Long-term depot antipsychotics. A risk-benefit assessment

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

OBJECTIVES

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

SETTING

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

PARTICIPANTS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Population Pharmacokinetic Modeling and Simulation of TV-46000: A Long-Acting Injectable Formulation of Risperidone

TV‐46000 is a long‐acting subcutaneous antipsychotic that uses a novel copolymer drug delivery technology in combination with a well‐characterized molecule, risperidone, that is in clinical development as a treatment for schizophrenia. A population pharmacokinetic (PPK) modeling and simulation approach was implemented to identify TV‐46000 doses and dosing schedules for clinical development that would provide the best balance between clinical efficacy and safety. The PPK model was created by applying pharmacokinetic data from a phase 1 study of 97 patients with a diagnosis of schizophrenia or schizoaffective disorder who received either single or repeated doses of TV‐46000. The PPK model was used to characterize the complex release profile of the total active moiety (TAM; the sum of the risperidone and 9‐OH risperidone concentrations) concentration following subcutaneous injections of TV‐46000. The PK profile was best described by a double Weibull function of the in vivo release rate and by a 2‐compartment disposition and elimination model. Simulations were performed to determine TV‐46000 doses and dosing schedules that maintained a median profile of TAM concentrations similar to published TAM exposure following oral risperidone doses that have been correlated to a 40% to 80% dopamine‐D2 receptor occupancy therapeutic window. The simulations showed that therapeutic dose ranges for TV‐46000 are 50 to 125 mg for once‐monthly and 100 to 250 mg for the once every 2 months regimens. This PPK model provided a basis for prediction of patient‐specific exposure and dopamine‐D2 receptor occupancy estimates to support further clinical development and dose selection for the phase 3 studies.

New approaches to antipsychotic medication adherence - safety, tolerability and acceptability

INTRODUCTION

Antipsychotic pharmacotherapy is considered a first-line treatment in schizophrenia-related disorders and is associated with favorable prognosis and lower mortality rates. However, low adherence rates present a major clinical challenge. In this paper, we will review contemporary approaches to improve adherence to antipsychotic treatment, considering their mechanism of action, safety, tolerability and acceptability.

AREAS COVERED

Novel pharmacological delivery methods included different routes of administration of registered medications (such as intramuscular clozapine preparation and transdermal asenapine), modifications of existing compounds (such as 3-monthly injectable formulation of paliperidone palmitate), and increased interest in oral long-acting medication formulations (such as with penfluridol). In addition, we reviewed innovative technology to monitor adherence, based on the use of electronic digital medicine systems and ingestible sensors.

EXPERT OPINION

All of these diverse approaches were clinically relevant in enhancing treatment adherence and found to be safe and tolerable. The place of each approach is predicated on a personalized approach in each patient, and future research could usefully use large comparative studies to establish robust treatment guidelines. The implementation of new and varied approaches to antipsychotic treatment adherence is welcomed and have the potential to make a significant impact on morbidity in this often difficult-to-treat population.

Pharmacokinetic Evaluation of Blonanserin Transdermal Patch: Population Analysis and Simulation of Plasma Concentration and Dopamine D2 Receptor Occupancy in Clinical Settings

Blonanserin is an atypical antipsychotic drug with high affinity and selective antagonism for dopamine D₂ and D₃ and serotonin 5-HT_2A receptors. Blonanserin transdermal patch is the first transdermal formulation developed for the treatment of schizophrenia. The purpose of this population pharmacokinetic (PPK) analysis was to evaluate the characteristics of blonanserin pharmacokinetics after transdermal patch application, to estimate the daily fluctuation in blonanserin plasma concentration, and to evaluate the impact of patch application noncompliance to support usage in clinical settings. A total of 3747 plasma blonanserin concentrations from 9 clinical studies (93 healthy volunteers and 348 patients with schizophrenia) were used in the PPK analysis. The plasma concentration was predicted using the final PPK model, and dopamine D₂ receptor occupancy was estimated on the basis of the results of a separately reported positron emission tomography study. A 2-compartment, parallel zero-order absorption with a lag time and first-order elimination model was developed to describe the pharmacokinetics of blonanserin, including the change in absorption rate during patch application. The maximum/minimum ratio of plasma concentration was estimated as 1.10 at steady state, indicating minimal fluctuation. In the case of failure to remove the previous patch or a missing application, the increase or decrease in plasma concentration and dopamine D₂ receptor occupancy was <20%. These results indicated that the plasma blonanserin concentration and dopamine D₂ receptor occupancy were stable after blonanserin transdermal patch application, which may lead to improved tolerability during the treatment of patients with schizophrenia.

Clinically established biodegradable long acting injectables: An industry perspective

Long acting injectable formulations have been developed to sustain the action of drugs in the body over desired periods of time. These delivery platforms have been utilized for both systemic and local drug delivery applications. This review gives an overview of long acting injectable systems that are currently in clinical use. These products are categorized in three different groups: biodegradable polymeric systems, including microparticles and implants; micro and nanocrystal suspensions and oil-based formulations. Furthermore, the applications of these drug delivery platforms for the management of various chronic diseases are summarized. Finally, this review addresses industrial challenges regarding the development of long acting injectable formulations.

Antipsychotic agents. Gradually improving treatment from the traditional oral neuroleptics to the first atypical depot

Relapse is one of the key factors in the long-term outcome of schizophrenia. The consequences of relapse are diverse and often unpredictable, and the time to recovery and degree of recovery worsen with each successive relapse. There is now overwhelming evidence that advances in antipsychotic drug treatment have led to significant reductions in the rate of relapse. This review charts the developments that have taken place in antipsychotic therapy from the introduction of depot formulations, through atypical agents, to the development of the first long-acting atypical antipsychotic. Depot formulations of conventional antipsychotics were developed in the 1960s and led to fewer relapses and episodes of hospitalization, compared with oral equivalents. Meta-analysis has confirmed that patients receiving depot antipsychotics experience significantly greater global improvement than those receiving the respective oral agents. Conventional antipsychotics are, however, associated with a range of potentially serious adverse events. The atypical antipsychotics were introduced in the 1990s and have significant advantages over conventional agents with regard to positive and negative symptoms. There is also evidence that atypical agents can reduce the risk of relapse. Importantly, atypical antipsychotics have an improved safety profile compared with older agents, particularly with regard to extrapyramidal symptoms. One disadvantage of atypical agents has been that they are only available in an oral form. The recent development of a long-acting injectable formulation of risperidone means that a new treatment option is available to physicians.

