Prospective 6-month follow-up of patients prescribed risperidone long-acting injection: factors predicting favourable outcome

Mental healthcare utilisation by patients before and after receiving paliperidone palmitate treatment: mirror image analyses

OBJECTIVES

To compare mental healthcare use and healthcare professional (HCP) contacts for patients before and after initiation of paliperidone palmitate.

SETTING

The South London and Maudsley NHS Foundation Trust (SLAM) Biomedical Research Centre Clinical Record Interactive Search.

PARTICIPANTS

We identified all adults with a diagnosis of schizophrenia (International Classification of Diseases 10th Revision: F20.x), who had received paliperidone palmitate prescription for at least 365 days and had at least 1 year of recorded treatment from SLAM, prior to the first recorded receipt of paliperidone palmitate.

PRIMARY AND SECONDARY OUTCOME MEASURES

Inpatient and community mental healthcare service use, such as inpatient bed days, number of active days in the service, face-to-face and telephone HCP use in the 12 months before and after paliperidone palmitate initiation.

RESULTS

We identified 664 patients initiated on paliperidone palmitate. Following initiation, inpatient bed days were lower, although patients remained active on the service case load longer for both mirror approach 1 (mean difference of inpatient bed days -10.48 (95% CI -15.75 to -5.22); days active 40.67 (95% CI 33.39 to 47.95)) and mirror approach 2 (mean difference of inpatient bed days -23.96 (95% CI -30.01 to -17.92); mean difference of days active 40.69 (95% CI 33.39 to 47.94)). The postinitiation period was further characterised by fewer face-to-face and telephone contacts with medical and social work HCPs, and an increased contact with clinical psychologists.

CONCLUSIONS

Our findings indicate a change in the profile of HCP use, consistent with a transition from treatment to possible rehabilitation.

Factors predicting relapse and treatment discontinuation with paliperidone 3-monthly long-acting injection: A 2-year naturalistic follow-up study

BACKGROUND

Paliperidone 3-monthly (PP3M) long-acting injection has proven efficacy and effectiveness in schizophrenia. Little is known of its effectiveness in other diagnoses.

METHODS

All patients starting PP3M were followed up for 2 years. Main outcome measures were relapse and discontinuation from PP3M. Post hoc we examined outcomes in those switched back to one monthly paliperidone (PP1M) long-acting injection.

RESULTS

Overall, 186 patients were followed-up. At the 2-year end point, 110 patients (59%) were still receiving PP3M, and 129 (70%) were receiving some form of paliperidone long-acting injection. Discontinuation from paliperidone long-acting injections (PPLAIs) was more likely with a nonschizophrenia diagnosis (hazard ratio [HR] for continuation 0.429 [95% confidence intervals (CI) - 0.21, 0.87 p = 0.018)), and prior clozapine use [in PP3M patients; HR for discontinuation 1.87 [95% CI - 1.05, 3.30 p = 0.032]). Relapse occurred in 20 (11%) of those receiving PP3M. Relapse on PP3M and PPLAIs was more likely in nonschizophrenia diagnosis (HR 0.17 for remaining relapse-free [95% CI - 0.06, 0.50; p = 0.001]; HR 0.21 [95% CI - 0.08, 0.58 p = 0.002], respectively), polypharmacy in PP3M patients (HR for relapse 7.91 [95% CI - 3.73, 22.9; p < 0.001]) and PPLAI patients (HR for relapse 6.45 [95% CI - 2.49, 16.5; p < 0.001]), and prior clozapine use in PP3M patients (HR for relapse 6.11 [95% CI - 1.82, 20.5; p = 0.003]) and PPLAI patients (HR for relapse 4.52 (95% CI - 1.51, 13.5; p = 0.007).

CONCLUSIONS

Outcomes with PP3M are excellent in practice, even when used outside its formal license. PP3M was relatively more effective in those with an F20 schizophrenia diagnosis and in those never before considered for or prescribed clozapine.

Comparing Long-Acting Antipsychotic Discontinuation Rates Under Ordinary Clinical Circumstances: A Survival Analysis from an Observational, Pragmatic Study

BACKGROUND

Recent guidelines suggested a wider use of long-acting injectable antipsychotics (LAI) than previously, but naturalistic data on the consequences of LAI use in terms of discontinuation rates and associated factors are still sparse, making it hard for clinicians to be informed on plausible treatment courses.

OBJECTIVE

Our objective was to assess, under real-world clinical circumstances, LAI discontinuation rates over a period of 12 months after a first prescription, reasons for discontinuation, and associated factors.

METHODS

The STAR Network 'Depot Study' was a naturalistic, multicentre, observational prospective study that enrolled subjects initiating a LAI without restrictions on diagnosis, clinical severity or setting. Participants from 32 Italian centres were assessed at baseline and at 6 and 12 months of follow-up. Psychopathology, drug attitude and treatment adherence were measured using the Brief Psychiatric Rating Scale, the Drug Attitude Inventory and the Kemp scale, respectively.

RESULTS

The study followed 394 participants for 12 months. The overall discontinuation rate at 12 months was 39.3% (95% confidence interval [CI] 34.4-44.3), with paliperidone LAI being the least discontinued LAI (33.9%; 95% CI 25.3-43.5) and olanzapine LAI the most discontinued (62.5%; 95% CI 35.4-84.8). The most frequent reason for discontinuation was onset of adverse events (32.9%; 95% CI 25.6-40.9) followed by participant refusal of the medication (20.6%; 95% CI 14.6-27.9). Medication adherence at baseline was negatively associated with discontinuation risk (hazard ratio [HR] 0.853; 95% CI 0.742-0.981; p = 0.026), whereas being prescribed olanzapine LAI was associated with increased discontinuation risk compared with being prescribed paliperidone LAI (HR 2.156; 95% CI 1.003-4.634; p = 0.049).

CONCLUSIONS

Clinicians should be aware that LAI discontinuation is a frequent occurrence. LAI choice should be carefully discussed with the patient, taking into account individual characteristics and possible obstacles related to the practicalities of each formulation.

