotic Disorders ◽

Pharmacological Intervention ◽

Psychotic Illness ◽

Treatment As Usual ◽

Early Stages ◽

Hospitalization Rates ◽

Real World Setting ◽

The Difference ◽

Competing Interest ◽

Long Acting

IntroductionIntervention in the early-stages of psychosis may be able to shape the clinical course; critical period (CP) is best represented by the first 5 years from first admission (FA).ObjectivesTo investigate the effectiveness of pharmacological intervention within and beyond the CP.Aims(1) To compare hospitalization rates of patients stabilized on treatment with LAIs and CLZ. (2) To determine whether treatment with LAIs and CLZ within CP can influence hospitalization rates.MethodsData were retrospectively collected from patients diagnosed with non-affective psychoses with FA between 2000 and 2014; 200 patients were then divided into three groups, according to stabilized treatment regimen during the final year of observation: treatment as usual (TAU), CLZ, LAIs. hospitalization duration (HSPD) and frequency (HSP) were calculated for each group.ResultsDespite a major severity before assignment to either CLZ or LAIs treatment, HSPD and HSP in both groups shifted below those observed for the TAU arm. Patients who began treatment with LAIs within the CP showed a highly significant decrease of both HSPD and HSP (respectively 17.4 ± 18 vs. 2.6 ± 8.2; Z = −2.856; P < 0.005 and 1.1 ± 0.8 vs. 0.2 ± 0.5; Z = −3.115; P < 0.005). No significant changes in hospitalization rates were observed for subjects who began treatment with LAIs after the CP.ConclusionsOur study confirms that treatment with either CLZ or LAIs significantly impacts the course of psychotic disorders. The data seem to suggest that LAIs and CLZ should be considered more effective than conventional oral antipsychotics in the early-stages of psychotic illness. The difference among treatments tends to wane beyond the CP, especially for LAIs.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Antipsychotic and anticholinergic drugs

New Oxford Textbook of Psychiatry ◽

10.1093/med/9780198713005.003.0064 ◽

2020 ◽

pp. 639-667

Author(s):

Herbert Y. Meltzer ◽

William V. Bobo

Keyword(s):

Developmental Disorders ◽

Negative Symptoms ◽

Psychotic Disorders ◽

Drug Action ◽

Anticholinergic Drugs ◽

Efficacy And Safety ◽

Drug Induced ◽

Minimal Weight ◽

Long Acting

Antipsychotic drugs are utilized for far more than the treatment of psychosis in schizophrenia, their first indication. They now find wide use in a variety of psychotic disorders, mood disorders, developmental disorders, and drug-induced disorders. The classification of drugs as typical or atypical is based on their differences in extra-pyramidal side effects (EPS). This chapter emphasizes the greater diversity, efficacy, and safety of the atypical drugs, and the risk of tardive dyskinesia of the typical drugs. The atypical drug action may produce improvement in cognitive function and negative symptoms, as well as psychosis and mood in some patients. This diversity includes atypical drugs which produce minimal weight gain. Long-acting injectable formulations are recommended for non-adherent patients. The exceptional ability of clozapine to reduce the risk for suicide and to decrease mortality in schizophrenia is discussed. Anticholinergic and other drugs to treat EPS are also discussed.

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S206. ARIPIPRAZOLE LONG-ACTING INJECTABLE IN SCHIZOPHRENIA DURING PREGNANCY: A CASE REPORT

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa031.272 ◽

2020 ◽

Vol 46 (Supplement_1) ◽

pp. S117-S117

Author(s):

Eva Sole ◽

Juan Ignacio Duran ◽

Sara Lera ◽

Anna Torres ◽

Susana Andres ◽

...

Keyword(s):