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

Background

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

Hypothesis

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

Method

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

Results

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

Conclusion

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

Evaluation of Prescribing Patterns of Long-Acting Injectable Antipsychotics Within a Community Health System

PURPOSE/BACKGROUND

Long-acting injectable antipsychotics (LAIAs) are used in the management of schizophrenia, bipolar disorder, and related psychiatric conditions. The efficacy of LAIAs has been established in randomized controlled trials; however, usage of LAIAs outside of randomized controlled trials may not correlate to naturalistic prescribing habits. The purpose of this analysis was to evaluate the prescribing patterns of LAIAs within our health system and identify any inconsistencies between medications' published labeling information and clinical practice.

METHODS/PROCEDURES

All patients who received a LAIA at the time of the analysis were included for review. Areas of inconsistency between the prescribed LAIA and each medication's published labeling information were targeted and assessed. Frequency statistics were used to review the following areas for inconsistencies: indication, trial of oral therapy, dose, frequency, and titration method.

FINDINGS/RESULTS

This analysis included 427 patient cases who received a combined 1480 injections during the analysis period. Overall consistency rates between labeling information and prescribed LAIAs within the analysis period were as follows: 71.2% for indication, 67.4% for trial of oral therapy, 94.4% for dose of LAIA, 84.5% for injection frequency, and 93.9% for titration method.

IMPLICATIONS/CONCLUSIONS

Inconsistencies were observed between labeling information and clinical practice for LAIAs prescribed within the community health system. Patients who are more symptomatic and have additional psychological comorbidities are commonly excluded from clinical trials. Alternative dosing may be clinically necessary to obtain an adequate response, and this may have been captured in this review. This analysis may be hypothesis generating for future studies on LAIAs.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

A post hoc analysis on hospitalization risk in Asian patients with schizophrenia switching to once-monthly paliperidone palmitate from oral antipsychotics

Background: In this post hoc analysis in patients recently diagnosed (≤5 years) with schizophrenia, the effect on hospitalization risk after switching from oral antipsychotic to once-monthly paliperidone palmitate (PP1M) was evaluated. Research design and methods: Change in hospitalization risk following PP1M initiation among patients switching from oral antipsychotics was assessed using prescription sequence symmetry analysis. Hospitalization risk was expressed as an adjusted sequence ratio (ASR) of the number of patients hospitalized prior to PP1M initiation/post PP1M initiation. Cumulative distribution of the time to hospitalization was estimated by the Kaplan-Meier method and symmetry of distribution was assessed using log-rank test. Hazard ratio and 95% CI were calculated using the Cox proportional hazard model. Results: The number of patients hospitalized after switching to PP1M: no change, 203/300 (67.7%); increase, 18/300 (6.0%); and decrease, 79/300 (26.3%). Following PP1M initiation, ASR (95% CI) was 3.56 (2.67, 5.33) suggesting asymmetry and a significant decline in hospitalization risk. Asymmetry in distribution of hospitalization events with significant (p ≤ 0.001) delay in time to hospitalization was also observed. Conclusion: Switching to PP1M treatment from oral antipsychotics is likely to be associated with a significant reduction in hospitalization risk along with a delay in time to hospitalization and rehospitalization.

Deciphering reward-based decision-making in schizophrenia: A meta-analysis and behavioral modeling of the Iowa Gambling Task

BACKGROUND

Patients with schizophrenia (SZP) have been reported to exhibit impairments in reward-based decision-making, but results are heterogeneous with multiple potential confounds such as age, intelligence level, clinical symptoms or medication, making it difficult to evaluate the robustness of these impairments.

METHODS

We conducted a meta-analysis of studies comparing the performance of SZP and healthy controls (HC) in the Iowa Gambling Task (IGT) as well as comprehensive analyses based on subject-level data (n = 303 SZP, n = 188 HC) to investigate reward-based decision-making in SZP. To quantify differences in the influence of individual deck features (immediate gain, gain frequency, net loss) between SZP and HC, we additionally employed a least-squares model.

RESULTS

SZP showed statistically significant suboptimal decisions as indicated by disadvantageous deck choices (d from 0.51 to −0.62) and lower net scores (d from −0.35 to −1.03) in a meta-analysis of k = 29 samples (n = 1127 SZP, n = 1149 HC) and these results were confirmed in a complementary subject-level analysis. Moreover, decision-making in SZP was characterized by a relative overweighting of immediate gain and net losses and an underweighting of gain frequency. Moderator analyses revealed that in part, decision-making in the IGT was moderated by intelligence level, medication and general symptom scores.

CONCLUSION

Our results indicate robust impairments in reward-based decision-making in SZP and suggest that decreased cognitive resources, such as working memory, may contribute to these alterations.

Why aren't depot antipsychotics prescribed more often and what can be done about it?

Long-acting depot antipsychotics were developed specifically to promote treatment adherence (compliance) and they are a valuable option for patients requiring maintenance medication for schizophrenia. Depot use has fallen in recent years, perhaps owing to the introduction of oral atypical antipsychotics. Psychiatrist and patient acceptance of depot medication is variable. The depot formulation and the traditional ‘depot clinic’ seem to have an image problem, although many patients already receiving depot medication like it. Some psychiatrists may not adequately consider the risks and benefits when contemplating prescribing depot medication. Further, public opinion and planning forces in psychiatric health services may have a negative influence on the use of long-acting treatments. This review considers possible reasons for underutilisation of depot antipsychotics in maintenance treatment of schizophrenia and highlights the potential benefits and future role of depot drugs.

Why indeed? Invited commentary on… Why aren't depot antipsychotics prescribed more often and what can be done about it?

A recent review concluded that replicated, evidence-based studies have demonstrated several areas of advantage for long-acting antipsychotics over oral antipsychotics. These include improved global outcome and reduced risk of rehospitalisation, psychopharmacological benefits such as more consistent bioavailabilty and more predictable dose–blood level correlations, an improved pharmacokinetic profile allowing lower dosages to be used with a consequent reduced likelihood of side-effects, and a reduced burden of care when injections are required only every 2–6 weeks (Robert & Geppert, 2004). Further, if a patient relapses despite receiving uninterrupted depot treatment, this indicates the need to consider reasons for deterioration other than poor adherence. However, perhaps the critical advantage over oral preparations is the avoidance of covert non-adherence (Barnes & Curson, 1994). With depot treatment, any decision by the patient not to continue medication will be signalled by failure to attend for, or refusal of, injection. The clinical team can therefore act to intervene appropriately, bearing in mind that non-adherence may be both a cause and consequence of worsening of illness. Lastly, with depot preparations the risk of self-poisoning is reduced.