Long-term outcomes in patients with schizophrenia treated with risperidone long-acting injection or oral antipsychotics in Spain: Results from the electronic Schizophrenia Treatment Adherence Registry (e-STAR)

Background

The electronic Schizophrenia Treatment Adherence Registry (e-STAR) is a prospective, observational study of patients with schizophrenia designed to evaluate long-term treatment outcomes in routine clinical practice.

Methods

Parameters were assessed at baseline and at 3 month intervals for 2 years in patients initiated on risperidone long-acting injection (RLAI) (n = 1345) or a new oral antipsychotic (AP) (n = 277; 35.7% and 36.5% on risperidone and olanzapine, respectively) in Spain. Hospitalization prior to therapy was assessed by a retrospective chart review.

Results

At 24 months, treatment retention (81.8% for RLAI versus 63.4% for oral APs, p < 0.0001) and reduction in Clinical Global Impression Severity scores (−1.14 for RLAI versus −0.94 for APs, p = 0.0165) were significantly higher with RLAI. Compared to the pre-switch period, RLAI patients had greater reductions in the number (reduction of 0.37 stays per patient versus 0.2, p < 0.05) and days (18.74 versus 13.02, p < 0.01) of hospitalizations at 24 months than oral AP patients.

Conclusions

This 2 year, prospective, observational study showed that, compared to oral antipsychotics, RLAI was associated with better treatment retention, greater improvement in clinical symptoms and functioning, and greater reduction in hospital stays and days in hospital in patients with schizophrenia. Improved treatment adherence, increased efficacy and reduced hospitalization with RLAI offer the opportunity of substantial therapeutic improvement in schizophrenia.

Remission amongst elderly schizophrenia patients

Remission in elderly patients has been little studied. The present analysis utilized a European database to focus on the elderly. Using five different instruments examining remission, we report that aging did not adversely affect remission in the elderly. Management of elderly schizophrenia patients should thus be targeted towards remission.

Effect of paliperidone palmitate on hospitalisation in a naturalistic cohort – a four-year mirror image study

Background

Clinical trial outcomes are heavily influenced by the non-naturalistic clinical trial process. Observations of outcomes in clinical practice are a valuable adjunct to clinical trial results.

Hypothesis

Our null hypothesis was that clinically indicated switching to paliperidone palmitate had no effect on hospital admissions or hospital bed days.

Method

This was a part-prospective mirror image study examining outcomes 2 years before starting paliperidone palmitate and 2 years after. Sensitivity analyses examined the effect of different placings of the mirror in the mirror image design.

Results

We prospectively followed-up 225 patients prescribed paliperidone palmitate in clinical practice. At 2 years, 41.8% of patients were still receiving paliperidone palmitate. In the primary analysis, the mean number of admissions fell from 1.80 in the two years before starting paliperidone palmitate to 0.81 in two years following the drug’s initiation (outpatients) or two years following hospital discharge (inpatients) (P < 0.001). More than half of patients were not admitted to hospital during two years follow-up. Mean total bed days was reduced from 79.6 in the two years before to 46.2 in the two years after paliperidone palmitate initiation or discharge (P < 0.001). Sensitivity analyses gave broadly similar outcomes. Continuers demonstrated better outcomes than discontinuers in sensitivity analyses but not in the primary analysis.

Conclusion

Paliperidone palmitate initiation is associated with a substantial reduction in hospital admissions and days spent in hospital. The reduction in costs associated with reduced use of health care facilities is likely to exceed the purchase and administration costs of the drug.

Estimating the optimal dose of flupentixol decanoate in the maintenance treatment of schizophrenia-a systematic review of the literature

RATIONALE

The licensed dose range for the long-acting injectable antipsychotic flupentixol decanoate (Depixol®) in the treatment of schizophrenia is very broad. This provides little useful direction to prescribers and may ultimately result in patients receiving unnecessarily high doses.

OBJECTIVES

We aimed to estimate the effect of dose of flupentixol decanoate on relapse rates in schizophrenia and on tolerability by expanding on an earlier review and including non-RCT and German-language studies, as well as using pharmacokinetic and pharmacodynamic data to offer guidance on dosing.

METHODS

A literature review using EMBASE, Medline, PsycINFO and PubMed was conducted. Treatment success rates at 6 months were extracted or extrapolated from the studies and plotted against dose to estimate a dose-response curve.

RESULTS

Data from 16 studies (n = 514) allowed estimation of a dose-response curve which rises steeply between the chosen placebo anchor (25% success rate) and 10 mg every 2 weeks before reaching a maximum between 20 and 40 mg every 2 weeks (80-95% success rates). Extrapyramidal side effects (EPSEs) were frequently seen (12-71% of participants) in that dose range. Two -weekly injections seem to provide the highest trough plasma concentration per dose administered and the lowest peak-to-trough concentration ratio. Plasma concentration varied up to 5-fold among individuals receiving the same dose.

CONCLUSIONS

The optimal dose of flupentixol decanoate is likely to be between 20 mg and 40 mg every 2 weeks although higher doses may be required in some individuals owing to variation in drug handling. Doses of flupentixol should be individually established in the range of 10 to 40 mg every 2 weeks according to response and tolerability.

A prospective year-long follow-up of lurasidone use in clinical practice: factors predicting treatment persistence

BACKGROUND

Our aim was to follow up patients prescribed lurasidone over 1 year to determine factors predicting treatment persistence.

METHODS

We used noninterventional, observational, prospective follow up of patients consecutively prescribed lurasidone in a large inner-city NHS mental health trust. We also performed retrospective analysis of outcomes from patient case notes.

