Long-acting injectable risperidone: safety and efficacy in stable patients switched from conventional depot antipsychotics

Current and emerging long-acting antipsychotics for the treatment of schizophrenia

Introduction: In this review, the authors discuss the role of long-acting injectable antipsychotics (LAIs) for schizophrenia, focusing on the effectiveness and new perspectives introduced by such treatment strategy. Despite their promising pharmacokinetic features and their potential advantages in medication adherence, clinical outcomes, and medical costs, LAIs are not habitually presented as an option for patients, especially in the early phase of schizophrenia.Areas covered: This review explores the panorama of available LAIs for the treatment of schizophrenia, first-episode of psychosis, approved indications, medical costs, medication adherence, side effects, effectiveness and differences between first-generation (FGA)-LAIs and second-generation (SGA)-LAIs.Expert Opinion: LAIs differ in terms of specific indications, approved injection sites, needle size, injection volume, injection interval as well as potential drug-drug interactions, and commonly reported adverse reactions. The approved indications have expanded beyond schizophrenia to include bipolar and schizoaffective disorder. SGA-LAIs are often preferred to FGA-LAIs. FGA-LAIs although are less chosen in new patients due to the induction of cognitive and extrapyramidal side effects, even if, on the other hand, many SGA-LAIs are burden by hyperprolactinemia and weight gain. After a review of the available evidence, insight is provided into the potential and current therapeutic opportunities offered by LAI antipsychotic formulations.

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.

Efficacy and safety of aripiprazole lauroxil in schizophrenic patients presenting with severe psychotic symptoms during an acute exacerbation

Aripiprazole lauroxil (AL), a new long-acting injectable antipsychotic, demonstrated safety and efficacy in treating acute exacerbation symptoms of schizophrenia in a 12-week placebo-controlled trial of two doses of AL (441mg and 882mg) administered every 4weeks. We performed a post hoc analysis of this trial to evaluate the efficacy of AL in the subgroup of patients with severe psychotic symptoms, defined as those with baseline Positive and Negative Syndrome Scale (PANSS) Total score above the median score of 92 (n=309). Change from baseline to Day 85 in PANSS Total score; Positive, Negative, and General Psychopathology subscale scores; and overall response rate were assessed. Statistically significant and clinically meaningful improvements in PANSS Total score were demonstrated with AL 441mg and AL 882mg, with placebo-adjusted differences of -14.7 (p<0.0001) and -16.6 (p<0.0001), respectively. Significant and clinically meaningful findings with both doses of AL were also demonstrated for the PANSS subscales and responder rates. Overall responder rates at Day 85 were significantly greater for AL 441mg (49%; p<0.001) and 882 mg (61%; p<0.001) groups vs. placebo (18%). Common adverse events (>5%) were schizophrenia, akathisia, headache, insomnia, and anxiety. AL demonstrated robust efficacy in treatment of the subgroup of patients experiencing severe psychotic symptoms. Both doses (441mg and 882mg) were effective, with numerically greater improvement in symptoms and proportion of responders favoring the higher dose arm. Both doses had a side effect profile consistent with the known safety profile of aripiprazole.

Paliperidone palmitate in non-acute patients with schizophrenia previously unsuccessfully treated with risperidone long-acting therapy or frequently used conventional depot antipsychotics

PALMFlexS, a prospective multicentre, open-label, 6-month, phase IIIb interventional study, explored tolerability, safety and treatment response in adults (n = 231) with non-acute but symptomatic schizophrenia switching to flexibly dosed paliperidone palmitate (PP) after unsuccessful treatment with risperidone long-acting injectable therapy (RLAT) or conventional depot antipsychotics (APs). Treatment response was measured by change in Positive and Negative Syndrome Scale (PANSS) total score from baseline (BL) to last-observation-carried-forward (LOCF) endpoint (EP). Safety and tolerability assessments included Extrapyramidal Symptom Rating Scale (ESRS) total score and treatment-emergent adverse events. Significant reductions in mean PANSS total score were observed for all groups (-7.5 to -10.6; p ⩽ 0.01 [BL to LOCF EP]). After switching to PP, more than 50% of all patients achieved ⩾20% and one-third of RLAT-treated patients even achieved ⩾50% improvement in PANSS total score. Across groups, there were significant improvements (p < 0.05) in symptom severity as measured by Clinical Global Impression-Severity (CGI-S; trend for improvement with RLAT; p = 0.0568), subjective well-being, medication satisfaction, and patient functioning with PP. PP was generally well tolerated. Clinically relevant benefits were observed in non-acute patients with schizophrenia switched from RLAT or conventional depot APs to PP.

Fluphenazine decanoate (depot) and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long-acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To assess the effects of fluphenazine decanoate and enanthate versus oral anti-psychotics and other depot neuroleptic preparations for individuals with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (February 2011 and October 16, 2013), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials.

SELECTION CRITERIA

We considered all relevant randomised controlled trials (RCTs) focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, assessed the quality, and extracted data of the included studies. For dichotomous data, we estimated risk ratio (RR) with 95% confidence intervals (CI). Analysis was by intention-to-treat. We used the mean difference (MD) for normal continuous data. We excluded continuous data if loss to follow-up was greater than 50%. Tests of heterogeneity and for publication bias were undertaken. We used a fixed-effect model for all analyses unless there was high heterogeneity. For this update. we assessed risk of bias of included studies and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table.

MAIN RESULTS

This review now includes 73 randomised studies, with 4870 participants. Overall, the quality of the evidence is low to very low.Compared with placebo, use of fluphenazine decanoate does not result in any significant differences in death, nor does it reduce relapse over six months to one year, but one longer-term study found that relapse was significantly reduced in the fluphenazine arm (n = 54, 1 RCT, RR 0.35, CI 0.19 to 0.64, very low quality evidence). A very similar number of people left the medium-term studies (six months to one year) early in the fluphenazine decanoate (24%) and placebo (19%) groups, however, a two-year study significantly favoured fluphenazine decanoate (n = 54, 1 RCT, RR 0.47, CI 0.23 to 0.96, very low quality evidence). No significant differences were found in mental state measured on the Brief Psychiatric Rating Scale (BPRS) or in extrapyramidal adverse effects, although these outcomes were only reported in one small study each. No study comparing fluphenazine decanoate with placebo reported clinically significant changes in global state or hospital admissions.Fluphenazine decanoate does not reduce relapse more than oral neuroleptics in the medium term (n = 419, 6 RCTs, RR 1.46 CI 0.75 to 2.83, very low quality evidence). A small study found no difference in clinically significant changes in global state. No difference in the number of participants leaving the study early was found between fluphenazine decanoate (17%) and oral neuroleptics (18%), and no significant differences were found in mental state measured on the BPRS. Extrapyramidal adverse effects were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n = 259, 3 RCTs, RR 0.47 CI 0.24 to 0.91, very low quality evidence). No study comparing fluphenazine decanoate with oral neuroleptics reported death or hospital admissions.No significant difference in relapse rates in the medium term between fluphenazine decanoate and fluphenazine enanthate was found (n = 49, 1 RCT, RR 2.43, CI 0.71 to 8.32, very low quality evidence), immediate- and short-term studies were also equivocal. One small study reported the number of participants leaving the study early (29% versus 12%) and mental state measured on the BPRS and found no significant difference for either outcome. No significant difference was found in extrapyramidal adverse effects between fluphenazine decanoate and fluphenazine enanthate. No study comparing fluphenazine decanoate with fluphenazine enanthate reported death, clinically significant changes in global state or hospital admissions.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. Fluphenazine decanoate produced fewer movement disorder effects than other oral antipsychotics but data were of low quality, and overall, adverse effect data were equivocal. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal

