Long-acting antipsychotics in the treatment of schizophrenia: opportunities and challenges

Pharmacokinetic characteristics of risperidone ISM for the treatment of schizophrenia

INTRODUCTION

Risperidone-ISM is a novel intramuscular long-acting injectable formulation (LAI) of risperidone approved for the treatment of schizophrenia in adults. Knowledge regarding the pharmacokinetic properties of risperidone-ISM can improve care.

AREAS COVERED

We assessed the pharmacokinetic properties of risperidone-ISM. Most importantly, risperidone-ISM achieves therapeutic blood levels within 12-48 h after the first injection without the need for overlapping oral cotreatment, loading dose, or booster injection. Second, the in-situ microparticle (ISM) technology achieves stable blood levels, allowing currently 1-monthly injections. Third, females and patients with higher body mass index may have lower risperidone-ISM clearance, translating into higher risperidone serum levels. Fourth, there are only minimal risperidone-ISM clearance differences between deltoid and gluteal injections that balance out at steady state. However, aspects including pharmacogenetic and drug-drug interactions involving risperidone-ISM would benefit from further clarification.

EXPERT OPINION

Risperidone-ISM achieves therapeutic blood levels within 12-48 h after a single injection, currently lasting for 1 month, easing the initiation of a LAI risperidone formulation in adults with schizophrenia where LAIs remain underutilized. Prescriptions of LAIs, including risperidone-ISM, are likely to increase with an improved understanding of pharmacokinetic profiles and patient acceptability and outcomes, including in real-world settings informing drug selection.

Real-world outcomes and practice patterns among patients with schizophrenia when switched from oral antipsychotics to long-acting injectable formulations after hospitalization

This study compared rehospitalization and practice patterns among patients with schizophrenia in the United States prescribed oral antipsychotics (OAs), alone or with long-acting injectable antipsychotics (LAIs) at hospital discharge. Data came from a hospital-based payer database from December 2019-June 2021. At discharge, 23,336 (84 %) patients were prescribed OAs and 4293 (16 %) were prescribed LAIs±OAs (first-generation LAIs±OAs, 2990/4293 [70 %]; second-generation LAIs±OAs, 1303/4293 [30 %]). The most prescribed OA and LAI±OA were risperidone (26 %) and haloperidol (37 %), respectively. Significantly greater proportions of patients were rehospitalized within 30, 60, or 90 days after discharge with OAs (11 %, 15 %, and 18 %, respectively) vs LAIs±OAs (8 %, 12 %, and 15 %; numbers needed to treat [NNTs], 37, 35, and 38), and with first-generation (9 %, 13 %, 16 %) vs second-generation (7 %, 10 %, 13 %) LAIs (p < 0.05 for all). Significantly greater proportions prescribed LAIs dosed once every 2 weeks vs monthly were rehospitalized within 60 days (15 % vs 11 %, respectively; NNT 33) and 90 days (18 % vs 14 %; NNT 26) (p < 0.05 for all). Prescriptions were based on clinical characteristics at discharge; those prescribed LAIs±OAs may have had less favorable prognoses. However, these results suggest that prescribing second-generation LAIs±OAs with less frequent dosing at discharge may lower rehospitalization risk for patients with schizophrenia.

Retrospective cohort study of long-acting injectable (LAI) antipsychotic initiation in the inpatient setting: impact of LAI characteristics on transition and continuation of care among patients with schizophrenia in the USA

OBJECTIVES

To investigate long-acting injectable (LAI) antipsychotic prescribing patterns and their associations with transition and continuation of care and healthcare resource utilisation (HCRU) for patients with schizophrenia in the USA.

DESIGN

A retrospective cohort study.

SETTING

Electronic health record data from adults in the USA with schizophrenia were extracted from the NeuroBlu Database V.21R2.

PARTICIPANTS

Adults (aged ≥18 years) with a schizophrenia diagnosis who initiated LAI antipsychotic treatment during psychiatric inpatient admission. The index date was the date of LAI initiation. Patients who had ≥1 primary, secondary or tertiary ICD-9/10 (International Classification of Diseases) diagnosis of schizophrenia at clinical sites that had both inpatient and outpatient facilities were included.