A PLGA-reinforced PEG in situ gel formulation for improved sustainability of hypoglycaemic activity of glimepiride in streptozotocin-induced diabetic rats

Glimepiride (GMD) is a third-generation sulfonylurea derivative and one of the top three most-prescribed oral antidiabetic drugs. The need for a depot formulation exists, and a safe and effective antidiabetic therapy is the goal of this study. The aims were to design a depot in situ gel (ISG) formulation and investigate the main factors that control the initial burst and sustain the GMD effect using the Box-Behnken design. The studied factors were polymer percent (X₁), plasticizer percent (X₂) and benzyl benzoate percent in N-methyl-2-pyrrolidone (X₃). The results revealed that X₂ is the only factor that showed significant effects on all investigated responses. Scanning electron microscopy images showed that an increase in PEG % improved the smoothness and reduced the porosity of the ISG formulation surface. The GMD plasma levels in diabetic rats revealed no significant difference (p < 0.05) between the maximum GMD plasma concentrations of the optimized GMD-ISG formula (10 mg/ kg) and oral marketed GMD tablets (1 mg/kg). This result ensures that the optimized formula does not exceed the maximum safe plasma concentration. In addition, the optimized GMD-ISG formulation showed a depot effect that lasted for 14 days post-injection. This approach to controlling GMD release using an in situ forming system could be useful for improving patient compliance and diabetes treatment effectiveness.

Indications for and use of long-acting injectable antipsychotics: consideration from an inpatient setting

Studies have examined the differences in sociodemographic/clinical characteristics between patients on long-acting injectable (LAI) versus oral medications. However, most studies did not focus specifically on patients for whom LAIs would clearly be indicated. We performed a chart review of patients with schizophrenia or schizoaffective disorder. Patients were categorized as having an 'indication for an LAI' or not on the basis of their adherence history. Patients for whom an LAI was indicated and prescribed on discharge were then compared with similar patients for whom an LAI was not prescribed. Of 305 charts reviewed, consisting of 279 unique patients, 27.2% were judged to have an indication for an LAI (n=76), but only 32.9% of these (n=25) were discharged on an LAI. In the multiregression model, being African American, residing in a psychiatric residence, having a previous history of an LAI trial, and being treated with a higher antipsychotic dose were predictive of LAI prescription. It is important to focus on the population who are not likely to receive an LAI, but who have such indications for treatment.

The impact of Lithium on thyroid function in Chinese psychiatric population

BACKGROUND

Lithium was known to cause thyroid dysfunction and most commonly subclinical hypothyroidism (SCH). The aim of this study is to determine the prevalence of Lithium associated thyroid dysfunction and to identify risk factors associated with development of SCH in patients receiving Lithium.

METHODS

A retrospective cross-sectional study was conducted. Subjects who developed elated thyroid stimulating hormone (TSH) were compared with those who remained euthyroid with Lithium treatment. Logistic regression and survival analysis were applied to identify the significant factors associated with SCH.

RESULTS

The prevalence of Lithium associated with SCH was 31.7 %. The significant risk factors associated with increased risk of SCH included being female, higher serum Lithium level, concomitant use of Valproate Sodium and use of antidepressant. Use of depot injection was associated with decreased risk of SCH.

CONCLUSIONS

Use of depot and avoidance of Valproate or antidepressant should be taken into account before starting patient on Lithium treatment. Thyroxine replacement should be considered when Lithium associated SCH was identified.

Five-year patient outcomes with risperidone long-acting injection or oral aripiprazole

BACKGROUND

This study examined 5-year outcomes of patients prescribed risperidone long-acting injection (RLAI) or aripiprazole in a clinical setting, using treatment discontinuation as a measure of effectiveness.

METHOD

Patients who received RLAI or aripiprazole in the 18 months following their respective UK launches were included. Two-year outcome data were previously reported for these cohorts; this study reported an additional 3 years of follow up for each group. Data were collected from pharmacy records and by retrospective case note review. Patients were classified as continuers or discontinuers at 5 years and reasons for treatment discontinuation noted.

RESULTS

The number of patients remaining on treatment at 2 years (and included in this study) was 28/84 and 27/92 for RLAI and aripiprazole respectively. Two patients treated with RLAI and three treated with aripiprazole were lost to follow up. Therefore, 5-year outcome data were available for 50 patients. Fifteen patients from each group were continuers at 5 years. Of these, four receiving RLAI and three receiving aripiprazole were coprescribed other antipsychotics at study endpoint. Reasons for discontinuation of RLAI and aripiprazole respectively were lack of effect (n = 4; n = 4), adverse effects (n = 3; n = 1), noncompliance or patient choice (n = 2; n = 4) and patient death (n = 2; n = 0).

CONCLUSION

There was no significant difference between the proportions of patients continuing RLAI or aripiprazole for 5 years. Continuation rates were relatively low (18% and 16% of the original RLAI and aripiprazole cohorts respectively), whilst coprescription of other antipsychotics at endpoint was relatively common. Lack of effectiveness was the most common reason for discontinuation of both compounds. These findings suggested that clinical effectiveness was somewhat disappointing, although the long period of follow up and number of patients previously treated with clozapine in the original cohorts were confounding factors.

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.

Treatment of early episode in patients with schizophrenia: the role of long acting antipsychotics

The use of long-acting injectable antipsychotics (LAIs) in schizophrenia is usually restricted to patients in long-term treatment, who prefer them to oral antipsychotics, and to patients with multiple relapses who have a history of non-adherence. However, preliminary evidence from patients in the early phases of the disease suggest that second generation LAIs may be superior to second generation oral medications with regard to the control of negative symptoms and psychosocial functioning. Moreover, several studies have found that psychiatrists are generally reluctant to prescribe LAI antipsychotics and under-estimate their acceptability by patients. Key elements to take into account when offering a LAI in the early course of schizophrenia should include their potential superiority in allowing early detection of non-adherence and in reducing the number of rehospitalisations and relapses.