Despite their widespread use, long-acting injectable (LAI) antipsychotics (APs) are often regarded with some negativity because of the assumption of punishment, control and insufficient evolution towards psychosocial development of patients. However, LAI APs have proved effective in schizophrenia and other severe psychotic disorders because they assure stable blood levels, leading to a reduction of the risk of relapse. Therapeutic opportunities have also arisen after introduction of newer, second-generation LAI APs in recent years. Newer LAI APs are more readily dosed optimally, may be better tolerated and are better suited to integrated rehabilitation programmes. This review outlines the older and newer LAI APs available for the treatment of schizophrenia, with considerations of past and present pharmacological and therapeutic issues. Traditional, evidence-based approaches to systematic reviews and randomized clinical trials are of limited utility in this area so this paper's blending of experimental trials with observational research is particularly appropriate and effective.

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.

Risperidone long-acting injection in the treatment of schizophrenia spectrum illnesses: A retrospective chart review of 19 patients in the Vancouver Community Mental Health Organization (Vancouver, Canada)

BACKGROUND

Schizophrenia is a chronic debilitating disease that affects ~110,000 Canadians (0.55% lifetime prevalence). Risperidone long-acting injection (RLAI) is the first injectable, long-acting, atypical antipsychotic drug marketed in Canada.

OBJECTIVE

The aim of this study was to assess the clinical effectiveness and hospitalization rates of patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder treated with RLAI in a community mental health care setting.

METHODS

Data were collected between August 1, 2006 and September 30, 2006 via a retrospective chart review of outpatients diagnosed with schizophrenia, schizoaffective disorder, or schizophreniform disorder who received treatment from 1 of the 8 mental health teams within the Vancouver Community Mental Health Organization (VCMHO) in Vancouver, British Columbia, Canada. Collected data included: frequency and duration of institutional care, discharge and relapse rates, demographic variables, diagnosis history, RLAI medication history, and history of other medications. The overall severity of symptoms before and after RLAI treatment and the improvement in symptoms during treatment were evaluated using the Clinical Global Impression Scales for severity (CGI-S)(1 = not ill to 7 = extremely ill) and improvement (CGI-I)(1 = very much improved to 7 = very much worse).

RESULTS

Forty-four patients were identified as having received RLAI. The charts of 19 patients (10 men, 9 women; mean [SD] age at time of chart audit, 36.7 [11.7] years; mean [SD] age at primary diagnosis, 23.6 [7.4] years; race: white, 10 [52.6%]; Asian, 6 [31.6%]; American Indian, 1 [5.3%]; black, 1 [5.3%]; other, 1 [5.3%]) were included in the analysis. The majority of patients (78%) had been treated with another antipsychotic drug prior to treatment with RLAI: risperidone (77%), quetiapine (47%), zuclopenthixol (43%), olanzapine (43%), and loxapine (17%). Mean (SD) CGI-S Scale score declined significantly from 5.29 (1.3) before treatment initiation to 3.05 (1.0) posttreatment (P < 0.001). Mean (SD) CGI-I Scale score was 2.58 (0.71) (P < 0.001); 94% of patients had a CGI-I score ≤3. Mean (SD) duration of hospitalization decreased significantly from 15.7 (19.7) days before treatment to 2.4 (6.0) days after treatment (P < 0.05). Mean (SD) number of hospializations also decreased significantly from 2.0 (1.8) before treatment to 0.5 (1.3) after treatment (P < 0.01).

CONCLUSIONS

The results of this pilot study suggest that use of the atypical-antipsychotic medication RLAI significantly decreased duration and rates of hospitalization, compared with baseline, in these VCMHO patients with schizophrenia spectrum illnesses.

Understanding depot antipsychotics: an illustrated guide to kinetics

Long-acting injectable (LAI) antipsychotics can have considerable advantages over oral medications for the management of patients with schizophrenia. Despite the high prevalence of treatment nonadherence with oral pharmacotherapy, LAI antipsychotics are significantly underutilized in this patient population. The availability of newer LAI antipsychotic preparations combined with a resurgent interest in the use of typical antipsychotics has rekindled awareness of the value of LAI medications. This article is intended to provide a visual understanding of the various kinetic profiles of LAI antipsychotics to facilitate initiation and greater use of these agents.

Long-acting injectable formulations of new-generation antipsychotics: a review from a clinical perspective

Antipsychotics are the mainstay of the long-term treatment of patients with schizophrenia. In this context, the evidence also supports the effectiveness of long-acting injections (LAIs) or depots of antipsychotics regarding their relapse-preventing properties. When a LAI formulation of risperidone was launched as the first second-generation depot, there was a renaissance of interest in these formulations. In the meantime, olanzapine, paliperidone, and aripiprazole have been approved by regulatory authorities as LAIs in various countries. All studies using the new-generation depots have shown a clear advantage over placebo regarding relapse prevention and symptom reduction. Safety profiles of the long-acting compounds are comparable to their oral formulations with the exception of olanzapine pamoate injections, which can sometimes lead to a post-injection delirium. Despite the fact that many treatment guidelines recommend LAI antipsychotics as an important treatment option for the long-term management of schizophrenia, they are still most frequently used in chronically ill patients with considerable compliance problems. It is imperative to overcome this indication bias in order to be able to utilize all available treatment options in the long-term management of schizophrenia. There is little evidence on comparisons between LAIs and their oral mother compounds, and even less concerning effectiveness comparisons between different depots. The purpose of this manuscript is to review the recent clinical evidence on new-generation depot antipsychotics.