RESULTS

Data were available for 69 patients consecutively prescribed lurasidone, of whom three (4%) were lost to follow up. Out of the 66 patients not lost to follow-up, 21 (32%) remained on lurasidone at 1 year. The main reasons for discontinuation were perceived ineffectiveness (49% of discontinuers) and adverse effects (36% of discontinuers), whilst a further seven refused all treatment. Median treatment time on lurasidone was 154 days (95% confidence interval (CI), 33-275). Patients who were not treatment-resistant had a substantially reduced risk of discontinuation, relative risk (RR) 0.18 [95% CI 0.08, 0.41, p < 0.001]. Medium doses (>37-74 mg) of lurasidone reduced the risk of discontinuation by 75% [RR 0.25 (95% CI 0.11, 0.58, p = 0.001)]; high doses (>74-148 mg) reduced the risk of discontinuation by 86% [RR 0.14 (95% CI 0.06, 0.35, p < 0.001)]. Risk of discontinuation was approximately doubled when the reason for prescribing lurasidone was poor tolerability of prior treatment [RR 2.01 (95% CI 1.05, 3.85, p = 0.035)].

CONCLUSION

The likelihood of treatment continuation with lurasidone can be vastly improved by targeting individuals most likely to benefit and by using optimal doses.

Paliperidone palmitate: factors predicting continuation with treatment at 2 years

Our aim was to determine factors relating to continuation with treatment with paliperidone palmitate long-acting injection (PP) in a 2 year, non-interventional, observational study of the use of PP in consecutive patients treated in a secondary care environment. We followed-up 300 consecutive patients; 24 (8%) were lost to follow-up (7 deceased and 17 left the care of the trust). Overall, 107 patients of the remaining 276 who were not lost to follow-up (38.7%) completed 2 years' continuous treatment. A further 21 (7.6%) patients discontinued PP but restarted it after >2 months, 11 (4.0%) of whom were still receiving PP at 2 years. Median treatment time for PP was 465 days (95% CI 333, 583 days). Prior treatment with risperidone reduced the risk of discontinuation by 39% (RR 0.61 (95% CI -0.44, 0.86, p=0.004)); being initiated as an out-patient by 49% (RR 0.51 (95% CI 0.36, 0.73 p=0.001)). Risk of discontinuation was increased by 63% when the reason for prescribing PP was poor tolerability of prior treatment (RR 1.63 (95% CI 1.05, 2.51 p=0.028)). The rate of continuation with PP at 2 years was higher than that seen with other long acting depot formulations. Likelihood of continuation can be vastly improved by targeting PP for those most likely to benefit.

Comparative effectiveness of long-acting injectable risperidone vs. long-acting injectable first-generation antipsychotics in bipolar disorder

OBJECTIVE

The aim of this study was to compare the treatment effectiveness between long-acting injectable risperidone and long-acting injectable first-generation antipsychotics among patients with bipolar disorder.

METHOD

We conducted a retrospective cohort study using Taiwan's National Health Insurance Research Database. Patients with bipolar disorder aged 15 years or higher, who were newly administered long-acting injectable antipsychotics between June 1, 2004 and December 31, 2011 were included. The clinical outcome indexes were hospitalization for any mood, manic/mixed, or depressive episodes. In addition, the all-cause discontinuation of long-acting injectable antipsychotic treatment was also assessed.

RESULTS

A total of 3916 patients with bipolar disorder were extracted. Compared with risperidone, the use of first-generation antipsychotics was associated with a higher rate of hospitalization for any mood episode and major depressive episode. However, there was no statistically significant difference in treatment discontinuation rate between risperidone and first-generation antipsychotics.

LIMITATIONS

Information for the severity of mood symptoms, social support, life style, neurological and metabolic adverse effect was not available in this database. In addition, we only measured severe mood episodes with hospitalization as our outcome index. It may not be possible to generalize our findings to mild mood episodes.

CONCLUSIONS

Our findings suggested that patients treated with long-acting injectable risperidone might be superior to first-generation antipsychotics in the rate of psychiatric hospitalization.

Effectiveness, Good Tolerability, and High Compliance of Doses of Risperidone Long-Acting Injectable Higher Than 75 mg in People With Severe Schizophrenia: A 3-Year Follow-Up

Tolerability and effectiveness of antipsychotics are important to increase treatment compliance in people with schizophrenia. The aim of this study was to evaluate effectiveness, tolerability, and adherence to treatment with high doses of risperidone long-acting injectable (RLAI) in patients with severe schizophrenia.It is a 3-year prospective, observational study of patients with severe (Clinical Global Impression Severity scale [CGI-S] score of ≥5) schizophrenia according to International Classification of Diseases (ICD-10) criteria. Subjects were the consecutive 60 who first underwent treatment with RLAI with doses of 75 mg or higher every 14 days to get clinical stabilization.Assessment included the following: CGI-S, World Health Organization Disability Assessment Schedule, Camberwell Assessment of Need (CAN), Medication Adherence Rating Scale, laboratory tests, weight, and hospital admissions.The mean (SD) dose of RLAI was 111.2 (9.1) mg per 14 days. Tolerability was good and there were almost no interruptions due to adverse effects or to relevant biological parameters alterations. Also, weight gain was not significant.Retention rate in treatment after 3 years was 95%. Clinical Global Impression Severity (P < 0.01) and Camberwell Assessment of Need (P < 0.01) decreased and also Disability Assessment Schedule in the 4 areas (P < 0.01). Medication Adherence Rating Scale score increased from 3.6 (0.7) to 8.9 (0.9) (P < 0.001). There were significantly few hospital admissions than during the previous 36 months (1.9 [1.3] vs 0.31 [0.2], P < 0.001).As a conclusion, we highlight that the effectiveness and tolerability of 75 mg or higher every 14 days of RLAI were high, being useful in improving treatment adherence in patients with severe schizophrenia, getting good clinical and functional outcomes.