PRIMARY OUTCOME MEASURES

Transition-of-care (eg, risk of rehospitalisation, number of hospital readmissions, number of outpatient visits post discharge), continuation-of-care (eg, first treatment path after discharge, time to index LAI discontinuation and number of patients who restarted LAIs after discontinuation) and HCRU endpoints (eg, length of stay of index hospitalisation and estimated cost for psychiatric outpatient visits pre-index and post-index) were the primary outcome measures.

RESULTS

A total of 1197 patients were included who initiated an LAI in an inpatient setting. Of 339 patients with ≥3 months pre-index and post-index data, median time to rehospitalisation was 135 days. Patients discharged taking an LAI alone had lower frequency of rehospitalisation (incidence rate ratio (IRR)=0.62 (95% CI, 0.46 to 0.84)), lower risk of longer hospital stays (IRR=0.60 (95% CI, 0.43 to 0.84)), lower risk of becoming rehospitalised (HR=0.49 (95% CI, 0.35 to 0.69)) and lower risk of outpatient visits (IRR=0.50 (95% CI, 0.36 to 0.70)) versus patients co-prescribed an oral antipsychotic (LAI+OA). Patients discharged taking an LAI dosed once every 1-2 months or once every 2 weeks had lower frequency of rehospitalisation (IRR=0.85 (95% CI, 0.64 to 1.14)), lower risk of longer hospital stays (IRR=0.90 (95% CI, 0.70 to 1.15)) and lower risk of becoming rehospitalised versus an LAI dosed once every 2 weeks; risk of becoming rehospitalised was no different (HR=1.00 (95% CI, 0.76 to 1.32)) and risk of outpatient visits was greater (IRR=1.25 (95% CI, 0.96 to 1.63)). During hospitalisation, 73.4% of patients were co-prescribed an OA, most frequently risperidone, with their index LAI. From pre-admission to post-discharge, psychiatric clinic costs significantly increased (US$14 231, p<0.01 post-discharge vs pre-admission) among patients co-prescribed an OA. For patients who were prescribed an LAI alone there was minimal change in costs from pre-admission to post-discharge (p=0.068). At 12 months post-index, 75.3% of patients discontinued LAIs, dosed once every 1-2 months versus LAIs, dosed once every 2 weeks (86.5%) and median days to discontinuation was longer (67 (IQR 60-91) vs 32 (IQR 28-49).

CONCLUSIONS

Patients prescribed a combination of LAI and OA at discharge had a higher risk of rehospitalisation compared with those prescribed LAI alone. Additionally, the study findings suggest that patients are more likely to be prescribed oral risperidone, the most frequently used second-generation OA, which may support an easier transition to an LAI of the same molecule.

Clinician differences in attitudes and perceptions on the use of long-acting injectable antipsychotic agents in treating patients with schizophrenia: results from the US DECIDE survey

BACKGROUND

Long-acting injectable antipsychotics (LAIs) reduce relapses in schizophrenia; however, most clinicians reserve LAIs for nonadherence with oral antipsychotics (OAs) or severe disease.

METHODS

US psychiatric clinicians were surveyed regarding their schizophrenia management practices and use of LAIs. Respondents were grouped by LAI use (high [≥ 31% of patients using LAIs], low [≤ 14% using LAIs]; mid not analyzed) and mindset based on their response to "Which of the following best fits the current way you view your use of [LAIs] for your patients with schizophrenia?"

RESULTS

Respondents (n = 380) were distributed across LAI use (106 high, 130 low) and mindset (123 early-use, 88 severity-reserved, 113 adherence-reserved, 56 LAI-hesitant) subgroups. Across subgroups, clinicians estimated that OA nonadherence was lower for patients in their practice (21-52%) than for patients nationwide (50-56%). Compared with other subgroups, greater proportions with high LAI use or an early-use mindset were confident in key aspects of LAI treatment like dosing, managing side effects, and access (67-74% high LAI use, 59-70% early-use vs. 11-57% other subgroups; P < .05 each), agreed it was "worth [their] time to resolve issues with the insurance company" (42%, 45% vs. 16-30%; P < .05 each), and were optimistic they would be able to do so (23%, 20% vs. 2-11%; P < .05 each). Clinicians with high LAI use estimated the proportion of patients who initially accept LAIs to be higher (mean, 56%) than clinicians with low LAI use (45%, P < .01); there were no differences among mindsets (49-54%). Clinicians with high LAI use or early-use mindset were more likely to "use any means necessary to ensure that a patient is on an LAI" than clinicians in other subgroups (44% high LAI use, 51% early-use vs. 5-22% other subgroups; P < .01 each) or had used guardianship to assist with treatment (70%, 69% vs. 32-56%; P < .05 each).