Risperidone long-acting injection in Schizophrenia Spectrum Illnesses compared to first generation depot antipsychotics in an outpatient setting in Canada

BACKGROUND

Depot formulations of antipsychotics provide a potential solution to the poor adherence to oral therapies in schizophrenia. However, there have been few comparative studies on the effectiveness and tolerability of first and second generation depot antipsychotics in a real clinical practice setting. The objectives of the present study were to compare safety and outcomes in patients with schizophrenia initiated on risperidone long-acting injection (RLAI) or first generation antipsychotic injections (FGAI) at a Mental Health Centre in British Columbia.

METHODS

Data were collected by retrospective chart review of all active patients starting depot therapy who were ≥ 18 years of age, had received at least 3 injections of depot antipsychotic and had no prior clozapine treatment. Kaplan Meier survival curves were used to estimate probability of treatment discontinuation and hospitalization.

RESULTS

A total of 70 RLAI and 102 FGAI patient charts were reviewed. At baseline patients in both groups had similar ages (39.7 and 42.7 years for RLAI and FGAI patients (p = 0.09), respectively) but FGAI patients had a longer time since diagnosis (13.6 vs. 9.85 years (p = 0.003)). Treatment retention at 18 months was 77% for RLAI and 86% for FGAI patients (p = 0.22) and 82% and 88% of patients, respectively (p = 0.28), had not been hospitalized. However, RLAI analyses were compromised by lack of long-term patient data. Concomitant medication utilization was similar in both groups except for anticholinergics which were used less frequently in RLAI patients (5.7% vs. 35.3%, p < 0.001). Adverse event frequency was also similar except for extrapyramidal symptoms (EPS) which were more common in FGAI patients (52.9% vs. 17.0% for RLAI (p < 0.001)).

CONCLUSIONS

There was no apparent difference in treatment discontinuation or hospitalization between RLAI and FGAI treated patients, although analysis was compromised by low patient numbers. However, decreased EPS with RLAI may offer a significant clinical benefit to patients with schizophrenia.

Effectiveness of switching from long-acting injectable fluphenazine or haloperidol decanoate to long-acting injectable risperidone microspheres: an open-label, randomized controlled trial

OBJECTIVE

This multisite randomized trial addressed risks and benefits of staying on long-acting injectable haloperidol or fluphenazine versus switching to long-acting injectable risperidone microspheres.

METHOD

From December 2004 through March 2008, adult outpatients with a Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition diagnosis of schizophrenia or schizoaffective disorder who were taking haloperidol decanoate (n = 40) or fluphenazine decanoate (n = 22) were randomly assigned to stay on current long-acting injectable medication or switch to risperidone microspheres and followed for 6 months under study protocol and an additional 6 months naturalistic follow-up. Kaplan-Meier and Cox regression analyses were used to examine the primary outcome (time to treatment discontinuation), and random regression models were used to examine secondary outcomes.

RESULTS

Groups did not differ significantly in time to treatment discontinuation through 6 months of protocol-driven treatment. When the 6-month naturalistic follow-up period was included, time to treatment discontinuation was significantly shorter for individuals assigned to switch than for individuals assigned to stay (10% of stayers discontinued versus 31% of switchers; P = .01). Groups did not differ with respect to psychopathology, hospitalizations, sexual side effects, new-onset tardive dyskinesia, or new-onset extrapyramidal symptoms. However, those randomized to switch to long-acting injectable risperidone microspheres had greater increases in body mass (increase of 1.0 body mass index [BMI] versus decrease of -0.3 BMI; P = .00) and prolactin (maximum increase to 23.4 ng/mL versus decrease to 15.2 ng/mL, P = .01) compared to those randomized to stay.

CONCLUSION

Switching from haloperidol decanoate or fluphenazine decanoate to risperidone microspheres resulted in more frequent treatment discontinuation as well as significant weight gain and increases in prolactin.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00044655.

Partial adherence to antipsychotic medication impacts the course of illness in patients with schizophrenia: a review

OBJECTIVE

Although many clinicians acknowledge the occurrence of adherence problems with medication regimens among patients with schizophrenia, the problem shows no sign of improving. This may be because, in thinking about the issue, clinicians have tended to focus on patients who openly refuse or repeatedly discontinue treatment. While this description applies to only a minority of patients, in our experience, full adherence is rare; most patients are only partially adherent at best. This article examines the issue of adherence behavior in schizophrenia, focusing on the impact of partial adherence on treatment outcomes, particularly early in the course of illness. We also review potential strategies for managing the problem.

DATA SOURCES

Original research and review articles published in English from 1980 to 2008 were identified using the PubMed database, with the search terms schizophrenia or psychosis combined with compliance, noncompliance, partial compliance, adherence, nonadherence, or partial adherence.

STUDY SELECTION

Articles were selected by the authors on the basis of the hypotheses and/or data described.

DATA SYNTHESIS

Failure to adhere to medication as prescribed can have a major impact on the course of illness and treatment outcomes in patients with schizophrenia. Even relatively short gaps in medication coverage increase the risk of relapse. Problems with adherence are common early in the course of illness, when the consequences of relapse can be particularly devastating.

CONCLUSION

Clinicians in primary care and psychiatric settings need to be vigilant for signs of adherence problems among their patients and to act when necessary to prevent or alleviate the consequences of inadequate medication cover. Relapse prevention strategies, particularly for patients with early psychosis, should include ensuring that medication lapses are minimized or eliminated.

A 52-week open-label study of the safety and tolerability of paliperidone palmitate in patients with schizophrenia

The safety and tolerability of paliperidone palmitate, an injectable atypical antipsychotic agent, were assessed in a 1-year open-label extension of a double-blind study in patients with schizophrenia. Patients from the double-blind study who experienced a recurrence, remained recurrence free until study end, or who were in the transition, maintenance or double-blind phases and had received at least one injection of paliperidone palmitate when enrollment was stopped, were eligible for the open-label extension. Patients received gluteal injections of paliperidone palmitate once every 4 weeks: starting dose 50 mg eq. followed by 25, 50, 75, or 100 mg eq. flexible dosing. Of the 388 patients enrolled, 288 completed the open-label extension. During the open-label extension, the median (range) duration of exposure to paliperidone palmitate was 338 days (10; 390), and 74% of patients received all 12 open-label injections of paliperidone palmitate. The most frequent (≥ 5% in total group) adverse events were insomnia (7%); worsening of schizophrenia; nasopharyngitis; headache; and weight increase (6% each). Potentially prolactin-related adverse events occurred in 13 (3%) patients, mostly women, and none resulted in study discontinuation. Extrapyramidal treatment-emergent adverse events were reported in 25 (6%) patients; tremor was the most frequently reported (n = 8, 2%). At open-label extension endpoint, investigator-rated redness at the injection site was observed in ≤ 4% of patients in each group. Injection-site pain was rated by investigators as absent in 82-87% of patients. Schizophrenia symptoms measured by Positive and Negative Syndrome Scale and personal and social performance changes improved during the open-label extension.