Effectiveness and Predictors of Continuation of Paliperidone Palmitate Long-Acting Injection Treatment: A 12-Month Naturalistic Cohort Study

Antipsychotic long-acting injectable (LAI) medication has an important place as a treatment option in schizophrenia with evolving evidence to support clinical benefit over oral medication. Paliperidone palmitate is recently licensed as an LAI. We studied a naturalistic cohort of all identifiable patients who initiated paliperidone LAI in a specific United Kingdom region (Sussex) from first availability up to January 2013 (n = 179). Favorably, 60% of the cohort continued paliperidone LAI beyond 12 months from initiation. Schizophrenia diagnosis was significantly associated with 12-month continuation on univariate analysis (65% continuation rate at 12 months in this diagnostic subgroup). No baseline variables were identified as independently associated with 12-month continuation. However, fewer inpatient days after initiation (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.003-1.011; P = 0.002), dose adjustment up or down (OR, 3.46; 95% CI, 1.26-9.51; P = 0.016), and a higher maintenance dose (OR, 8.31; 95% CI, 1.84-37.51; P = 0.006) during treatment course were all independently associated with continuation on multivariate analysis. Our findings support the importance of a collaborative approach with the LAI recipient in treatment decision making to enhance treatment effectiveness.

A prospective, open-label study to evaluate symptomatic remission in schizophrenia with risperidone long-acting injectable in Korea

This study was designed to investigate long-term clinical outcomes of risperidone long-acting injectable (RLAI) in patients with schizophrenia or schizoaffective disorder. An open-label, 48-week, prospective study of RLAI treatment was carried out at 63 centers in South Korea. Initial and maintenance dosage of RLAI were adjusted according to clinical judgment. Efficacy was measured by the remission rate, continuation rate, and changes in the clinical measurements such as eight items of the Positive and Negative Symptom Scale (PANSS), the Clinical Global Impression - Severity, and the Schizophrenia Quality of Life Scale. In terms of the safety, Simpson-Angus rating Scale, adverse events (AEs), and BMI were investigated. Of the 522 patients who were enrolled, 472 patients who had been assessed on the eight items of PANSS at baseline and at least once during RLAI treatment were included in the intention-to-treat (ITT) population. The per-protocol (PP) population included 184 patients (39.0%), who completed all assessments during 48 weeks of the follow-up period. Total scores of eight items of PANSS, Clinical Global Impression - Severity, and Schizophrenia Quality of Life Scale were reduced significantly from baseline to endpoint in both ITT and PP populations. The mean dose (SD) of RLAI was 33.2 (7.6) mg. In the PP population, the number of patients who scored 1-3 on eight items of PANSS were 47 (25.5%) at baseline and 144 (78.3%) at 48 weeks. According to the remission defining as scores 1-3 on eight items of PANSS sustaining of at least 6 months' duration by Andreasen, the numbers of patients who achieved remission were 45 (24.5%) at 24 weeks and 120 (65.2%) at 48 weeks. A significant decrease in the mean score of Simpson-Angus rating Scale and a significant increase in BMI over time in last observation carried forward were observed, and patients who fulfilled the remission criteria during the study showed more weight gain than those who did not. During the study period, a total of 645 AEs were noted in 233 patients (49.3%) who were included in the ITT population. Sixty-nine serious AEs in 51 patients were reported, but all of them were not directly attributable to administration of RLAI. This prospective, open-label study showed improvements in symptom and AEs and a significant increase in BMI during 48 weeks of biweekly RLAI treatment. The rate of study completion was 39.0% and the remission rate among those who completed the study was 65.2%. None of the serious AEs were directly related to the administration of RLAI.

Paliperidone palmitate long-acting injection--prospective year-long follow-up of use in clinical practice

OBJECTIVE

To follow-up patients prescribed paliperidone palmitate long-acting injection (PP) over 1 year to determine factors predicting continuation with PP treatment.

METHOD

Naturalistic observation of patients registered as starting PP in a single healthcare unit in London, UK. Monovariate and multivariate (Cox regression) analysis of factors predicting continuation at 1 year.

RESULTS

Data were available for 210 patients consecutively prescribed PP of whom 10 were lost to follow-up. At 1 year, 65% of 200 patients (176 with a diagnosis of schizophrenia or schizoaffective disorder) started on PP were still receiving it. The main reason for discontinuation was perceived ineffectiveness (52% of discontinuers); only 10 subjects (5% of total) discontinued because of adverse effects. Initiation as an out-patient [hazard ratio (HR) 0.39, 95%CI, 0.20, 0.67, P = 0.001]; being switched from risperidone (HR 0.56, 95%CI 0.32, 0.94, P = 0.026) and correct initiation (HR 0.56, 95%CI 0.34, 0.93, P = 0.024) were significantly associated with a lower likelihood of discontinuation.

CONCLUSION

Paliperidone palmitate was effective and well tolerated in this naturalistic cohort. Optimising treatment by targeting PP for patients identified as having lower risk of discontinuation can give rise to continuation rates approaching 80% at 1 year.

Long-acting paliperidone palmitate - interim results of an observational study of its effect on hospitalization

Paliperidone palmitate (PP) is a recently introduced long-acting atypical, or second-generation, antipsychotic. Published data on PP are currently limited to controlled trials and case reports. In this observational study, we followed up 200 consecutive patients prescribed PP in normal practice. After 1 year, 65% of patients were still receiving PP. The number of admissions to hospital in the year following PP initiation was 0.49/patient compared with 0.69/patient/year, 3 years before initiation (P=0.0001). The mean number of bed days fell from 38.78 to 23.09/patient/year over the corresponding period (P=0.0001). The median number of bed days 3 years before PP initiation was 21.50/year and in the year following PP initiation, it was 0. Outcomes were numerically but not statistically better in those continuing PP than in those who ceased PP within a year of initiation. PP was effective and well-tolerated and, given its positive effect on hospital bed days, broadly cost-effective.