CONCLUSIONS

These results indicate that multiple factors (e.g., environmental/demographic factors, access, attitudes, motivation, knowledge/confidence) combine to influence LAI use, and highlight the need to tailor educational materials aimed at improving patient outcomes through increased LAI use.

Temporal trends of antipsychotic utilization patterns in 62,607 patients with schizophrenia-spectrum disorders in Hong Kong: An 11-year population-based study with joinpoint regression analysis

Antipsychotics are the mainstay treatment for schizophrenia-spectrum disorders (SSD). Existing data on real-world antipsychotic utilization patterns were primarily derived from Western countries and disregarded specific psychiatric diagnosis. There is limited research in Asia in this respect. This population-based study identified 62,607 patients aged ≥18-years with an SSD diagnosis who redeemed at least one antipsychotic prescription within 2006-2016, using data from health-record database of Hong-Kong public healthcare-services. We calculated annual prescription rates (per 1000 persons) for any antipsychotic, antipsychotic drug-classes (first- or second-generation-antipsychotics, FGAs or SGAs), formulations (oral or long-acting injectable, LAI), and individual antipsychotics. Joinpoint-regression analyses were performed to assess temporal antipsychotic prescription trends, quantified by average-annual-percent-change (AAPC), with 95% confidence-intervals (CIs). Result showed that overall antipsychotic prescription rate declined over time from 84.7% in 2006 to 79.9% in 2016. Oral-SGA use gradually surpassed oral-FGA use, rising from 23.8% in 2006 to 54.1% in 2016. LAI-use was relatively low in prevalence and significantly, albeit modestly, dropped from 23.7% to 18.8% over 11 years (AAPC: -2.20[-2.50 to -1.09]), but LAI-SGA use raised over time (APPC: 12.96 [6.59-19.70]), mainly driven by paliperidone-LAI. Risperidone and olanzapine represented two most frequently-prescribed oral-SGAs, while clozapine prescription rate was generally low (4.3%-6.1%), but showed significant upward trend (AAPC: 3.36[2.95-3.78]) over the study period. Our results affirm significant rising trend of SGA prescription over time. Yet, clozapine and LAIs remained relatively underutilized, indicating discrepancies between clinical-treatment recommendations and real-world prescribing practices. Further investigation is needed to clarify barriers to guideline-concordant practices to optimize treatment outcome.

Assessing the impact of long-acting injectable compared to oral antipsychotic medications on readmission to a state psychiatric hospital

WHAT IS KNOWN ON THE SUBJECT

People living with schizophrenia spectrum disorder (SSD) have a higher death rate which is caused, in part, by poorer adherence to treatment as compared to those with other mental illnesses. Using long-acting injectable antipsychotic (LAI) medications can improve medication adherence and reduce hospitalizations for people living with SSD but are often underutilized.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

As compared to oral antipsychotic medications provided to patients with SSD at discharge from a psychiatric hospitalization, being provided with an LAI antipsychotic medication may reduce subsequent rehospitalization. Specifically, patients discharged on an atypical or second-generation LAI medication are less likely to be readmitted to the hospital when compared to those discharged on a typical first-generation oral medication.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Because LAI antipsychotic medications are often underutilized as treatment options, the study findings suggest that this modality may be considered for patients with SSD when being discharged from a psychiatric hospitalization. Ideally, psychiatric-mental health nurses can educate patients about indications, benefits, and risks of using atypical or second-generation LAI antipsychotic medications during hospitalization and at discharge prevent the risk for future rehospitalizations.