An evaluation of the use of olanzapine pamoate depot injection in seriously violent men with schizophrenia in a UK high-security hospital

BACKGROUND

Oral olanzapine is a well-established treatment for patients suffering from schizophrenia. Advantages of depot olanzapine may include improved compliance. However, it is expensive, causes metabolic side effects, and carries a risk of postinjection syndrome. Clinical trials have shown olanzapine pamoate to be effective, but further work is needed in this area. This study was a retrospective service evaluation, carried out in a high-security hospital, where the majority of patients have complex, treatment resistant schizophrenia spectrum disorder and a very high propensity for violence. Compliance is a significant problem, both in the high-security setting and on discharge. There has been no previous published work that the authors are aware of evaluating the effects of olanzapine pamoate in this subgroup of patients.

METHODS

The aim of the study was to evaluate the clinical efficacy of olanzapine pamoate, its effect on violence as well as its side effects, in a high-security setting for the first time. Anonymized patient records were used to identify the main outcome measure and clinical global improvement, and to ascertain secondary outcome measures which included seclusion hours, risk of violence and side effects. Metabolic parameters and number of incidents were also recorded. Eight patients were treated with olanzapine pamoate.

RESULTS

Six showed an improvement in symptoms, with an associated decrease in violence and number of incidents. Four showed an associated decrease in seclusion hours. Two showed an increase in body mass index and two showed an increase in glucose.

CONCLUSIONS

The findings of this study are important in showing that all patients who responded to olanzapine pamoate also showed a decrease in violent behaviour. The potential anti-aggression effects of olanzapine pamoate may represent a very promising area for further work. A depot antipsychotic medication that reduces violence could have significant implications for management of high-security patients.

Development of novel risperidone implants using blends of polycaprolactones and in vitro in vivo correlation studies

The objective of this study was to develop a novel implant containing risperidone intended for long-term treatment in Schizophrenia utilizing in vitro in vivo correlation (IVIVC) studies. Different implants (F1-F8) containing an antipsychotic drug, risperidone, were prepared using a hot melt extrusion technique by taking polycaprolactones of different molecular weights (Mwt. 15000, 45000, 80000) either alone or as their blends, and PLGA (75:25). The implants contained 40% of the drug. After fabrication, the implants were characterized for various in vitro properties such as drug release and physical strength. Prior to conducting drug release studies, optimum drug release method was developed based on IVIVC studies. An optimized formulation based on drug release and physical strength at the end of fabrication was selected from the various implants fabricated. The bioactivity, reversibility, and IVIVC of optimized formulation were determined using pharmacokinetic studies in rats. Short-term stability studies were conducted with optimized formulation. Drug release depended on polymer molecular weight. Implant fabricated using 50:50 polycaprolactone 45,000 and polycaprolactone 80,000 was considered optimized implant. Optimized formulation selected released the drug for 3-months in vitro and was physically rigid. The optimized implant was able to release the drug in vivo for a period of 3 months, the implants are reversible throughout the delivery interval and, a 100% IVIVC was achieved with optimized implant, suggesting the development of 3-month drug-releasing implant for risperidone. The optimized implant was stable for 6 months at room temperature (25°C) and 45°C. A novel implant for risperidone was successfully prepared and evaluated.

Flupenthixol decanoate (depot) for schizophrenia or other similar psychotic disorders

BACKGROUND

Long-acting depot injections of drugs such as flupenthixol decanoate are extensively used as a means of long-term maintenance treatment for schizophrenia.

OBJECTIVES

To evaluate the effects of flupenthixol decanoate in comparison with placebo, oral antipsychotics and other depot neuroleptic preparations for people with schizophrenia and other severe mental illnesses, in terms of clinical, social and economic outcomes.

SEARCH METHODS

We identified relevant trials by searching the Cochrane Schizophrenia Group Trials Register in March 2009 and then for this update version, a search was run in April 2013. The register is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We contacted relevant pharmaceutical companies, drug approval agencies and authors of trials for additional information.

SELECTION CRITERIA

All randomised controlled trials that focused on people with schizophrenia or other similar psychotic disorders where flupenthixol decanoate had been compared with placebo or other antipsychotic drugs were included. All clinically relevant outcomes were sought.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed trial quality and extracted data. For dichotomous data we estimated risk ratios (RR) with 95% confidence intervals (CI) using a fixed-effect model. Analysis was by intention-to-treat. We summated normal continuous data using mean difference (MD), and 95% CIs using a fixed-effect model. We presented scale data only for those tools that had attained prespecified levels of quality. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) we created 'Summary of findings tables and assessed risk of bias for included studies.

MAIN RESULTS

The review currently includes 15 randomised controlled trials with 626 participants. No trials compared flupenthixol decanoate with placebo.One small study compared flupenthixol decanoate with an oral antipsychotic (penfluridol). Only two outcomes were reported with this single study, and it demonstrated no clear differences between the two preparations as regards leaving the study early (n = 60, 1 RCT, RR 3.00, CI 0.33 to 27.23,very low quality evidence) and requiring anticholinergic medication (1 RCT, n = 60, RR 1.19, CI 0.77 to 1.83, very low quality evidence).Ten studies in total compared flupenthixol decanoate with other depot preparations, though not all studies reported on all outcomes of interest. There were no significant differences between depots for outcomes such as relapse at medium term (n = 221, 5 RCTs, RR 1.30, CI 0.87 to 1.93, low quality evidence), and no clinical improvement at short term (n = 36, 1 RCT, RR 0.67, CI 0.36 to 1.23, low quality evidence). There was no difference in numbers of participants leaving the study early at short/medium term (n = 161, 4 RCTs, RR 1.23, CI 0.76 to 1.99, low quality evidence) nor with numbers of people requiring anticholinergic medication at short/medium term (n = 102, 3 RCTs, RR 1.38, CI 0.75 to 2.25, low quality evidence).Three studies in total compared high doses (100 to 200 mg) of flupenthixol decanoate with the standard doses (˜40mg) per injection. Two trials found relapse at medium term (n = 18, 1 RCT, RR 1.00, CI 0.27 to 3.69, low quality evidence) to be similar between the groups. However people receiving a high dose had slightly more favourable medium term mental state results on the Brief Psychiatric Rating Scale (BPRS) (n = 18, 1 RCT, MD -10.44, CI -18.70 to -2.18, low quality evidence). There was also no significant difference in the use of anticholinergic medications to deal with side effects at short term (2 RCTs n = 47, RR 1.12, CI 0.83 to 1.52 very low quality evidence). One trial comparing a very low dose of flupenthixol decanoate (˜6 mg) with a low dose (˜9 mg) per injection reported no difference in relapse rates (n = 59, 1 RCT, RR 0.34, CI 0.10 to 1.15, low quality evidence).