Cost-effectiveness of long-acting injectable risperidone versus flupentixol decanoate in the treatment of schizophrenia: a Markov model parameterized using administrative data

We use longitudinal patient-level data from a German sickness fund with 7.26 million insured in a Markov-simulation model to assess the cost-effectiveness of long-acting injectable risperidone (LAI-RIS) compared with long-acting injectable flupentixol (LAI-FLX) in the long-term management of schizophrenia. We simulate treatment costs from the payer's perspective, hospitalization, the probability to be prescribed co-medication, and treatment discontinuation over a 2-year time horizon. Model inputs were derived from 935 patients hospitalized with schizophrenia between 2005 and 2008 who received either LAI-RIS or LAI-FLX for at least 1 month. After 2 years, 89.4% (95.8%) of patients who were initiated on LAI-RIS (LAI-FLX) discontinued the initial regimen. The number of days spent in hospital per month and patient was slightly lower with LAI-RIS (1.08 vs. 1.28 days, p<0.001). The proportion of patients receiving side-effect co-medication was lower with LAI-RIS (8.3 vs. 15.0% per month, p<0.001). Mean total costs of treatment per patient and month were 1,015 € under LAI-RIS and 395 € under LAI-FLX, resulting in an ICER of 3,088 € (95% CI [-913 €; 3,551 €]) for an avoided hospital day per patient and month in the base case scenario with a 15.1% probability of LAI-FLX being the dominant treatment strategy. Cost differences were mainly attributable to the higher drug costs of LAI-RIS. The effectiveness of LAI-RIS in preventing hospital days appears to be similar to LAI-FLX, with a slight superiority in side-effect and switching rates. This comes at the cost of substantially higher treatment expenses. From a decision-maker's point of view, the use of health insurance data as a source of input for decision models appears to be a reasonable alternative to models driven by clinical data only.

A naturalistic evaluation and audit database of agomelatine: clinical outcome at 12 weeks

OBJECTIVE

To determine the effectiveness of agomelatine in routine clinical practice and explore factors associated with response and continuation.

METHOD

Consecutive patients prescribed agomelatine in participating psychiatric services were included. Patient demographic and outcome data were collected at treatment initiation and then at weeks 4, 8 and 12. Outcomes were analysed with respect to clinical and demographic factors.

RESULTS

A total of 110 patients from nine NHS trusts were followed through 12 weeks of treatment. Agomelatine was largely used in difficult-to-treat or refractory patients: 83 (75%) had failed to respond to, or relapsed on, prior antidepressants. There were high rates of physical (54.5%) and psychiatric (50.0%) comorbidity. At 12 weeks of treatment, 68 (62%) continued agomelatine treatment. Overall, 69 subjects (62.7%) improved by at least one point of the Clinical Global Impression (severity) scale. Of 42 who discontinued, 23 (56%) discontinued because of lack of efficacy and 10 (24%) due to an adverse event. Of all variables examined, only a history of more than five episodes of depression significantly predicted discontinuation of treatment (OR continuation - 0.36, 95% CI 0.14, 0.95).

CONCLUSION

Agomelatine was effective and generally well tolerated in a cohort of difficult-to-treat patients in clinical practice.

Psychiatrists' use, knowledge and attitudes to first- and second-generation antipsychotic long-acting injections: comparisons over 5 years

Psychiatrists' attitudes and knowledge about antipsychotic long-acting injections (LAIs) are important given the increasing emphasis on patient choice in treatment and the availability of second-generation antipsychotic (SGA) LAIs. A cross-sectional study of consultant psychiatrists' attitudes and knowledge in North West England was carried out. A pre-existing questionnaire on clinicians' attitudes and knowledge regarding LAIs was updated. Of 102 participants, 50% reported a decrease in their use of LAIs. LAI prescribing was evenly split between first-generation antipsychotic (FGA) and SGA-LAIs. Most regarded LAIs as associated with better adherence (89%) than tablets. A substantial proportion believed that LAIs could not be used in first-episode psychosis (38%) and that patients always preferred tablets (33%). Compared with a previous sample, the current participants scored more favourably on a patient-centred attitude subscale (60.4% vs 63.5%, P = 0.034) and significantly fewer regarded LAIs as being stigmatising and old-fashioned. Reported LAI prescribing rates have decreased in the last 5 years despite an SGA-LAI becoming available and most clinicians regarding LAIs as effective. Most attitudes and knowledge have remained stable although concerns about stigma with LAI use have decreased. Concerns about patient acceptance continue as do negative views about some aspects of LAI use; these may compromise medication choices offered to patients.

Once-monthly paliperidone injection for the treatment of schizophrenia

Paliperidone palmitate is a new long-acting antipsychotic injection for the treatment of acute and maintenance therapy in schizophrenia. Paliperidone (9-hydroxyrisperidone) is the major active metabolite of risperidone and acts at dopamine D(2) and serotonin 5HT(2A) receptors. As with other atypical antipsychotics, it exhibits a high 5HT(2A):D(2) affinity ratio. It also has binding activity as an antagonist at α(1)-and α(2) adrenergic receptors and H(1) histaminergic receptors, but has virtually no affinity for cholinergic receptors. Paliperidone palmitate has been shown to be effective in reducing Positive and Negative Syndrome Scale total scores in four short-term trials in acute schizophrenia. It was also effective as maintenance therapy in a long-term trial in which time to recurrence of symptoms was significantly longer in paliperidone-treated patients compared with placebo. In addition, paliperidone was shown to be noninferior to risperidone long-acting injection in one study, but this noninferiority was not established in another longer study comparing the two drugs. Treatment should be initiated with 234 mg on day 1 and 156 mg on day 8, followed by a recommended monthly maintenance dose of 39-234 mg based on efficacy and tolerability. Paliperidone palmitate is generally well tolerated, although it can cause weight gain and a rise in prolactin levels, which is generally greater in women than in men. Overall, paliperidone palmitate may have advantages over other currently available long-acting injections, and therefore may be a useful alternative for the treatment of schizophrenia, although further long-term trials comparing it with active treatments are warranted.

Psychopharmacology and adverse effects of antipsychotic long-acting injections: a review

BACKGROUND

Depot antipsychotics are widely used in clinical practice. Long-acting formulations of second-generation antipsychotics are now being developed and introduced.

AIMS

To review the pharmacology, pharmacokinetics and adverse effect profiles of currently available antipsychotic long-acting injections (LAIs).