ABSTRACT

INTRODUCTION: People living with schizophrenia spectrum disorder (SSD) have poorer medication adherence compared to those with other mental illnesses. Long-acting injectable antipsychotic (LAI) medication use is associated with greater adherence, reduced re-hospitalizations, and improved recovery outcomes when compared to oral formulations.

AIM

To compare LAI antipsychotic medication use versus oral formulations on readmission to an inpatient hospital.

METHOD

Medical records (N = 707) from a state psychiatric hospital in the southern region of the United States were reviewed. Controlling for demographic variables, logistic regression analyses were used to examine LAI compared to oral formulations on readmission.

RESULTS

Compared to patients discharged with oral antipsychotic medications, those with LAIs had a lower proportion of readmission rates in 6-month and 1-year periods, but not 30-day or 2-year periods. When controlling for demographic variables, those discharged with an atypical LAI had significantly lower odds of being readmitted within the 24-year period compared to those discharged on a typical oral antipsychotic.

DISCUSSION

Compared to orals, LAIs do not increase and may mitigate readmissions to psychiatric hospitalization.

IMPLICATIONS FOR PRACTICE

Psychiatric-mental health nurses and other professionals may recommend LAIs when indicated for those with SSD.

Comparing two transitioning strategies to paliperidone palmitate once-every-6-months

BACKGROUND

A double-blind, randomized, active-controlled, parallel-group, noninferiority trial (NCT03345342) demonstrated that paliperidone palmitate once-every-6-months (PP6M) was noninferior to paliperidone palmitate once-every-3-months (PP3M) in preventing relapse in clinically stable adults with schizophrenia. This post hoc analysis assessed efficacy and safety following transition to PP6M from paliperidone once-monthly (PP1M) versus PP3M.

METHODS

Adults with schizophrenia who were clinically stable on moderate/high doses of PP1M or PP3M were randomly assigned 1:2 to dorsogluteal PP3M or PP6M treatment for 12 months. The primary efficacy measure was time to relapse during the 12-month DB phase. Secondary endpoints included change from DB baseline to endpoint in Positive and Negative Syndrome Scale (PANSS) total and subscale scores, Clinical Global Impression-Severity (CGI-S) scale score, and Personal and Social Performance (PSP) scale score. Safety was assessed by treatment-emergent adverse events (TEAEs), vital signs, and clinical laboratory tests.

RESULTS

Of 702 patients in the study, 231 transitioned from PP1M to PP6M and 247 transitioned from PP3M to PP6M. Low relapse rates for PP6M were observed regardless of transition pathway (PP1M/PP6M: 7.8%; PP3M/PP6M: 7.3%). Changes from DB baseline to endpoint in PANSS total, PSP, and CGI-S scores were similar between transition groups. In the DB phase, ≥1 TEAE was observed in 61.0% and 63.2% of patients in the PP1M/PP6M and PP3M/PP6M, groups, respectively.

CONCLUSION

Adults with schizophrenia who transitioned to PP6M from either PP1M or PP3M experienced similarly low relapse rates. Additionally, symptom and functionality scores supported the primary analysis and, along with TEAE incidences, were comparable between transition groups.

Impact of Demographics and Insurance Coverage on Schizophrenia Treatment and Healthcare Resource Utilization Within an Integrated Healthcare System

Purpose

Little is known about the impact of health disparities on antipsychotic treatment and healthcare resource utilization (HRU) among patients with schizophrenia. The objective of this analysis is to examine treatment patterns and HRU by age, race/ethnicity, and insurance coverage among patients with schizophrenia in an integrated delivery network (IDN).

Patients and Methods

This cross-sectional study used electronic health record data from MedStar Health, an IDN in the Baltimore-Washington, DC, area. Patients were aged ≥18 years and had ≥2 outpatient encounters or ≥1 hospitalization with a diagnosis of schizophrenia between January 1, 2017 and March 31, 2021. Outcomes assessed included oral antipsychotic prescriptions, long-acting injectable antipsychotic (LAI) utilization, hospitalizations, emergency department (ED) visits, and outpatient visits. Analyses compared subgroups based on age, race/ethnicity (non-Hispanic Black, non-Hispanic White, and other), and type of insurance coverage at index (Medicare, Medicaid, and other) during 12 months of follow-up.