Long-acting injectable risperidone in partially adherent and nonadherent patients with schizophrenia

BACKGROUND

Long-acting injectable antipsychotics may improve medication adherence, thereby improving overall treatment effectiveness. This study aimed to evaluate the effectiveness, safety, and tolerability of risperidone long-acting injection in schizophrenic patients switched from oral antipsychotic medication.

METHODS

In a 12-month, multicenter, open-label, noncomparative study, symptomatically stable patients on oral antipsychotic medication with poor treatment adherence during the previous 12 months received intramuscular injections of risperidone long-acting injection (25 mg starting dose) every 2 weeks. The primary endpoint was the change in Positive and Negative Syndrome Scale (PANSS) total score.

RESULTS

Of the 60 patients who were screened, 53 received at least one injection (safety population), and 51 provided at least one postbaseline assessment. Mean PANSS total scores improved significantly throughout the study and at endpoint. Significant improvements were also observed in Clinical Global Impression of Severity, Personal and Social Performance, and Drug Attitude Inventory scales. Risperidone long-acting injection was safe and well-tolerated. Severity of movement disorders on the Extrapyramidal Symptom Rating Scale was reduced significantly. The most frequently reported adverse events were insomnia (22.6%), increased prolactin (17.0%), and weight gain (13.2%).

CONCLUSION

Risperidone long-acting injection was associated with significant symptomatic improvements in stable patients with schizophrenia following a switch from previous antipsychotic medications.

Clinical outcomes of long-acting injectable risperidone in patients with schizophrenia: six-month follow-up from the Electronic Schizophrenia Treatment Adherence Registry in Latin America

BACKGROUND

Risperidone long-acting injection (RLAI) has been shown to be efficacious, improve compliance, and increase long-term retention rate on therapy. The aim of this work was to determine the effect of RLAI on clinical outcome and hospitalization rate in patients with schizophrenia or schizoaffective disorder enrolled in the electronic Schizophrenia Treatment Adherence Registry in Latin America.

METHODS

Data were collected at baseline, retrospectively for the 12 months prior to baseline, and prospectively every three months for 24 months. Hospitalization prior to therapy was assessed by a retrospective chart review. Efficacy and functioning were evaluated using Clinical Global Impression of Illness Severity (CGI-S), Personal and Social Performance (PSP), and Global Assessment of Functioning (GAF) scores. Relapse and treatment were also registered.

RESULTS

Patients were recruited in Mexico (n = 53), Brazil (n = 11), and Colombia (n = 15). Sixty-five percent (n = 52) were male, and mean age was 32.9 years. Patients were classified as having schizophrenia (n = 73) or schizoaffective disorder (n = 6). The mean dose of RLAI at six months was 34.1 mg (standard deviation = 10.2 mg). The percentage of hospitalized patients before treatment was 28.2% and 5.1% at six months after initiating RLAI (P < 0.001). Significant changes were registered on CGI-S, GAF, and PSP scores.

CONCLUSIONS

RLAI was associated with an improvement in clinical symptoms and functioning, and a greater reduction in hospitalization.

Second-generation antipsychotic long-acting injections: systematic review

BACKGROUND

Second-generation antipsychotics (SGAs) represent an advance in the long-term management of schizophrenia.

AIMS

To review the available evidence concerning SGA long-acting injections (LAIs).

METHOD

A systematic review of the literature was conducted using PubMed.

RESULTS

Risperidone long-acting injection was the first licensed SGA-LAI compound and is effective in the long-term management of schizophrenia, with a safety profile similar to that of oral risperidone. Olanzapine pamoate has recently been approved in Europe. In terms of efficacy, at injection intervals of up to 4 weeks it appears comparable to oral olanzapine, although the potential for ;post-injection syndrome' (delirium) calls for additional safety considerations. Paliperidone palmitate is currently under review with the licensing authorities. It also affords the potential advantage of monthly dosing.

CONCLUSIONS

More long-term comparisons of SGA-LAIs with oral SGAs as well as with first-generation antipsychotic LAIs are needed. These studies should include cost-effectiveness data.

Risperidone long-acting injection as monotherapy and adjunctive therapy in the maintenance treatment of bipolar I disorder

IMPORTANCE OF THE FIELD

It is very rare for patients with bipolar disorder to have a single episode of mania or depression over a lifetime and the vast majority of these individuals need long-term prophylactic/maintenance treatment. However, treatment nonadherence is a major issue for close to half of subjects with bipolar disorder who are prescribed medications. Risperidone long-acting injection (LAI) has proven efficacious for the maintenance phase of bipolar disorder and may mitigate the problem of nonadherence in the substantial group of patients for whom this is a significant concern.

AREAS COVERED IN THIS REVIEW

This paper comprises a review and commentary regarding the use of risperidone LAI in bipolar disorder.

WHAT THE READER WILL GAIN

The reader will gain an understanding regarding the risks and benefits of risperidone LAI in bipolar disorder. We review the available evidence and discuss the strengths and weaknesses of published studies, providing an opinion about the clinical usefulness of risperidone LAI as well as suggestions for future research.

TAKE HOME MESSAGE

The use of risperidone LAI, through improved adherence, has the potential to ameliorate the course of bipolar disorder.

Long-term observation of patients successfully switched to risperidone long-acting injectable: A retrospective, naturalistic 18-month mirror-image study of hospitalization rates and therapy costs

Abstract Objective. The aim of the present 18-month retrospective study was to assess the association between a continuous long-term treatment with risperidone long-acting injectable (RLAI) of at least 12 months and in-patient care of patients suffering of schizophrenia or schizoaffective disorder. Furthermore we wanted to assess the cost-effectiveness of a long-term treatment with RLAI. Methods. In a mirror-image design, data of 119 patients with schizophrenia and schizoaffective disorder who were switched to RLAI treatment were analyzed retrospectively. Hospitalization rates, the duration of inpatient treatment and the overall treatment costs were assessed 12 and 18 months after switching to RLAI and compared to the equivalent time preceding the switch. Results. After 12 and 18 months of RLAI treatment, the mean reduction of inpatient care was 27.4 and 38.4 days per patient, respectively, compared to the equivalent time period prior to switching to RLAI (Wilcoxon P < 0.001). The overall savings in drug and institutional-care costs were 21.1 and 21.9%, respectively. Conclusions. Patients receiving RLAI for at least 12 months showed a reduction in inpatient days and lower overall treatment costs.