METHOD

The psychopharmacological properties of first- and second-generation antipsychotic LAIs are reviewed using data available up to October 2008.

RESULTS

First-generation antipsychotic (FGA) LAIs are associated with a high rate of acute and chronic movement disorders. Risperidone LAI is better tolerated in this respect, but is associated with hyperprolactinaemia and weight gain. Olanzapine LAI causes weight gain and other metabolic effects but appears not to be associated with an important incidence of movement disorders.

CONCLUSIONS

Dosing of LAIs is complicated by delayed release of drug, changes in plasma levels without change in dose, and by the lack of data establishing clear dose requirements. All LAIs offer the prospect of assured adherence (although patients may still default on treatment) but their use is complicated by adverse effects, complex pharmacokinetics and confusion over dose-response relationships.

The combined use of risperidone long-acting injection and clozapine in patients with schizophrenia non-adherent to clozapine: a case series

Poor adherence to clozapine treatment represents an important problem in clinical practice because additional useful treatment options are unavailable. Although switching to risperidone long-acting injection (RLAI) has been recommended for those with compliance problems, this medication has been found to be less suitable for patients who previously received clozapine. Based on the suggested beneficial effects of RLAI, such as higher rates of treatment continuation and patient satisfaction, and the possible effectiveness of oral risperidone augmentation, it seems worthwhile to try RLAI augmentation for clozapine non-adherence. In this article, we present the cases of four patients with schizophrenia undergoing combined treatment with RLAI and clozapine for more than one year after multiple relapses related to clozapine non-adherence. Durations and frequencies of hospitalizations markedly declined after RLAI augmentation. Indeed, three patients receiving RLAI and clozapine for 1.2-3.5 years were never hospitalized during this period. The lengths of hospitalizations before and after augmenting with RLAI were 54.7 +/- 33.1 and 4.2 +/- 4.2 days/year, respectively. Participants also showed great improvements in social skills. These findings suggest the possible beneficial effects of RLAI augmentation in cases of clozapine nonadherence. However, controlled clinical trials are necessary to confirm whether RLAI augmentation represents a useful treatment option for patients who have not adhered to clozapine treatment.

Risperidone long-acting injection: factors associated with changes in bed stay and hospitalisation in a 3-year naturalistic follow-up

We examined factors associated with hospital admissions and bed stay for 211 patients prescribed risperidone long-acting injection (RLAI) in clinical practice. Hospital bed days increased by a median of 74 days in the 3 years after RLAI initiation compared with the 3 years before initiation (P < 0.0001). Only subjects starting RLAI as outpatients showed no increase in bed days after RLAI initiation. A greater than expected number of bed days was observed in women (36% increase), patients prescribed >25 mg/2 weeks (70% increase) and patients previously treated with clozapine (118% increase). Overall, number of hospital admissions did not increase, although those previously prescribed clozapine saw a 31% increase in admissions compared with patients not previously exposed to clozapine. This and other analyses of the same patient cohort indicate that RLAI produces most favourable outcomes in outpatients and those not previously treated with clozapine.

Treatment of schizophrenia with depot preparations of fluphenazine, haloperidol, and risperidone among inpatients at state-operated psychiatric facilities

BACKGROUND

This study aimed to characterize the inpatient utilization of depot antipsychotics.

METHOD

The characteristics of adults with schizophrenia or schizoaffective disorder, hospitalized for at least 28 days, and who were prescribed depot antipsychotics were examined from 2004 to 2006 using a database from a large state-operated psychiatric hospital system. Demographic and clinical characteristics of patients receiving depot fluphenazine or haloperidol were compared to those prescribed depot risperidone.

RESULTS

We identified 2210 unique patients who initiated treatment with a depot antipsychotic (after receiving oral antipsychotics). Of these, 1484 (67.1%) received depot fluphenazine or haloperidol, and 726 (32.9%) received risperidone as their initial depot antipsychotic. Patients who received depot risperidone did not differ from those receiving depot fluphenazine or haloperidol with regard to demographics, diagnosis of schizoaffective disorder, number of comorbid psychiatric or medical diagnoses, or diagnosis of substance abuse. Patients started on depot risperidone during the observation period had a longer length of stay prior to initiation of depot than those started on depot fluphenazine or haloperidol (583 days vs. 237 days, t=5.489, p<.001). Patients who started on depot risperidone were less likely to be discharged on that medication than were patients who started on depot fluphenazine or haloperidol (odds ratio from Cox regression model=0.846 [95% CI 0.745-0.960]).

CONCLUSIONS

Patients initiated on depot risperidone had a longer length of stay prior to their first injection and were less likely to be discharged on that medication compared to patients initiated on depot fluphenazine or haloperidol, possibly indicating that patients initiating depot risperidone had a more severe or treatment-resistant course of illness and/or that there were reimbursement barriers for the outpatient utilization of depot risperidone, or that efficacy differences exist between the depot antipsychotics at the doses used in this population.

Risperidone long-acting therapy in stable patients with recently diagnosed schizophrenia

Early and maintained treatment is important for better long-term outcomes in schizophrenia. We hypothesized that treatment with injectable risperidone long-acting therapy (RLAT) would be associated with improved outcomes in recently diagnosed patients compared with those having longer illness duration. Post-hoc analyses were conducted from a 1-year study of stable patients receiving RLAT (25 or 50 mg every 2 weeks) to compare patients diagnosed with schizophrenia in < or ears (recently diagnosed; n=57) with those diagnosed more than 3 years (n=266). Relapse rates were 10.5 and 21.8%, respectively [P=0.053, chi(2)azard ratio 2.2 (95% confidence interval=0.95, 5.13)]. Both groups improved significantly in mean total Positive and Negative Syndrome Scale and Clinical Global Impressions-Severity (CGI-S) scores (P<0.01). Recently diagnosed patients showed greater improvement versus patients diagnosed for more than 3 years in adjusted mean Positive and Negative Syndrome Scale total (-10.2+/-2.0 vs. -3.8+/-0.9; P=0.004) and Clinical Global Impressions-Severity (-0.5+/-0.1 vs. -0.2+/-0.1; P=0.002) scores. The most common adverse events were insomnia (31.6 vs. 26.7%), psychiatric disorders (19.3 vs. 20.7%), headache (15.8 vs. 19.2%), anxiety (12.3 vs. 17.3%), and influenza (10.5 vs. 5.3%). These findings confirm the benefit of RLAT in patients with schizophrenia and suggest that earlier treatment with long-acting preparations is associated with better outcomes.