Results

A total of 78.1% of patients had ≥1 prescription for an antipsychotic and 69.1% received ≥1 second-generation antipsychotic. Second-generation long-acting injectables (SGA LAI) were utilized by 9.0% of patients, with the elderly and Medicaid beneficiaries having the lowest SGA LAI utilization. Overall, 61.7% of patients had ≥1 hospitalization, 56.4% had ≥1 outpatient visit, and 50.5% had ≥1 ED visit. Hospitalizations and ED visits were most common in those 18 to 24 years of age and in Medicaid beneficiaries, whereas outpatient visits were more common for the elderly and Medicare beneficiaries.

Conclusion

At the population level, the results indicate widespread underprescription/underutilization of antipsychotics that have been shown to improve clinical and economic outcomes in patients with schizophrenia, particularly SGA LAI. Within specific subpopulations, disparities in treatment selection and HRU were observed, suggesting the need for increased attention to at-risk groups to ensure consistent quality of care regardless of age, race/ethnicity, or insurance coverage.

Impact of psychopathology on day-to-day living in patients with schizophrenia: A network analysis

Although the relationship between schizophrenia and disability is well established, the association between the symptoms of the disorder and functional domains remains unclear. The current study explored the nuances of the relationship between symptoms and domains of functioning in a sample of 1127 patients with schizophrenia. We assessed the symptoms of schizophrenia with the Positive and Negative Syndrome Scale (PANSS) and psychosocial functioning with the mini-ICF-APP (mini-International Classification of Functioning Rating for Limitations of Activities and Participation in Psychological Disorders). The mean PANSS score was 94.28 (27.20), and the mean mini-ICF-APP score was 25.25 (8.96), both of which are indicative of severe symptom load and impairment. We were able to show a strong relationship and overlap between symptoms and disability in patients with schizophrenia. We identified several symptoms related to functional impairment. Deficits in judgment and abstract thinking contribute to impairment through poor adherence (to routines and compliance with rules) and difficulties in planning and organizing. We believe that in schizophrenia, symptoms and their interactions constitute a disorder beyond any single manifestation. Furthermore, we suggest that cognitive testing and cognitive treatment should become part of the standard of care for patients with schizophrenia.

What Remains to Be Discovered in Schizophrenia Therapeutics: Contributions by Advancing the Molecular Mechanisms of Drugs for Psychosis and Schizophrenia

Schizophrenia is a frequently debilitating and complex mental disorder affecting approximately 1% of the global population, characterized by symptoms such as hallucinations, delusions, disorganized thoughts and behaviors, cognitive dysfunction, and negative symptoms. Traditional treatment has centered on postsynaptic dopamine antagonists, commonly known as antipsychotic drugs, which aim to alleviate symptoms and improve functioning and the quality of life. Despite the availability of these medications, significant challenges remain in schizophrenia therapeutics, including incomplete symptom relief, treatment resistance, and medication side effects. This opinion article explores advancements in schizophrenia treatment, emphasizing molecular mechanisms, novel drug targets, and innovative delivery methods. One promising approach is novel strategies that target neural networks and circuits rather than single neurotransmitters, acknowledging the complexity of brain region interconnections involved in schizophrenia. Another promising approach is the development of biased agonists, which selectively activate specific signaling pathways downstream of receptors, offering potential for more precise pharmacological interventions with fewer side effects. The concept of molecular polypharmacy, where a single drug targets multiple molecular pathways, is exemplified by KarXT, a novel drug combining xanomeline and trospium to address both psychosis and cognitive dysfunction. This approach represents a comprehensive strategy for schizophrenia treatment, potentially improving outcomes for patients. In conclusion, advancing the molecular understanding of schizophrenia and exploring innovative therapeutic strategies hold promise for addressing the unmet needs in schizophrenia treatment, aiming for more effective and tailored interventions. Future research should focus on these novel approaches to achieve better clinical outcomes and improve the functional level and quality of life for individuals with schizophrenia.