AUTHORS' CONCLUSIONS

In the current state of evidence, there is nothing to choose between flupenthixol decanoate and other depot antipsychotics. From the data reported in clinical trials, it would be understandable to offer standard dose rather than the high dose depot flupenthixol as there is no difference in relapse. However, data reported are of low or very low quality and this review highlights the need for large, well-designed and reported randomised clinical trials to address the effects of flupenthixol decanoate.

Long-acting injectables and risk for rehospitalization among patients with schizophrenia in the home care program in Taiwan

We aimed at evaluating the relationship between medication and treatment effectiveness in a home care setting among patients with schizophrenia. Patients with schizophrenia hospitalized between 2004 and 2009 with a primary International Classification of Diseases, Ninth Revision, Clinical Modification code of 295 were identified from Psychiatric Inpatient Medical Claims Data released by the National Health Research Institute in Taiwan. Patients who joined the home care program after discharge and were prescribed long-acting injection (LAI) (the LAI group) or oral antipsychotic medications (the oral group) were included as study subjects. The final sample for the study included 810 participants in the LAI group and 945 in the oral group. Logistic regression was performed to examine the independent effect of LAI medication on the risk for rehospitalization within the 12-month observation window after controlling for patient and hospital characteristics and propensity score quintile adjustment. The unadjusted odds ratio for rehospitalization risk was 0.80 (confidence interval, 0.65-0.98) for the LAI group compared to the oral group. The adjusted odds ratio was further reduced to 0.78 (confidence interval, 0.63-0.97). Results remained unchanged when the propensity score quintiles were entered into the regression for further adjustment. In a home care setting, patients treated with long-acting antipsychotic agents are at a significantly lower risk for psychiatric rehospitalization than those treated with oral medication. Consequently, LAI home-based treatment for the prevention of schizophrenia relapse may lead to substantial clinical and economic benefits.

Development of Risperidone PLGA Microspheres

The aim of this study was to design and evaluate biodegradable PLGA microspheres for sustained delivery of Risperidone, with an eventual goal of avoiding combination therapy for the treatment of schizophrenia. Two PLGA copolymers (50 : 50 and 75 : 25) were used to prepare four microsphere formulations of Risperidone. The microspheres were characterized by several in vitro techniques. In vivo studies in male Sprague-Dawley rats at 20 and 40 mg/kg doses revealed that all formulations exhibited an initial burst followed by sustained release of the active moiety. Additionally, formulations prepared with 50 : 50 PLGA had a shorter duration of action and lower cumulative AUC levels than the 75 : 25 PLGA microspheres. A simulation of multiple dosing at weekly or 15-day regimen revealed pulsatile behavior for all formulations with steady state being achieved by the second dose. Overall, the clinical use of Formulations A, B, C, or D will eliminate the need for combination oral therapy and reduce time to achieve steady state, with a smaller washout period upon cessation of therapy. Results of this study prove the suitability of using PLGA copolymers of varying composition and molecular weight to develop sustained release formulations that can tailor in vivo behavior and enhance pharmacological effectiveness of the drug.

Effect of prior treatment with antipsychotic long-acting injection on randomised clinical trial treatment outcomes

BACKGROUND

It is uncertain whether antipsychotic long-acting injection (LAI) medication in schizophrenia is associated with better clinical outcomes than oral preparations.

AIMS

To examine the impact of prior treatment delivery route on treatment outcomes and whether any differences are moderated by adherence.

METHOD

Analysis of data from two pragmatic 1-year clinical trials in which patients with schizophrenia were randomised to either an oral first-generation antipsychotic (FGA), or a non-clozapine second-generation antipsychotic (SGA, CUtLASS 1 study), or a non-clozapine SGA or clozapine (CUtLASS 2 study).

RESULTS

Across both trials, 43% (n = 155) of participants were prescribed an FGA-LAI before randomisation. At 1-year follow-up they showed less improvement in quality of life, symptoms and global functioning than those randomised from oral medication. This difference was confined to patients rated as less than consistently adherent pre-randomisation. The relatively poor improvement in the patients prescribed an LAI pre-randomisation was ameliorated if they had been randomised to clozapine rather than another SGA. There was no advantage to being randomly assigned from an LAI at baseline to a non-clozapine oral SGA rather than an oral FGA.

CONCLUSIONS

A switch at randomisation from an LAI to an oral antipsychotic was associated with poorer clinical and functional outcomes at 1-year follow-up compared with switching from one oral antipsychotic to another. This effect appears to be moderated by adherence, and may not extend to switching to clozapine. This has implications for clinical trial design: the drug from which a participant is randomised may have a greater effect than the drug to which they are randomised.

Patients' and clinicians' attitude towards long-acting depot antipsychotics in subjects with a first episode of psychosis

OBJECTIVES

The acceptance and use of long-acting depot antipsychotics has been shown to be influenced by the attitudes of patients and clinicians. Depot treatment rates are low across countries and especially patients with first-episode psychosis are rarely treated with depot medication. The aim of this article was to review the literature on patients' and clinicians' attitudes towards long-acting depot antipsychotics in subjects with first-episode psychosis.

METHODS

A systematic search of Medline, Embase, PsycINF and Google Scholar was conducted. Studies were included if they reported original data describing patients' and clinicians' attitudes towards long-acting depot antipsychotic in subjects with first-episode psychosis.

RESULTS

Six studies out of a total of 503 articles met the inclusion criteria. Four studies conveyed a negative and two a positive opinion of clinicians toward depot medication. No systematic study directly addressed the attitude of patients with first-episode psychosis. Psychiatrists frequently presume that patients with first-episode psychosis would not accept depot medication and that depots are mostly eligible for chronic patients.

CONCLUSIONS

Full information of all patients especially those with first episode psychosis in a therapeutic relationship that includes shared decision-making processes could reduce the negative image and stigmatization attached to depots.

Bromperidol decanoate (depot) for schizophrenia

BACKGROUND

Antipsychotic drugs are the mainstay treatment for schizophrenia. Long-acting depot injections of drugs such as bromperidol decanoate are extensively used as a means of long-term maintenance treatment.