Upcoming agents for the treatment of schizophrenia: mechanism of action, efficacy and tolerability

Since the introduction of a group of atypical antipsychotics in the 1990s, there has been a decline in the rate of new antipsychotics being introduced into clinical practice. However, with increasing safety and efficacy concerns over currently available drugs and a dearth of options available for atypical depot formulations, there is a considerable need for the development of new formulations and agents. This review examines the profile of seven antipsychotic drugs currently in the premarketing stage of development and summarizes their mechanism of action, clinical potential and safety.Asenapine is an antipsychotic with activity for multiple receptors and has potential to improve negative and cognitive symptoms of schizophrenia. Bifeprunox is a partial dopamine D2 and serotonin 5-HT(1A) receptor agonist showing a less than convincing efficacy profile, but which may offer safety advantages over available agents by means of a reduced risk of metabolic complications. Iloperidone is a D2 and 5-HT(2A) receptor antagonist requiring further studies to establish its effectiveness. It has a high affinity for alpha(1)-adrenoceptors, which can lead to associated haemodynamic adverse effects. Nemonapride is essentially a typical antipsychotic drug, similar in structure to sulpiride, which has been available for some time in Japan. It has efficacy against positive symptoms and has shown some antidepressant and anxiolytic properties, although efficacy data for it are somewhat limited. Norclozapine (N-desmethylclozapine) is a major metabolite of clozapine formed by its demethylation. Its partial agonist activity at D2 receptors has raised interest in it as an antipsychotic in its own right. In addition, it appears to have muscarinic agonist activity, which is believed to be responsible for the observed positive effects it has on cognition. It was envisaged to be effective as an adjunct to other agents or at high doses in the treatment of refractory schizophrenia, although a recent randomized, controlled study showed that it was no more effective than placebo in patients with schizophrenia experiencing an acute psychotic episode. Olanzapine pamoate depot injection has shown comparable efficacy to oral olanzapine in several studies. However, it has provoked considerable safety concerns by its association with inadvertent intravascular injection events in numerous patients. This accidental intravascular administration of olanzapine pamoate leads to excessive sedation, confusion, dizziness and altered speech. Post-injection observation periods and postmarketing surveillance are planned following the introduction of the depot. Paliperidone palmitate is the palmitate ester of paliperidone, the major metabolite of risperidone, and is formulated as a long-acting injection for intramuscular use. Its pharmacology is comparable to risperidone, having D2 and 5-HT(2A) receptor antagonist activity. Efficacy studies have shown positive results, and because paliperidone has no antagonistic activity at cholinergic receptors, it has low potential for anticholinergic adverse effects, including cognitive dysfunction. However, with higher doses, the frequency of extrapyramidal side effects and orthostatic hypotension have been shown to be greater than with placebo.

Risperidone long acting injection: Findings of a 2-year retrospective follow-up study

Objective. The aim of this retrospective study was to assess the clinical effectiveness of risperidone long acting injection (RLAI) at 2 years within an acute mental health setting. Method. All patients who received RLAI between July 2002 and December 2004 were identified from pharmacy records, and data collected by retrospective case note review. In order to give an indication that their condition was unresponsive to treatment, patients' drug histories were reviewed to determine whether or not they had previously been treated with clozapine or received two or more failed trials of other antipsychotic medication. Results. Eighty-four patients were included in the study and 56 discontinued at 2 years. The most common reason for treatment discontinuation was lack of effectiveness, accounting for 32 patients, whilst eight patients discontinued due to adverse effects. Patients remaining on treatment spent 67% of the time in an outpatient setting. Conclusion. The proportion of patients remaining on RLAI at 2 years was 33%. Limitations of the naturalistic methodology used in this study hindered any precise determination of which patients were likely to continue RLAI. However, it was apparent that a history of previous treatment failure with at least two antipsychotics was associated with RLAI treatment discontinuation.

Symptomatic remission in elderly schizophrenia patients treated with long-acting risperidone

BACKGROUND

In elderly schizophrenia patients remission is difficult to determine due to long disease duration, exposure to differing treatments, long-standing side-effects, non-adherence, cognitive decline and physical comorbidity.

METHOD

Retrospective chart reviews were undertaken of 48 elderly (60+ years) schizophrenia patients admitted to a university-affiliated tertiary psychiatric center in 2006. These patients were experiencing an exacerbation of symptoms at admission. Remission criteria used were those of the American Psychiatric Association's "Remission in Schizophrenia Working Group", and clinical status and improvement were quantified using the Clinical Global Impression scale (CGI).

RESULTS

Of 25 patients treated with long-acting risperidone (LAR), 19 (76%) continued uninterrupted treatment for 6 months or longer. In six patients treatment was discontinued due to insufficient response. The clinical severity ratings with the CGI of all patients were in the range 5-7 prior to treatment. Following six months of LAR treatment, mean dose 36.0 mg/2 weeks (range: 25-50), 18 patients were rated as "improved" or "very much improved" on the CGI-global improvement item scale. In 15/25 patients (60%) symptomatic remission was achieved.

CONCLUSION

LAR may be effective in achieving remission among elderly schizophrenia patients. Tolerability was high and adherence rates improved. However, the results must be treated with caution owing to the inherent bias in this retrospective analysis.

Use of depot antipsychotic medications for medication nonadherence in schizophrenia

OBJECTIVES

To describe factors associated with initiation of depot antipsychotic medications in psychiatric outpatients with schizophrenia and recent medication nonadherence.