Efficacy and safety of long-acting injectable versus oral antipsychotics in the treatment of patients with early-phase schizophrenia-spectrum disorders: a systematic review and meta-analysis

Background

Long-acting injectable antipsychotics (LAIs) have advantages over oral antipsychotics (OAPs) in preventing relapse and hospitalization in chronically ill patients with schizophrenia-spectrum disorders (SSDs), but evidence in patients with first-episode/recent-onset, that is, early-phase-SSDs is less clear.

Objectives

To assess the relative medium- and long-term efficacy and safety of LAIs versus OAPs in the maintenance treatment of patients with early-phase SSDs.

Method

We searched major electronic databases for head-to-head randomized controlled trials (RCTs) comparing LAIs and OAPs for the maintenance treatment of patients with early-phase-SSDs.

Design

Pairwise, random-effects meta-analysis. Relapse/hospitalization and acceptability (all-cause discontinuation) measured at study-endpoint were co-primary outcomes, calculating risk ratios (RRs) with their 95% confidence intervals (CIs). Subgroup analyses sought to identify factors moderating differences in efficacy or acceptability between LAIs and OAPs.

Results

Across 11 head-to-head RCTs (n = 2374, median age = 25.2 years, males = 68.4%, median illness duration = 45.8 weeks) lasting 13-104 (median = 78) weeks, no significant differences emerged between LAIs and OAPs for relapse/hospitalization prevention (RR = 0.79, 95%CI = 0.58-1.06, p = 0.13) and acceptability (RR = 0.92, 95%CI = 0.80-1.05, p = 0.20). The included trials were highly heterogeneous regarding methodology and patient populations. LAIs outperformed OAPs in preventing relapse/hospitalization in studies with stable patients (RR = 0.65, 95%CI = 0.45-0.92), pragmatic design (RR = 0.67, 95%CI = 0.54-0.82), and strict intent-to-treat approach (RR = 0.64, 95%CI = 0.52-0.80). Furthermore, LAIs were associated with better acceptability in studies with schizophrenia patients only (RR = 0.87, 95%CI = 0.79-0.95), longer illness duration (RR = 0.88, 95%CI = 0.80-0.97), unstable patients (RR = 0.89, 95%CI = 0.81-0.99) and allowed OAP supplementation of LAIs (RR = 0.90, 95%CI = 0.81-0.99).

Conclusion

LAIs and OAPs did not differ significantly regarding relapse prevention/hospitalization and acceptability. However, in nine subgroup analyses, LAIs were superior to OAPs in patients with EP-SSDs with indicators of higher quality and/or pragmatic design regarding relapse/hospitalization prevention (four subgroup analyses) and/or reduced all-cause discontinuation (five subgroup analyses), without any instance of OAP superiority versus LAIs. More high-quality pragmatic trials comparing LAIs with OAPs in EP-SSDs are needed.

Trial registration

CRD42023407120 (PROSPERO).

Barriers to long-acting injectable atypical antipsychotic use in Japan: Insights from a comparative psychiatrist survey

AIMS

To investigate the negative attitudes of Japanese psychiatrists toward atypical long-acting injectable (LAI) antipsychotics, which are the current mainstream LAIs in Japan.

METHODS

We surveyed 69 Japanese psychiatrists using a 5-point Likert scale to assess their attitudes toward atypical LAI antipsychotics. Our assessment referenced concerns identified in a study conducted in Japan a decade ago, which found significant differences when compared with a survey of German psychiatrists. We also identified the factors influencing these negative attitudes. Additionally, the results were compared with those of previous Japanese and German studies.

RESULTS

More than 50% of Japanese psychiatrists expressed negative attitudes toward atypical LAI antipsychotics in various areas. These concerns included apprehensions about cost, reluctance to recommend them initially, pain from injections, complexity of switching to LAI, usage in first-episode cases, and sufficient medication adherence with oral drugs. In all three studies, cost and adequate adherence to oral medication were concerns that exceeded the average of the three negative comments. Age and experience in psychiatry influenced the psychiatrists' attitudes toward using these drugs in first-episode cases.

CONCLUSIONS

These findings shed light on the reasons for the underutilization of atypical LAI antipsychotics and suggest opportunities to enhance their appropriate use in clinical settings.