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.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: reasons for switching and safety

OBJECTIVE

An international, non-randomised study evaluated efficacy and safety of risperidone long-acting injectable (RLAI) compared to previous treatment. To investigate generizability of the European data set to the UK subset safety and switching data are reported here.

METHODS

Patients with schizophrenia or other psychotic disorder, symptomatically stable on antipsychotic medication, received intramuscular injections of RLAI 25 mg (to a maximum of 50 mg) every 2 weeks for 6 months.

RESULTS

Of 182 UK patients enrolled, 79% had schizophrenia, 21% other psychotic disorders. Insufficient efficacy (43%), side effects (45%), and non-compliance (25%) were the most common reasons for switching. Sixty-nine per cent of patients completed the trial; 8% discontinued due to adverse events (AEs). Most frequent treatment-emergent AEs were headache (8.2%), relapse (7.7%) and insomnia (7.1%); 8 (4.4%) patients reported injection-related AEs. There were significant improvements in extrapyramidal symptom rating scale total and subscale (particularly Parkinsonism) scores, regardless of previous medication (total cohort, p < or = 0.0001). There was a small but significant increase in body weight at endpoint (1.2 kg, p = 0.0023). One patient suffered a myocardial infarction and died (not treatment-related). There were no substantial differences between the full data set and the UK sub-population

CONCLUSION

Switch to RLAI was well-tolerated in stable patients over 6 months. The European data set is generalizable to the UK patient population.

Pharmacokinetics and efficacy of a direct switch from conventional depot to risperidone long-acting injection in Chinese patients with schizophrenic and schizoaffective disorders

AIMS

This 12-week open-label study was designed to investigate the pharmacokinetics and efficacy of a direct switch from a conventional depot to long-acting injectable risperidone in patients with schizophrenia and schizoaffective disorder.

METHODS

Men or women from 18 to 65 years old with a diagnosis of schizophrenia or schizoaffective disorder were eligible for participation if they had been treated with conventional depot for at least 8 weeks before study entry. Intramuscular long-acting risperidone was administered starting from 25 mg, with the dose flexibly adjusted every two weeks for 12 weeks from week 4.

RESULTS

Of the 25 patients enrolled in this study, 21 completed at least one post-baseline assessment and were thus included in the analysis. The mean serum concentration of risperidone plus 9-hydroxyrisperidone was 29.1 ng/mL at the 12th week after switching, with an average injection dose of 31.25 mg long-acting risperidone every two weeks. The levels of active moiety of risperidone seemed to be higher in Chinese patients compared to those in Caucasian patients. Positive and Negative Syndrome Scale total scores (from 67.5 to 56.4; P = 0.002), scores for negative symptoms (P = 0.006) and general symptoms (P = 0.001) were improved significantly 12 weeks after the switch. Mean Extrapyramidal Symptom Rating Scale scores were improved significantly from 20.1 to 5.5 (P < 0.001). Significantly decreased levels of cholesterol and triglyceride were found at the 12th week. The levels of fasting glucose, low-density lipoprotein, high-density lipoprotein and bodyweight remained unchanged.

CONCLUSIONS

These findings suggest that switching from conventional depot to long-acting risperidone is feasible with the advantage of symptom reduction and side-effect profile decrement.

Partial compliance in schizophrenia and the impact on patient outcomes

This review evaluates the impact of partial compliance on treatment outcomes in schizophrenia and discusses strategies that may be implemented to enhance compliance. As such, a search of English language articles evaluating compliance in schizophrenia was performed using Medline and EMBASE, with no time limits. Abstracts and posters presented at key psychiatry congresses were also reviewed. Results demonstrated that partial compliance with antipsychotic medication is a significant barrier to achieving optimal outcomes in schizophrenia. The problem increases with the duration of treatment, and is difficult to monitor. The impact of partial compliance is significant, leading to increases in psychotic symptoms, the risk of relapse and rehospitalization, and even suicide. Compliance is a complex phenomenon, influenced by aspects of the illness itself such as cognitive impairment and patients' health beliefs. The patient's environment and therapeutic alliance also influence medication compliance. Behavioural and pharmacological measures should be used together to improve compliance. While atypical antipsychotics have demonstrated improvements in psychotic symptoms, insight and cognition, these may not be enough to ensure compliance with oral daily medication. Long-acting risperidone may therefore bring together the benefits of the atypical antipsychotics with the long-acting injection delivery system required to build a platform for improved outcomes.

Long-acting injectable risperidone v. olanzapine tablets for schizophrenia or schizoaffective disorder. Randomised, controlled, open-label study

BACKGROUND

The efficacy and safety of long-acting injectable risperidone have not been compared with those of an oral atypical antipsychotic.

AIMS

To compare long-acting risperidone and oral olanzapine in 377 patients with DSM-IV schizophrenia or schizoaffective disorder.

METHOD

Patients were randomised to receive long-acting risperidone (25 mg or 50 mg every 14 days) or olanzapine (5-20 mg/day).

RESULTS

In the 13-week phase, long-acting risperidone was at least as effective as (not inferior to) oral olanzapine. In the 12-month phase, significant improvements in the Positive and Negative Syndrome Scale (PANSS) total and factor scores from baseline to month 12 and end-point were seen in both groups of patients. Few patients discontinued treatment because of an adverse event.

CONCLUSIONS

Both treatments were efficacious and well tolerated.

Discovery of antiandrogen activity of nonsteroidal scaffolds of marketed drugs

Finding good drug leads de novo from large chemical libraries, real or virtual, is not an easy task. High-throughput screening is often plagued by low hit rates and many leads that are toxic or exhibit poor bioavailability. Exploiting the secondary activity of marketed drugs, on the other hand, may help in generating drug leads that can be optimized for the observed side-effect target, while maintaining acceptable bioavailability and toxicity profiles. Here, we describe an efficient computational methodology to discover leads to a protein target from safe marketed drugs. We applied an in silico "drug repurposing" procedure for identification of nonsteroidal antagonists against the human androgen receptor (AR), using multiple predicted models of an antagonist-bound receptor. The library of marketed oral drugs was then docked into the best-performing models, and the 11 selected compounds with the highest docking score were tested in vitro for AR binding and antagonism of dihydrotestosterone-induced AR transactivation. The phenothiazine derivatives acetophenazine, fluphenazine, and periciazine, used clinically as antipsychotic drugs, were identified as weak AR antagonists. This in vitro biological activity correlated well with endocrine side effects observed in individuals taking these medications. Further computational optimization of phenothiazines, combined with in vitro screening, led to the identification of a nonsteroidal antiandrogen with improved AR antagonism and marked reduction in affinity for dopaminergic and serotonergic receptors that are the primary target of phenothiazine antipsychotics.