OBJECTIVES

To assess the effects of depot bromperidol versus placebo, oral antipsychotics and other depot antipsychotic preparations for people with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH METHODS

For this 2012 update we searched the Cochrane Schizophrenia Group's Register (February 2012).

SELECTION CRITERIA

We sought all randomised trials focusing on people with schizophrenia where depot bromperidol, oral antipsychotics or other depot preparations. Primary outcomes were clinically significant change in global function, service utilisation outcomes (hospital admission, days in hospital), relapse.

DATA COLLECTION AND ANALYSIS

For the 2011 update MP independently extracted data, CEA carried out the reliability check. We calculated fixed-effect risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data, and calculated weighted or standardised means for continuous data. Where possible, we calculated the number needed to treat statistic (NNT). Analysis was by intention-to-treat.For the 2012 update, data collection and analysis was not carried out as no new studies were found.

MAIN RESULTS

The 2012 search found no new studies, we have therefore included no new trials in this 2012 update. The number of included trials remain 4 RCTs, total n = 117. A single, small study of six months' duration compared bromperidol decanoate with placebo injection. Similar numbers left the study before completion (n = 20, 1 RCT, RR 0.4 CI 0.1 to 1.6) and there were no clear differences between bromperidol decanoate and placebo for a list of adverse effects (n = 20, 1 RCT, RR akathisia 2.0 CI 0.21 to 18.69, RR increased weight 3.0 CI 0.14 to 65.9, RR tremor 0.33 CI 0.04 to 2.69). When bromperidol decanoate was compared with fluphenazine depot, we found no important change on global outcome (n = 30, RR no clinical important improvement 1.50 CI 0.29 to 7.73). People allocated to fluphenazine decanoate and haloperidol decanoate had fewer relapses than those given bromperidol decanoate (n = 77, RR 3.92 Cl 1.05 to 14.60, NNH 6 CI 2 to 341). People allocated bromperidol decanoate required additional antipsychotic medication somewhat more frequently than those taking fluphenazine decanoate and haloperidol decanoate, but the results did not reach conventional levels of statistical significance (n = 77, 2 RCTs, RR 1.72 CI 0.7 to 4.2). The use of benzodiazepine drugs was very similar in both groups (n = 77, 2 RCTs, RR 1.08 CI 0.68 to 1.70). People left the bromperidol decanoate group more frequent than those taking other depot preparation due to any cause (n = 97, 3 RCTs, RR 2.17 CI 1.00 to 4.73). Anticholinergic adverse effects were equally common between bromperidol and other depots (n = 47, RR 3.13 CI 0.7 to 14.0) and additional anticholinergic medication was needed with equal frequency in both depot groups, although results did tend to favour the bromperidol decanoate group (n = 97, 3 RCTs, RR 0.80 CI 0.64 to 1.01). The incidence of movement disorders was similar in both depot groups (n = 77, 2 RCTs, RR 0.74 CI 0.47 to 1.17).

AUTHORS' CONCLUSIONS

Minimal poorly reported trial data suggests that bromperidol decanoate may be better than placebo injection but less valuable than fluphenazine or haloperidol decanoate. If bromperidol decanoate is available it may be a viable choice, especially when there are reasons not to use fluphenazine or haloperidol decanoate. Well-conducted and reported randomised trials are needed to inform practice.

Addressing non-adherence to antipsychotic medication: a harm-reduction approach

This paper discusses the evidence base for interventions addressing non-adherence to prescribed antipsychotics. A case study approach is used, and the extent to which adherence improvement interventions might be used in collaboration with a specific patient is considered. The principles and application of harm-reduction philosophy in mental health are presented in a planned non-adherence harm-reduction intervention. This intervention aims to acknowledge the patient's ability to choose and learn from experience and to reduce the potential harm of antipsychotic withdrawal. The intervention evaluation method is outlined.

Bromperidol decanoate (depot) for schizophrenia

BACKGROUND

Antipsychotic drugs are the mainstay treatment for schizophrenia. Long-acting depot injections of drugs such as bromperidol decanoate are extensively used as a means of long-term maintenance treatment.

OBJECTIVES

To assess the effects of depot bromperidol versus placebo, oral antipsychotics and other depot antipsychotic preparations for people with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH STRATEGY

For this 2011 update we searched the Cochrane Schizophrenia Group's Register (February 2011).

SELECTION CRITERIA

We sought all randomised trials focusing on people with schizophrenia where depot bromperidol, oral antipsychotics or other depot preparations. Primary outcomes were clinically significant change in global function, service utilisation outcomes (hospital admission, days in hospital), relapse.

DATA COLLECTION AND ANALYSIS

For this 2011 update MP independently extracted data, CEA carried out the reliability check. We calculated fixed-effect risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data, and calculated weighted or standardised means for continuous data. Where possible, we calculated the number needed to treat statistic (NNT). Analysis was by intention-to-treat.

MAIN RESULTS

We have included no new trials in this 2011 update (4 RCTs, total n = 117). A single, small study of six months' duration compared bromperidol decanoate with placebo injection. Similar numbers left the study before completion (n = 20, 1 RCT, RR 0.4 CI 0.1 to 1.6) and there were no clear differences between bromperidol decanoate and placebo for a list of adverse effects (n = 20, 1 RCT, RR akathisia 2.0 CI 0.21 to 18.69, RR increased weight 3.0 CI 0.14 to 65.9, RR tremor 0.33 CI 0.04 to 2.69). When bromperidol decanoate was compared with fluphenazine depot, we found no important change on global outcome (n = 30, RR no clinical important improvement 1.50 CI 0.29 to 7.73). People allocated to fluphenazine decanoate and haloperidol decanoate had fewer relapses than those given bromperidol decanoate (n = 77, RR 3.92 Cl 1.05 to 14.60, NNH 6 CI 2 to 341). People allocated bromperidol decanoate required additional antipsychotic medication somewhat more frequently than those taking fluphenazine decanoate and haloperidol decanoate, but the results did not reach conventional levels of statistical significance (n = 77, 2 RCTs, RR 1.72 CI 0.7 to 4.2). The use of benzodiazepine drugs was very similar in both groups (n = 77, 2 RCTs, RR 1.08 CI 0.68 to 1.70). People left the bromperidol decanoate group more frequent than those taking other depot preparation due to any cause (n = 97, 3 RCTs, RR 2.17 CI 1.00 to 4.73). Anticholinergic adverse effects were equally common between bromperidol and other depots (n = 47, RR 3.13 CI 0.7 to 14.0) and additional anticholinergic medication was needed with equal frequency in both depot groups, although results did tend to favour the bromperidol decanoate group (n = 97, 3 RCTs, RR 0.80 CI 0.64 to 1.01). The incidence of movement disorders was similar in both depot groups (n = 77, 2 RCTs, RR 0.74 CI 0.47 to 1.17).