Evaluating the efficacy and safety of the currently available once-every-two months long-acting injectable formulations of aripiprazole for the treatment of schizophrenia or as a maintenance monotherapy for bipolar I disorder in adults

INTRODUCTION

An aripiprazole long-acting injectable (LAI) antipsychotic is now available for gluteal administration every 2 months via two different formulations: aripiprazole lauroxil (AL) and aripiprazole monohydrate (Ari 2MRTU). These longer dosing regimens of aripiprazole LAI offer new potential benefits for patients.

AREAS COVERED

The authors review the evidence supporting the efficacy and safety of aripiprazole LAIs given every 2 months for the treatment of schizophrenia or bipolar disorder (BD) in adults. The article culminates with the authors' expert perspectives on the subject.

EXPERT OPINION

AL 1064 mg every 2 months has established efficacy for the treatment of schizophrenia based on pharmacokinetic bridging studies and prospective data for treatment of an acute exacerbation of schizophrenia. In an open-label trial, Ari 2MRTU showed efficacy for the treatment of schizophrenia and BD type I based on pharmacokinetic parameters (comparable to aripiprazole once-monthly 400 mg); it also showed efficacy regarding the secondary endpoints. Multiple doses of AL 1064 mg or Ari 2MRTU 960 mg are generally well tolerated, in line with the safety profile of oral aripiprazole, with the exception of the injection-site reactions. While AL may require a 1-day initiation regimen, Ari 2MRTU 960 covers all the recommended doses of oral aripiprazole (10-20 mg).

Correlations between Negative Symptoms and Cognitive Deficits in Individuals at First Psychotic Episode or at High Risk of Psychosis: A Systematic Review

The present review aims to identify correlations between negative symptoms (NS) and deficits in neurocognition and social cognition in subjects with first-episode psychosis (FEP) and at-high-risk populations (HR). A systematic search of the literature published between 1 January 2005 and 31 December 2022 was conducted on PubMed, Scopus, and PsycInfo. Out of the 4599 records identified, a total of 32 studies met our inclusion/exclusion criteria. Data on a total of 3086 FEP and 1732 HR were collected. The available evidence shows that NS correlate with executive functioning and theory of mind deficits in FEP subjects, and with deficits in the processing speed, attention and vigilance, and working memory in HR subjects. Visual learning and memory do not correlate with NS in either FEP or HR subjects. More inconsistent findings were retrieved in relation to other cognitive domains in both samples. The available evidence is limited by sample and methodological heterogeneity across studies and was rated as poor or average quality for the majority of included studies in both FEP and CHR populations. Further research based on shared definitions of first-episode psychosis and at-risk states, as well as on more recent conceptualizations of negative symptoms and cognitive impairment, is highly needed.

Second Generation Long-Acting Injectable Antipsychotics in Schizophrenia: The Patient's Subjective Quality of Life, Well-Being, and Satisfaction

Schizophrenia (SZ) is among the twenty most disabling diseases worldwide. Subjective quality of life, well-being, and satisfaction are core elements to achieving personal recovery from the disorder. Long-acting injectable second-generation antipsychotics (SGA-LAIs) represent a valid therapeutic option for the treatment of SZ as they guarantee good efficacy and adherence to treatment. The aim of this rapid review is to summarize the evidence on the efficacy of SGA-LAIs in improving subjective quality of life, well-being, and satisfaction. The PubMed database was searched for original studies using SGA, LAI, risperidone, paliperidone, aripiprazole, olanzapine, SZ, and psychosis as keywords. Twenty-one studies were included: 13 clinical trials, 7 observational studies, and 1 post hoc analysis. It has been shown that SGA-LAIs bring an improvement to specific domains of subjective and self-rated quality of life, well-being, or satisfaction in prospective observational studies without a control arm and in randomized controlled trials versus placebo. The superiority of SGA-LAIs as compared with oral equivalents and haloperidol-LAI has been reported by some randomized controlled and observational studies. Although promising, the evidence is still limited because of the lack of studies and several methodological issues concerning the choice of the sample, the evaluation of the outcome variables, and the study design. New methodologically sound studies are needed.