Case Report ◽

Mental Disorder ◽

Clinical Case ◽

Psychotic Disorders ◽

Hospital Admissions ◽

Treatment Compliance ◽

Antipsychotic Treatment ◽

Pregnancy And Postpartum ◽

Long Acting ◽

Psychiatric Complications

Abstract Background Long-acting injectable (LAI) antipsychotics provide some advantages in treatment compliance of psychotic disorders. However, information about their effects during pregnancy is still very limited. We expose a clinical case of aripiprazole LAI use in a pregnant woman diagnosed of schizophrenia. Methods A non-systematic review using Pubmed was conducted using the following terms: schizophrenia, pregnancy, aripiprazole and aripiprazole LAI. A clinical record review was performed for the clinical case report. Results We report the case of a 30-year-old woman diagnosed of schizophrenia. She required several hospital admissions in the past because of the mental disorder and the lack of treatment adherence, what was the consequence of having no insight of illness and her pregnancy desires. She was initially treated with risperidone, suffering from some adverse effects like prolactine elevation and amenorrhea. In the last hospital admission, she started treatment with aripiprazol 20mg, having a good tolerability and being finally changed into aripiprazole LAI 400mg/28days. No incidences were reported and stability was achieved. After five months, she became pregnant and started being followed up in the Perinatal Mental Health Unit that belongs to the same hospital. The severity of the mental disorder and her stability at that moment made psychiatrists; obstetricians and patient decide to keep the antipsychotic treatment with subsequent appointments. The goal was to supervise psychopathology and blood tests during pregnancy. Prolactine was in physiologic levels and there were no obstetric complications. She finally delivered at 41 gestational weeks to a 3465g baby girl (Apgar 1’: 9 Apgar 5’: 10). No neonatal complications were reported. The Stafford interview was also administered in order to explore her social, obstetric and psychological background as well as possible psychiatric complications due to pregnancy and puerperium. No psychiatric complications were reported. Postpartum Bounding Questionnaire was also administered. No bounding disorder was detected. Discussion Pregnancy and postpartum are periods that carry a high risk of illness onset or recurrence in women with severe mental disorders, such as schizophrenia. Having a good control of the symptoms may prevent from risks to both patient and child, due to the important influence that exists on the development of the baby and the mother-infant relationship.

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P.464 The impact of long-acting injectable aripiprazole in the management of psychotic disorders

European Neuropsychopharmacology ◽

10.1016/j.euroneuro.2020.09.341 ◽

2020 ◽

Vol 40 ◽

pp. S262-S263

Author(s):

Á.D.L. Martín Pérez ◽

M.I. Ibernón Caballero ◽

M.Á. Bernal López ◽

K.A. Rozmus X ◽

F. Valdivia Muñoz ◽

...

Keyword(s):

Psychotic Disorders ◽

Long Acting ◽

The Impact

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Somatic Treatments for Psychotic Disorders

10.1093/med/9780199331505.003.0006 ◽

2016 ◽

Author(s):

Justin C. Ellison ◽

Jason B. Rosenstock ◽

Michael J. Marcsisin

Keyword(s):

Side Effects ◽

Electroconvulsive Therapy ◽

Gold Standard ◽

Psychotic Disorders ◽

Mood Stabilizers ◽

Positive Symptoms ◽

Second Generation Antipsychotics ◽

Treatment Refractory ◽

Long Acting ◽

Somatic Therapies

A variety of somatic therapies can be used to treat individuals suffering from psychosis. Most commonly, providers will prescribe antipsychotics, which generally block dopamine receptors and are particularly useful at reducing positive symptoms. Second-generation antipsychotics have fewer movement side effects than older agents do, but they are more expensive and have more metabolic side effects. Long-acting injectable (LAI) antipsychotics can be useful for improving outcomes, especially in non-adherent patients, and clozapine is the gold standard for treatment-refractory psychosis. Other agents may be useful for adjunct therapy, or in early psychosis, such as antidepressants, mood stabilizers, and benzodiazepines. In this chapter, we will also review other somatic therapies such as electroconvulsive therapy (ECT) and other neuromodulation approaches.

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Community perceptions of barriers to management of chronic psychotic disorders and knowledge and attitudes about long-acting injectable antipsychotic medication: qualitative study in Dar es Salaam, Tanzania

BJPsych Open ◽

10.1192/bjo.2020.4 ◽

2020 ◽

Vol 6 (2) ◽

Cited By ~ 1

Author(s):

Carol Blixen ◽

Isaac Lema ◽

Jessie Mbwambo ◽

Sylvia Kaaya ◽

Jennifer B. Levin ◽

...

Keyword(s):

Medication Adherence ◽

Focus Groups ◽

Psychotic Disorders ◽

Mental Healthcare ◽

Community Context ◽

Sub Saharan Africa ◽

Behavioural Intervention ◽

Cross Sectional ◽

Sub Saharan ◽

Long Acting

Background Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10–24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA. Aims To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania. Method In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes. Results Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context. Conclusions Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.