Long-acting risperidone injection: efficacy, safety, and cost-effectiveness of the first long-acting atypical antipsychotic

OBJECTIVE

To review the pharmacokinetics, efficacy, safety, and cost-effectiveness of long-acting risperidone.

METHODS

Studies published between January 2000 and October 2006 evaluating the pharmacokinetics, efficacy, safety, and cost-effectiveness of long-acting risperidone were reviewed, as identified from literature searches using Medline and EMBASE. Abstracts and posters on long-acting risperidone presented at key psychiatry congresses and available in the public domain during this time period were also reviewed.

RESULTS

The unique pharmacokinetic profile of long-acting risperidone is derived from the encapsulation of risperidone in a glycolide/lactide matrix in the form of microspheres such that after a single intramuscular injection, significant plasma levels of the drug are achieved after week 3. Steady state, after repeated administration at 2-week intervals, is achieved after 3 injection cycles. Short- and long-term studies have demonstrated that long-acting risperidone (25, 37.5, or 50 mg) is both efficacious and well tolerated in a wide variety of patients with schizophrenia and related psychoses. Most patients can be switched from other oral and long-acting antipsychotic agents without compromising efficacy and safety. Long-acting risperidone may also reduce overall healthcare costs by decreasing rates of relapse and hospitalization.

CONCLUSION

The assured delivery of an atypical antipsychotic medication with long-acting risperidone has important implications for patient compliance, maintenance of stability, consistency of treatment, and improving patient outcomes including the achievement of remission.

Long-term safety and tolerability of long-acting injectable risperidone in patients with schizophrenia or schizoaffective disorder

Subjects were patients with schizophrenia or schizoaffective disorder enrolled in extension studies (Study A and Study B) after participating in 12-week studies of long-acting injectable risperidone [Kane, J.M., Eerdekens, M., Lindenmayer, J.-P., Keith, S.J., Lesem, M., Karcher, K., 2003. Long-acting injectable risperidone: efficacy and safety of the first long-acting atypical antipsychotic. Am. J. Psychiatry 160, 1125-1132; Lindenmayer, J.-P., Eerdekens, L., Berry, S., Eerdekens, M., 2004. Safety and efficacy of long-acting risperidone in schizophrenia: a 12-week, multicenter, open-label study in stable patients switched from typical and atypical oral antipsychotics. J. Clin. Psychiatry 65, 1084-1089]. Twelve months of treatment were completed by 55% of Study A patients and 52% of Study B patients. The median modal dose of long-acting injectable risperidone was 50 mg/14 days in both studies. Most frequent adverse events were psychosis, headache, insomnia, agitation, and rhinitis. EPS-related adverse events were reported in 33% of patients in Study A and 22% in Study B. Patients with Clinical Global Impressions ratings of "not ill" and "mild" increased from 14% at baseline to 54% at endpoint in Study A and from 42% to 65% in Study B. It is concluded that treatment with long-acting injectable risperidone for 1 year or longer appeared to be safe and well tolerated in patients with schizophrenia or schizoaffective disorder.

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.

Pharmacological treatment of primary negative symptoms in schizophrenia: a systematic review

BACKGROUND

Optimal treatment of primary negative symptoms is important because their presence is associated with poor outcome.

AIMS

To systematically review all studies dealing with the efficacy of pharmacological agents on primary negative symptoms.

METHOD

A comprehensive search of the relevant literature was undertaken using electronic database, reference lists and personal contact.

RESULTS

There is a lack of standardized research designs. Amisulpride is the most extensively studied drug with respect to efficacy against primary negative symptoms. At low doses it demonstrates a consistent, modest effect compared to placebo, though not to conventional antipsychotics and has yet to be tested against other atypicals. Evidence from multiple studies that used simple statistical analyses and inclusion criteria for patients with primary negative symptoms does not support a direct effect for clozapine. Path-analysis studies support the direct effects of risperidone, olanzapine, sertindole and aripiprazole, however, different statistical analyses of the same risperidone study produced conflicting results and the direct effects of olanzapine were not confirmed in selected patients with primary negative symptoms. There are no studies supporting the use of ziprasidone or quetiapine. The effects of typical antipsychotics on primary negative symptoms are inconclusive and likely to depend on drug dosages. Selective serotonin reuptake inhibitors (SSRIs), mirtazepine and NMDA agonists show early promise but require further study. Novel agents such as selegiline, naltrexone, dehydroepiandrosterone, galantamine, Ginkgo, nitric oxide, L-deprenyl and pergolide show positive effects on general negative symptoms but remain untested against primary negative symptoms.

CONCLUSIONS

Further studies using standardized selective inclusion criteria and controlling for chronicity are needed. Research guidelines are discussed.

Symptom domains of schizophrenia: the role of atypical antipsychotic agents

Given their more obvious presentation, the reduction of positive symptoms and their associated behavioural problems have been considered the most important treatment outcome parameter in patients with schizophrenia. However, the development of the atypical antipsychotic agents in the early 1990s resulted in the adoption of more wide-reaching measures of therapeutic outcome. The aim of this review was to evaluate the efficacy of currently available atypical agents across multiple symptom domains of schizophrenia with a specific focus on negative symptoms, neurocognition, social functioning, quality of life and insight. As such, studies published between January 1990 and December 2005 that evaluated the clinical efficacy and tolerability of atypical antipsychotics in different symptom domains of schizophrenia were reviewed as identified from literature researches using MEDLINE and Embase. Abstracts and posters presented at key psychiatry and schizophrenia congresses during this period were also reviewed where available in the public domain. Results from the studies identified have consistently demonstrated that atypical antipsychotics have substantial advantages over conventional antipsychotics with a broader spectrum of efficacy across symptomatic domains of schizophrenia as proven by greater improvements in negative symptoms and cognitive function and a beneficial effect on affective symptoms and quality of life. However, their clinical advantages have often been limited by patients' partial compliance with therapy. As such, the development of a long-acting atypical antipsychotic agent may provide a new and valuable treatment option for patients with schizophrenia.

A prospective, multicenter, randomized, parallel-group, open-label study of aripiprazole in the management of patients with schizophrenia or schizoaffective disorder in general psychiatric practice: Broad Effectiveness Trial With Aripiprazole (BETA)

OBJECTIVE

BETA was designed to evaluate the overall effectiveness of aripiprazole in patients with schizophrenia or schizoaffective disorder treated in a general psychiatry outpatient practice setting.