Extrapyramidal adverse events and anticholinergics use after the long-term treatment of patients with schizophrenia with the new long-acting antipsychotic Risperidone ISM®: results from matching-adjusted indirect comparisons versus once-monthly formulations of Paliperidone palmitate and Aripiprazole monohydrate in 52-week studies

BACKGROUND

Risperidone ISM® is a newly developed long-acting injectable (LAI) treatment for schizophrenia in adults. In the absence of head-to-head comparisons with other similar antipsychotics, the objective of this study was to generate indirect evidence of some aspects of the safety and tolerability of Risperidone ISM compared to other LAI antipsychotics for treatment of patients with schizophrenia in the maintenance treatment setting.

METHODS

A literature review was conducted systematically to identify maintenance treatment studies reporting safety and tolerability outcomes for LAI antipsychotic therapies. Following an assessment of between-trial heterogeneity, a matching-adjusted indirect comparison (MAIC) was performed to account for between-trial imbalances in patient characteristics and to generate comparative evidence for safety and tolerability endpoints.

RESULTS

The analysis showed that incidence of extrapyramidal symptoms (EPS) was found to be numerically, but not statistically significantly, lower in patients receiving Risperidone ISM than in those receiving Paliperidone palmitate (PP) (OR [95% CI] 0.63 [0.29, 1.38], p = 0.253) and statistically significantly lower than with Aripiprazole monohydrate once-monthly (AOM) (OR [95% CI] 0.25 [0.12, 0.53], p < 0.001). Use of anticholinergic agents for the alleviation of EPS was also shown to be significantly lower in Risperidone ISM patients than in those receiving PP (OR [95% CI] 0.29 [0.10, 0.83], p = 0.021) or AOM (OR [95% CI] 0.01 [0.003, 0.06], p < 0.001), suggesting a superior tolerability profile for clinically relevant EPS. Results from the sensitivity analyses comparing stabilized and stable patients receiving Risperidone ISM to those receiving AOM yielded similarly favorable conclusions in line with the base case analyses.

CONCLUSIONS

This MAIC is consistent with the safety and tolerability results obtained during the PRISMA-3 clinical trial in the long-term treatment of schizophrenia and suggests a favorable safety and tolerability profile in terms of EPS incidence and anticholinergic agent use, relative to other antipsychotic therapies used for treatment of patients with schizophrenia in the maintenance setting.

Cost-utility analysis of using paliperidone palmitate in schizophrenia in China

Objective: Long-acting injections (LAIs) of paliperidone palmitate have been shown to improve medication adherence and relieve psychotic symptoms. However, the specific cost-utility analysis of these LAIs in schizophrenia in China remains unclear. Methods: A multi-state Markov model was constructed to simulate the economic outcomes of patients with schizophrenia in China who received paliperidone palmitate 1-month formulation (PP1M), paliperidone palmitate 3-month formulation (PP3M), and paliperidone extended-release (ER). A cost-utility analysis was conducted, mostly derived from published literature and clinical databases. All costs and utilities were discounted at a rate of 5% per annum. The primary outcome measure was the incremental cost-effectiveness ratios (ICERs). A series of sensitivity analyses were also applied. Results: After 20 years, compared to ER, using PP1M resulted in an increased discounted cost from $36,252.59 to $43,207.28. This increased cost was associated with a gain in quality-adjusted life years (QALYs) from 8.60 to 9.45. As a result, the ICER for PP1M was estimated to be $8,247.46/QALY, which was lower than the willingness-to-pay (WTP) threshold of $12,756.55/QALY. When using PP3M instead of ER, the incremental cost was $768.81 and the incremental utility was 0.88 QALYs, projecting an ICER of $873.13/QALY, which was also lower than the WTP threshold of $12,756.55/QALY. The univariate sensitivity analysis showed that the costs of PP1M, PP3M, and ER had the greatest impact on ICERs. The probability sensitivity analysis (PSA) revealed that when the WTP thresholds were $12,756.55/QALY, the probability of PP1M and PP3M being cost-effective was 59.2% and 66.0%, respectively. Conclusion: From the Chinese healthcare system perspective, PP3M and PP1M are both more cost-effective compared to ER, and PP3M has notable cost-utility advantages over PP1M.