AUTHORS' CONCLUSIONS

Minimal poorly reported trial data suggests that bromperidol decanoate may be better than placebo injection but less valuable than fluphenazine or haloperidol decanoate. If bromperidol decanoate is available it may be a viable choice, especially when there are reasons not to use fluphenazine or haloperidol decanoate. Well-conducted and reported randomised trials are needed to inform practice.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology

These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.

Long-acting injectable antipsychotics in the treatment of schizophrenia: their role in relapse prevention

IMPORTANCE OF THE FIELD

Antipsychotic medications are the cornerstone of treatment in schizophrenia, and a large body of data confirms the value of ongoing and continuous antipsychotic pharmacotherapy in controlling symptoms and preventing relapse. However, nonadherence with antipsychotic treatment is a significant issue, with estimates as high as 90%.

AREAS COVERED IN THIS REVIEW

This review focuses on long-acting injectable (LAI) antipsychotics and their role in the treatment of schizophrenia. The existing literature, with an emphasis on clinical evidence, is assessed. This includes both reviews and specific trials that examine LAIs and compare them with oral agents, with measures ranging from relapse and rehospitalization to adherence. Both advantages and limitations (e.g., challenges in terms of dose titration and time to steady state) are examined.

WHAT THE READER WILL GAIN

This overview serves as an update for clinicians wishing to understand LAIs better, including the newer second-generation antipsychotics (SGAs) with this formulation available, and their potential role in the long-term treatment of individuals with schizophrenia.

TAKE HOME MESSAGE

Despite identified advantages, LAIs are not used as widely as might be expected. It would seem that clinicians are at least partly responsible for this, influenced by our own misperceptions (e.g., that LAIs are not acceptable to patients) and, perhaps, misinformation (e.g., increased side effect risk). As clinicians, we may well be shortchanging LAIs if we position them as a treatment of last resort for the multi-episode, nonadherent, 'revolving door' patient, especially given recent evidence underscoring their potential benefits in first-episode patients. The search for new and more effective antipsychotics will continue, but we are reminded that suboptimal outcomes may have as much to do with nonadherence as inadequate treatments. Evidence has established that LAI antipsychotics demonstrate distinct benefits in this regard, and we would be remiss if we did not exploit this already available strategy. As well as additional research, we need to rethink how we position these agents in our treatment algorithms if we are to maximize their potential.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Community treatment orders and antipsychotic long-acting injections

BACKGROUND

The community treatment order (CTO) is the legal framework by which people in the community are compelled to accept treatment. Both antipsychotic long-acting injections (LAIs) and CTOs are used to address treatment non-adherence.

AIMS

To investigate the relationship between CTOs and LAI use in patients with schizophrenia.

METHOD

Prescribing, demographic and CTO data were collected for patients from four community mental health clinics in Melbourne, Australia, in 1998 and 2002.

RESULTS

Against a background of increasing use of oral second-generation antipsychotic (SGA) medication and decreasing use of LAIs, the rates of CTO implementation doubled from 13% to 26% of patients with schizophrenia between 1998 and 2002. Proportionally more patients with a CTO are prescribed LAIs rather than oral SGAs.

CONCLUSIONS

The relationship between receiving an LAI and being subject to a CTO is significant, and reflects the consideration given to enhancing adherence in a community mental health setting.

First-generation antipsychotic long-acting injections v. oral antipsychotics in schizophrenia: systematic review of randomised controlled trials and observational studies

BACKGROUND

Antipsychotic long-acting injections (LAIs) are often used in an attempt to improve medication adherence in people with schizophrenia.

AIMS

To compare first-generation antipsychotic long-acting injections (FGA-LAIs) with first- and second-generation oral antipsychotics in terms of clinical outcome.

METHOD

Systematic literature review.

RESULTS

A meta-analysis of randomised controlled trials (RCTs) showed no difference in relapse or tolerability between oral antipsychotics and FGA-LAIs but global improvement was twice as likely with FGA-LAIs. Four prospective observational studies were identified; two studies reported lower discontinuation rates for FGA-LAIs compared with oral medication and two found that outcome was either no different or better with oral antipsychotics. Mirror-image studies consistently showed reduced in-patient days and admissions following a switch from oral antipsychotics to FGA-LAIs.

CONCLUSIONS

The results are variable and inconclusive. Some evidence suggests that FGA-LAIs may improve outcome compared with oral antipsychotics. Methodological issues may partly explain the variable results. Selective recruitment in RCTs and lack of randomisation in observational studies are biases against LAIs, whereas regression to the mean in mirror-image studies favours LAIs. In terms of future research, a long-term pragmatic RCT of an FGA-LAI against an oral antipsychotic, in patients with problematic adherence, would be of value.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: efficacy, quality of life and functional outcome

OBJECTIVE

This international, non-randomised study evaluated maintained efficacy and safety of Risperidone Long-Acting Injectable (RLAI) compared to previous medications. To investigate the possible effect of differences in national health care systems across Europe, the UK subset efficacy, health-related quality of life (HRQoL) and functioning data are reported here.

METHODS

Patients with schizophrenia or other psychotic disorders, 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 recruited; 79% had schizophrenia (87% paranoid), 21% other psychotic disorders; 96% had been hospitalised at sometime. Improvement in mean Positive and Negative Syndrome Scale (PANSS) total score was significant at 1 month through to endpoint (p = 0.0001). There were significant improvements in PANSS subscales (p <or= 0.001), PANSS-Marder subscores (p <or= 0.0391), and in Clinical Global Impression-Severity (p = 0.0001) at endpoint. Patients reported improvements in: HRQoL (p < 0.05), Global Assessment of Functioning (p = 0.0001) and patient satisfaction (p = 0.0001) at endpoint. The proportion of patients rating RLAI treatment as 'very good' increased from 10% to 40%. 55% (22/40) of patients hospitalised at baseline were discharged by endpoint.

CONCLUSION

Sustained, significant improvement in symptom control, HRQoL and functioning was seen in stable patients treated with RLAI over 6 months following a switch from previous antipsychotic medications.