METHODS

In this 8-week, multicenter, open-label study, 1,599 outpatients with schizophrenia or schizoaffective disorder were randomly assigned to receive either aripiprazole (n=1,295) or another antipsychotic medication (safety control [SC] group; n=304). Aripiprazole was initiated at 15 mg/d with the option to adjust between 10-30 mg/d. The SC medication was specifically selected for each patient by the clinician and dosed according to prescribing guidelines for that medication. The primary effectiveness measure was the Clinical Global Impression-Improvement (CGI-I) score of the aripiprazole group at study end point. Secondary measures included response rates and preference of medicine (POM) ratings by patients and caregivers.

RESULTS

Sixty-five percent of aripiprazole patients completed the study. The mean aripiprazole dose at end point was 19.9 mg/d, with approximately 39% of patients starting and remaining at 15 mg/d. At end point, the mean CGI-I score of 2.77 demonstrated that aripiprazole was minimally to moderately effective; the mean CGI-I score for the SC group was 3.59 indicating minimally effective to no change. Fifty-three percent of aripiprazole patients responded to treatment (CGI-I score of 1 or 2; last-observation-carried-forward [LOCF]), and approximately 71% of patients and caregivers rated aripiprazole as better than the prestudy medication on the POM (LOCF). Incidence and severity of adverse events (AEs) were similar to those reported in double-blind, randomized, placebo-controlled aripiprazole clinical trials. The most frequent AE in the aripiprazole group was insomnia (24%).

CONCLUSIONS

Aripiprazole was effective for the treatment of schizophrenia and schizoaffective disorder in a general psychiatry outpatient practice setting. Overall, aripiprazole was found to be effective by the treating clinician and well accepted by patients and caregivers over the 8-week treatment course.

Long-acting risperidone: Focus on safety

BACKGROUND

Although atypical antipsychotics are generally regarded as having more favorable tolerability profiles than conventional antipsychotics, differences between specific atypical agents can be important when individualizing treatment. Long-acting risperidone (LAR), the first long-acting injectable atypical anti-psychotic, has been found to be effective in the treatment of schizophrenia and schizoaffective disorder.

OBJECTIVES

This review summarizes clinical evidence for the tolerability profile of LAR in patients with schizophrenia and schizoaffective disorder and assesses its utility in specific patient groups, including younger patients and the elderly.

METHODS

MEDLINE and EMBASE were searched for studies published between January 1994 and March 2006 that evaluated the tolerability of LAR. The primary search terms were long-acting risperidone, schizophrenia, schizoaffective, long term, tolerability, and safety. Abstracts and posters presented at major psychiatry and schizophrenia conferences during this period also were reviewed. Articles were included if they were reports of clinical studies and included tolerability data for LAR.

RESULTS

The literature search identified 7 open-label trials, 3 double-blind trials, 15 subanalyses, and 1 pooled analysis. When patients were switched directly or indirectly from another antipsychotic agent, LAR was generally well tolerated, with a low incidence of withdrawals due to adverse events (1%-16%). Moreover, LAR was associated with a weight-gain profile of 1 to 2 kg in the short term and did not appear to negatively affect lipids or glucose metabolism. Although LAR was associated with elevations in serum prolactin levels in 2% to 7% of patients, these elevations were not symptomatic, and levels decreased over time.

CONCLUSIONS

LAR was generally well tolerated in several patient groups, including the elderly and those with schizoaffective disorder. When patients were switched from other antipsychotics, use of LAR was not associated with an increased risk of adverse events compared with placebo.

Clinical experience and management considerations with long-acting risperidone

BACKGROUND

Risperidone is the first atypical anti-psychotic available in a long-acting injectable formulation.

OBJECTIVE

To provide an overview of the initial clinical experience gained with long-acting risperidone during clinical trials and in general treatment, including specific case studies, as well as providing practical advice on how to initiate treatment with this new drug.

METHODS

Studies published between January 2002 and June 2005 that evaluated the pharmacokinetics, efficacy and safety of long-acting risperidone for the treatment of schizophrenia were reviewed, as identified from literature searches using Medline and EMBASE. Although not peer-reviewed, abstracts and posters on long-acting risperidone presented at key psychiatry and schizophrenia congresses during this period were also reviewed where available in the public domain.

RESULTS

Clinical studies have consistently demonstrated that long-acting risperidone, available in dosage strengths of 25, 37.5 or 50 mg, given once every 2 weeks, is both effective and well tolerated in patients with schizophrenia. Furthermore, significant and sustained clinical improvement has been reported in patients switched to long-acting risperidone from other oral and long-acting antipsychotic agents. Several patients groups, including the young, the elderly and patients with schizoaffective disorder, have also been shown to derive significant benefit from long-acting risperidone.

CONCLUSION

A wide variety of patient groups may benefit from treatment with long-acting risperidone, including patients with suboptimal efficacy, particularly as a result of partial compliance, patients experiencing side-effects with another antipsychotic agent or those with a first episode of schizophrenia. Furthermore, long-acting risperidone, with its assured medication delivery, should improve patient compliance and assist patients in achieving remission, an important step towards functional recovery.

Symptom control, functioning and satisfaction among Swiss patients treated with risperidone long-acting injectable

OBJECTIVE

To investigate antipsychotic efficacy and tolerability of risperidone long-acting injectable (RLAI) in Swiss patients with schizophrenia or other psychotic disorders, changed directly from their previous antipsychotic medication.

METHODS

Patients symptomatically stable for ≥1 month on their previous medication and considered to require a treatment change, received 25 mg RLAI (increased to 37.5 or 50 mg, if required) every 2 weeks for 6 months.

RESULTS

Of 60 patients enrolled (68.3% male, average age 40.4 years), most (81.7%) had DSM-IV schizophrenia (mainly paranoid). Previous treatments were with atypical antipsychotics (58.3% of patients), depot (38.3%) and conventional oral (13.3%) neuroleptics. Mean total PANSS scores were significantly reduced from baseline to treatment endpoint (76.1 vs. 64.4, P<0.001), as were all PANSS subscale and symptom factor scores. The CGI, GAF, and patient satisfaction with treatment were also significantly improved at endpoint (P<0.001). At endpoint, 37.0% of patients rated their satisfaction as "very good" compared with only 4.3% at baseline. Mean scores for total ESRS and Parkinsonism subscales were significantly reduced at endpoint (P<0.001).

CONCLUSION

Treatment with RLAI significantly improved disease symptoms, functioning, patient satisfaction, and reduced movement disorders. It provides an important option for long-term treatment of patients with psychotic disorders.