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Comparison of clinical outcomes associated with long-acting injectable antipsychotics in people with psychotic disorders: an electronic case register study

The Lancet ◽

10.1016/s0140-6736(17)30473-7 ◽

2017 ◽

Vol 389 ◽

pp. S77

Author(s):

Rashmi Patel ◽

Edward Chesney ◽

Matthew Taylor ◽

David Taylor ◽

Philip McGuire

Keyword(s):

Clinical Outcomes ◽

Psychotic Disorders ◽

Case Register ◽

Long Acting

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Long-acting injectable antipsychotic (LAI) prescribing trends during COVID-19 restrictions in Canada: a retrospective observational study

BMC Psychiatry ◽

10.1186/s12888-021-03646-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Kyle A. McKee ◽

Candice E. Crocker ◽

Philip G. Tibbo

Keyword(s):

Psychotic Disorders ◽

Public Awareness ◽

Healthcare Services ◽

Prescribing Practices ◽

Patient Level ◽

Level Data ◽

Gender And Age ◽

Prescribing Trends ◽

Concomitant Medications ◽

Long Acting

Abstract Background The COVID-19 pandemic has had significant impacts on how mental health services are delivered to patients throughout Canada. The reduction of in-person healthcare services have created unique challenges for individuals with psychotic disorders that require regular clinic visits to administer and monitor long-acting injectable antipsychotic medications. Methods To better understand how LAI usage was impacted, national and provincial patient-level longitudinal prescribing data from Canadian retail pharmacies were used to examine LAI prescribing practices during the pandemic. Prescribing data on new starts of medication, discontinuations of medications, switches between medications, antipsychotic name, concomitant medications, payer plan, gender and age were collected from January 2019 to December 2020 for individuals ≥18-years of age, and examined by month, as well as by distinct pandemic related epochs characterized by varying degrees of public awareness, incidence of COVID-19 infections and public health restrictions. Results National, and provincial level data revealed that rates of LAI prescribing including new starts, discontinuations and switches between LAI products remained highly stable (i.e., no statistically significant differences) throughout the study period. Conclusions Equal numbers of LAI new starts and discontinuations prior to and during the pandemic suggests prescribing of LAI antipsychotics, for those already in care, continued unchanged throughout the pandemic. The observed consistency of LAI prescribing contrasts with other areas of healthcare, such as cardiovascular and diabetes care, which experienced decreases in medication prescribing during the COVID-19 pandemic.

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M209. TO WHOM WE PRESCRIBE LONG ACTING ANTPSYCHOTICS AT DISCHARGE FROM HOSPITAL?

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa030.521 ◽

2020 ◽

Vol 46 (Supplement_1) ◽

pp. S216-S216

Author(s):

Alp Ucok ◽

Olcay Şenay ◽

Zhala Mursalova ◽

Shahriyar Gadimov

Keyword(s):

Logistic Regression ◽

Psychotic Disorder ◽

Psychotic Disorders ◽

Treatment Resistance ◽

Involuntary Hospitalization ◽

Older Inpatients ◽

History Of ◽

Long Acting ◽

Abuse Treatment ◽

Discharge From Hospital

Abstract Background Although the growing evidence show the advantages of long acting injectable (LAI)antipsychotics on treatment of psychotic disorders, characteristics of the patients with psychotic disorders using LAI is not studied enough. The aim of this retrospective study is to understand the clinical characteristics of the patients with psychotic disorders to whom any LAI was prescribed at discharge from hospital Methods We screened the files of 400 inpatients with psychosis spectrum disorders who were treated in inpatient units of Istanbul Faculty of Medicine, Department of Psychiatry between 01.01.2014-01.016.2019. We recorded the last admission if the patient had more than one hospitalization. We compared the variables including illness duration, diagnosis, presence of involuntary hospitalization, insight, substance/alcohol abuse, forensic problems between those who were prescribed LAI and others. We also applied logistic regression analysis to detect the independent predictors of LAI prescription. Results Thirty-nine percent of the patients were given LAI at discharge. Patients with schizophrenia and schizoaffective disorders were more common compared to psychotic disorder NOS/schizophreniform disorder in LAI group (p<0.001). Those who prescribed LAI were older and had longer duration of psychotic disorder. Poor insight at admission, past and present noncompliance, involuntary admission (64,5% vs 35,5%, p=0.003) and history of forensi problems (63% vs 37%, p=0.01)were more common in LAI group. Past ECT treatment, antipsychotic polypharmacy and LAI treatment in past were more common in LAI group. Lack of insight at admission, history of LAI treatment before and noncompliance to medications before hospitalization were appeared as predictors of LAI prescription at discharge in logistic regression. We found no relationship between LAI prescription and drug abuse, treatment resistance and psychiatric comorbidity. Discussion Our findings suggest that LAIs were prescribed to chronic and older inpatients with lack of insight, and compliance at admission. The patients who were prescribed LAI also had indirect indicators of poor outcome, like previous ECT and polypharmacy. Contrary to previous reports, we found no difference in alcohol/substance abuse between those who were prescribed LAI and others.

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