METHODS

A national sample of psychiatrists reported on adult outpatients with schizophrenia who were nonadherent with oral antipsychotic medications in the last year.

RESULTS

In total, 17.6% of psychiatrists initiated depot antipsychotic injections. Initiation was significantly and positively associated with public insurance, prior inpatient admission, proportion of time nonadherent, average or above average intellectual functioning, and living in a mental health residence. Use was inversely associated with using second-generation antipsychotics and other oral psychotropic medications prior to medication nonadherence. Psychiatrists who were male, nonwhite, and more optimistic about managing nonadherence were more likely to initiate depot injections.

CONCLUSIONS

Initiation of depot injections is a joint function of patient, physician, treatment, and setting factors. Use of long-acting preparations in this population is uncommon despite clinical recommendations urging their use.

Aripiprazole: 6-month outcomes in a retrospective naturalistic study

Aim. The efficacy of aripiprazole has been demonstrated in randomised controlled trials, but due to inclusion and exclusion criteria, these may not be representative of clinical practice. The aim of this naturalistic study was to investigate patients from an acute mental health trust who received aripiprazole, using treatment discontinuation as a primary outcome measure. Method. All patients with schizophrenia or schizoaffective disorder who had received aripiprazole were identified from pharmacy records, and data collected by retrospective case note review. Results. Seventy subjects were included in the study. A total of 28 (40%, n=70) patients remained on aripiprazole monotherapy at 6 months. The most common reason for discontinuation was lack of effect, seen in 29 patients; only 12 patients discontinued due to adverse effects. Thirty-five percent of the subjects had previously been treated with clozapine, although this did not appear to influence outcome. Conclusion. Despite limitations of the naturalistic methodology used in this study, it appears that aripiprazole is relatively well tolerated, and effective in clinical practice. The 40% continuation rate seen with aripiprazole is comparable to that seen with risperidone, quetiapine, and perphenazine in the CATIE study at 6 months.

A prospective 6-month analysis of the naturalistic use of aripiprazole - factors predicting favourable outcome

OBJECTIVE

To evaluate the effectiveness of aripiprazole in clinical practice.

METHOD

Prospective follow-up of patients consecutively prescribed aripiprazole in an acute mental health unit. Retrospective analysis of outcome from casenotes.

RESULTS

Data were available on 228 patients. Fifty-one per cent discontinued aripiprazole over 6-month follow-up. Continuation with treatment was more likely in out-patients [relative risk (RR) 1.50; 95% CI: 1.13-2.00], those never before considered for clozapine treatment (RR 1.61, 95% CI: 1.06-2.44) and older patients [RR 1.05, 95% CI: 1.01-1.09 (per 5-year increase)]. The main reason for early discontinuation was the occurrence of minor adverse effects.

CONCLUSION

Aripiprazole is effective in practice. Outcome is likely to be improved by careful patient selection and by attending to adverse effects experienced early in treatment.

The effect of long-acting risperidone on working memory in schizophrenia: a functional magnetic resonance imaging study

Cognitive abnormalities represent an important therapeutic target in the treatment of schizophrenia. Working memory deficits are among the core abnormalities and affect social functioning. We used functional magnetic resonance imaging to examine cortical systems supporting working memory in patients with schizophrenia treated with risperidone long-acting injections (RLAIs) versus those on conventional depot medication (CONV). Sixteen patients on RLAI, 16 patients on CONV matched for clinical symptoms and other illness variables, and 8 HCs performed an n-back task (1-, 2-, 3-back) in the scanner. The level of performance decreased with increasing memory load, which was particularly evident in the CONV group. Patients on RLAI and controls demonstrated task-dependent decreases in activation in medial PFC, whereas the CONV group overactivated that region. The CONV group also showed underactivation of VLPFC compared with controls under conditions of increasing memory load, with the RLAI group showing an activation pattern not significantly different from either group. We conclude that RLAI may contribute to normalization of brain activation in regions involved in working memory functioning in people with chronic schizophrenia.

Long-Acting Injectable Risperidone for the Treatment of Schizophrenia

Schizophrenia remains a severe disorder that is associated with a poor outcome in a large subgroup of patients. Major efforts should be made to improve treatment for all patients who have this debilitating disease. Second-generation antipsychotics were a major step forward in this respect; however, important unmet needs remain, such as a better solution for frequent noncompliance problems. Depot formulations are known to have advantages in this respect. However, for a long time, only depot formulations of conventional antipsychotics were available, with their high risk of extrapyramidal adverse effects. Therefore, there has been only very restricted use of depot antipsychotics, which mainly focused on patients with chronic disease who were difficult to treat and had a high risk of noncompliance. The situation may change with the advent of a depot formulation of an atypical antipsychotic. The first depot formulation of an atypical antipsychotic to be introduced to the market is long-acting injectable risperidone. On the basis of the pharmacokinetic properties of the depot formulation, a 2-week interval between administrations is recommended. The antipsychotic efficacy of long-acting risperidone was demonstrated in two 12-week, double-blind, randomised, phase III studies, one versus placebo and the other versus oral risperidone. These two studies, together with one open-label, long-term study over 12 months, belong to the core group of trials that were relevant for the licensing of long-acting risperidone. A relapse-prevention, control group study comparing the long-acting formulation versus oral risperidone was not performed because of the known principal methodological problems of such a comparison. Instead, as much clinical data as possible was collected from observational studies that investigated questions relevant for clinical practice, such as efficacy, safety and tolerability in different subgroups, and transition from pre-treatment with different kinds of antipsychotics to long-acting risperidone. On the basis of these data, it can be stated that the efficacy of the long-term formulation of risperidone is proven, and that the safety and tolerability are more or less comparable to those of oral risperidone. The local tolerability at the injection site is good. Because it is well known that noncompliance is a frequent feature of the treatment of schizophrenia, and considering the advantages of atypical antipsychotics, consideration of whether long-acting atypical antipsychotics should have a broader indication than is the case with the depot formulations of the classical antipsychotics is warranted.