Symptom control, functioning, and hospitalization status in French patients changed from oral atypical antipsychotics to risperidone long-acting injectable

Objective. To investigate efficacy and tolerability of risperidone long-acting injectable (RLAI) in French patients with schizophrenia or other psychotic disorders, who were all switching from previous treatment with oral atypical antipsychotics. The impact of treatment with RLAI on the hospitalization status of these patients was also examined. Methods. Clinically stable patients requiring a treatment change received 25 mg RLAI (increased to 37.5 or 50 mg if required) every 2 weeks for 6 months. Results. Of 130 patients (68.5% male, mean age 36.2 years), most (83.8%) had DSM-IV schizophrenia (mainly paranoid). Previous treatments were risperidone (80.8%), olanzapine (10.0%) and amisulpride (10.0%). Out of 66 patients hospitalized at baseline, 51 were outpatients at endpoint. Mean total PANSS, CGI-S and GAF scores were significantly reduced from baseline to treatment endpoint (p<0.001). Of those patients reported as moderate to severely ill at the beginning of the trial (81.3%), fewer had the same classification at endpoint (50.8%). Mean scores for total ESRS and Parkinsonism subscales were significantly reduced after only 1 month of treatment (p<0.001). Conclusion. Treatment with RLAI significantly improved disease symptoms, functioning, hospitalization status, and reduced movement disorders, in psychotic patients considered clinically stable on oral atypical antipsychotics.

Long-Acting Injectable Risperidone: An Emerging Tool in Schizophrenia Treatment

Long-term treatment of patients with schizophrenia remains challenging. Functional and cognitive declines associated with schizophrenia compromise patients' ability to adhere to therapy. While medications can improve outcomes, partial adherence limits effectiveness and is associated with relapse and rehospitalization. Partial adherence has been shown to be high with both oral conventional and oral atypical antipsychotic agents. While long-acting conventional antipsychotic agents provide ensured medication delivery and reduce relapse rates, they carry a substantial risk of movement disorders. A new long-acting formulation of the atypical agent risperidone has shown improved efficacy with decreased risk of adverse events. Its use, along with psychosocial approaches focused on adherence, may help, if initiated during inpatient treatment, by promoting adherence immediately postdischarge and improving long-term treatment outcomes.

Long-acting risperidone compared with oral olanzapine and haloperidol depot in schizophrenia: a Belgian cost-effectiveness analysis

Patients with schizophrenia suffer numerous relapses and rehospitalizations that are associated with high direct and indirect medical expense. Suboptimal therapeutic efficacy and, in particular, problems with compliance are major factors leading to relapse. Atypical antipsychotic agents offer improved efficacy and a lower rate of extrapyramidal adverse effects compared with conventional antipsychotic drugs. Long-acting intramuscular risperidone combines these benefits with improvements in compliance associated with depot injections. To assist decision making regarding the place of long-acting risperidone in therapy, a cost-effectiveness analysis of strategies involving first-line treatment with long-acting risperidone, oral olanzapine or depot haloperidol was performed from the perspective of the Belgian healthcare system. A decision tree model was created to compare the cost effectiveness of three first-line treatment strategies in a sample of young schizophrenic patients who had been treated for 1 year and whose disease had not been diagnosed for longer than 5 years. The model used a time horizon of 2 years, with health state transition probabilities, resource use and cost estimates derived from clinical trials, expert opinion and published prices. The four health states in the model were derived from an analysis of the literature. The principal efficacy measure was the proportion of patients successfully treated, defined as those who responded to initial treatment and who had none to two episodes of clinical deterioration without needing a change of treatment over the 2-year period. Comprehensive sensitivity analysis was carried out to test the robustness of the model. A greater proportion of patients were successfully treated with long-acting risperidone (82.7%) for 2 years, compared with those treated with olanzapine (74.8%) or haloperidol (57.3%). Total mean costs per patient over 2 years were 16,406 Euro with long-acting risperidone, 17,074 Euro with olanzapine and 21,779 Euro with haloperidol (year of costing 2003). The mean cost-effectiveness ratios were 19,839 Euro, 22,826 Euro and 38,008 Euro per successfully treated patient for long-acting risperidone, olanzapine and haloperidol, respectively. Results of the sensitivity analysis confirmed that the results were robust to a wide variation of different input variables (effectiveness, dosing distribution, patient status according to healthcare system). Long-acting risperidone was the dominant strategy, being both more effective and less costly than either oral olanzapine or depot haloperidol. Long-acting risperidone appears to represent a favourable first-line strategy for patients with schizophrenia requiring long-term maintenance treatment.

A review of pharmacologic strategies for switching to atypical antipsychotics

BACKGROUND

In daily clinical practice, frequent switching of antipsychotic medications is widespread. There are various reasons for switching, including a partial or complete lack of efficacy, adverse side effects, and partial or noncompliance with medication. Patients switched from conventional drugs to oral atypical antipsychotic drugs have been shown to benefit from significant improvements in clinical response and tolerability. This review examines the strategies for switching patients from conventional antipsychotic drugs to both oral and long-acting formulations of atypical antipsychotic drugs that are the recommended treatment in the majority of patients with schizophrenia.

DATA SOURCES AND STUDY SELECTION

An electronic literature search of relevant studies using MEDLINE (January 1994-June 2004) was performed using the search terms antipsychotic, atypical, conventional, schizophrenia, and switching. English-language articles, references from bibliographies of reviews, original research articles, and other articles of interest were reviewed.

DATA EXTRACTION AND SYNTHESIS

Data quality was determined by publication in the peer-reviewed literature and the most important information identified. Data from clinical trials suggest that switching to an atypical antipsychotic drug is beneficial for the patient with schizophrenia.

CONCLUSIONS

If initiated appropriately, switching to atypical antipsychotic medications should not compromise patient functioning; indeed, individualized strategies have been shown to provide continuous treatment efficacy. Switching to atypical antipsychotic therapy should, therefore, be employed as a pharmacologic strategy to maximize patient outcomes.

Long-Acting Injectable Risperidone

OBJECTIVE

To review the pharmacology, pharmacokinetics, clinical efficacy, and safety profile of long-acting (LA) risperidone for the treatment of schizophrenia.

DATA SOURCES

Information was selected from PubMed (1965–July 2004). Applicable scientific posters were also used.

STUDY SELECTION AND DATA EXTRACTION

All published information on risperidone LA was considered. Material providing a comprehensive description was considered.

DATA SYNTHESIS

Risperidone LA is the first long-acting, injectable atypical antipsychotic. It is dosed at 25–50 mg every 2 weeks. Adverse effects are similar to those seen with oral risperidone. A short-term study showed that risperidone LA is better than placebo in reducing the signs and symptoms of schizophrenia, and a long-term trial showed that stable schizophrenic patients can be switched from either oral or other injectable antipsychotic medications to risperidone LA.

CONCLUSIONS

Risperidone LA is efficacious and safe in the treatment of schizophrenia.