Experience with injectable long-acting risperidone in long-term therapy after an acute episode of schizophrenia: the SPHERE Study

BACKGROUND

Risperidone long-acting injectable (RLAI) is the first long-acting formulation of an atypical antipsychotic introduced into clinical practice. RLAI combines the benefits of atypical antipsychotic agents with an extended duration of activity and is intended for long-term management of schizophrenia. This study evaluated the use of RLAI as part of a long-term management strategy in patients with an acute episode of schizophrenia.

OBJECTIVES

The primary objective was to determine clinicians' approaches to the use of RLAI in patients with an acute exacerbation of schizophrenia by examining the prescribing patterns of antipsychotic and other psychotropic medications. Other objectives were to evaluate the overall safety of switching patients to RLAI from previous antipsychotic therapy and to determine patients', caregivers' and relatives' attitudes towards RLAI treatment.

METHODS

The Safety and Profile of Handling and Employing of Risperdal Consta in Emergency/Acute Care Settings (SPHERE) study was an observational, non-interventional, multicenter, retrospective study involving a large cohort of patients with acute psychotic exacerbation who attended Spanish emergency/acute care facilities (between August and December 2003) and were treated with RLAI during hospitalization.

RESULTS

A total of 1232 patients (70% men; mean age 37 years; median of 8 months since most recent admission) were included in the analyses; 79% had been receiving antipsychotic therapy prior to admission. All patients received RLAI post-stabilization. The main reasons for initiating RLAI were the need for long-term treatment (76%) and a low adherence to previous treatment (71%). RLAI doses administered during hospitalization were: 25 (26%), 37.5 (29%), 50 (42%) and 75-100 mg (3%). The mean number of injections per patient (2 +/- 1) and mean hospitalization time (25 +/- 16 days) indicated that RLAI was administered every 2 weeks as per the manufacturer's recommendations. All patients were discharged on RLAI treatment; 62% were prescribed concomitant therapy, mainly oral risperidone (39%), anxiolytics (25%), antiparkinsonians (15%), hypnotics (11%) and anticonvulsants (11%). Only 5.7% of patients reported adverse events, most commonly extrapyramidal symptoms (1.1%) and somnolence (0.9%).

CONCLUSIONS

As part of a long-term management strategy aimed at improving treatment adherence in schizophrenic patients, RLAI was prescribed to a wide spectrum of patients with an acute episode of schizophrenia during hospitalization and at the time of discharge from emergency/acute care facilities. RLAI was well tolerated in the study population and the overall impression of patients, primary caregivers and relatives to RLAI therapy was positive.

The importance of cross-sectional remission in schizophrenia for long-term outcome: a clinical prospective study

INTRODUCTION

This study examines the relationship between having achieved cross-sectional remission and the need for future psychiatric and nursing home care. The study is a prospective long-term follow-up of patients with schizophrenia.

MATERIALS AND METHODS

Cross-sectional remission was defined by applying the Positive and Negative Syndrome Scale (PANSS) criteria requiring that none of the eight core positive and negative symptom items are scored greater than mild. Patients are followed-up by yearly clinical examinations and medical record review. Information on consumption of healthcare resources and residency status were also gathered. Visits to mental health professionals, number and duration of inpatient psychiatric or nursing home admissions were also recorded. The patients are enrolled in a 12 year prospective study, the Clinical Long-term Investigation of Psychosis in Sweden (the CLIPS study). This report covers the first seven years.

RESULTS

Those patients who achieved cross-sectional remission at baseline had a lower total consumption of healthcare services than those who were not in remission. The latter group displayed higher values for all measured variables.

DISCUSSION

Our results show that cross-sectional remission is likely to be an important goal to achieve in order to reduce future treatment needs. Patients in remission live a more independent life and have better preconditions for functioning in society.

Safety and tolerability of deltoid and gluteal injections of paliperidone palmitate in schizophrenia

Paliperidone palmitate is an investigational, injectable atypical antipsychotic. The safety and tolerability of initiating treatment with paliperidone palmitate via deltoid versus gluteal injections given once monthly, and of switching injection sites, in adults with stable schizophrenia were assessed. In this crossover trial, stable outpatients (N=252) were randomly assigned 1:1:1 to 3 dose groups (paliperidone palmitate 50, 75, or 100 mg eq.) and 2 treatment sequences (blinded to dose): deltoid muscle (period 1 [13 weeks]) followed by gluteal muscle (period 2 [12 weeks]) or the reverse. The intent-to-treat analysis set had 249 patients: mean age=43 (SD: 12.8) years; 57% men, 81% white, baseline mean Positive and Negative Syndrome Scale (PANSS) total score=56 (SD: 11.5). A total of 170 (68%) patients completed the study, with a similar proportion completing each treatment sequence. The incidence of systemic treatment-emergent adverse events (TEAEs) was similar between the 2 injection sites across doses during period 1 (deltoid [D]: 61% to 67%; gluteus [G]: 58% to 65%), and during the last 8 weeks of the 2 study periods (DG: 32% to 45% [period 1], 29% to 42% [period 2]; GD: 31% to 40% [period 1], 30% to 41% [period 2]). During the first treatment week, median plasma paliperidone concentrations were higher with treatment initiation in the deltoid muscle compared with the gluteal muscle. At apparent steady state, there was little difference in plasma paliperidone concentrations between the deltoid and gluteus sites for a given dose. Local tolerability was slightly better with gluteal injections. Patient preference for injection sites differed between geographical regions, e.g. patients from the US preferred deltoid to gluteal sites. The most common (>or=5% overall) TEAEs were: (period 1) insomnia, anxiety, headache, and agitation; and (period 2) insomnia, psychotic disorder, weight increased, and tachycardia. Paliperidone palmitate treatment was tolerated, irrespective of injection site, and thus could offer the choice of administration into either the deltoid or gluteal muscle to meet patient and physician preference.

A long-term prospective study on the outcome of bipolar patients treated with long-acting injectable risperidone

BACKGROUND

Risperidone is the first atypical antipsychotic to become available in a long-acting, injectable formulation. This is the first prospective study to assess the effectiveness of long-acting risperidone in a cohort of bipolar patients.

METHODS

Twenty-nine DSM-IV acutely manic bipolar inpatients with a history of poor or partial adherence to medication entered the mirror-design observational study. They received naturalistic treatment for a manic episode plus long-acting, injectable risperidone for a mean period of 2 years. The following measures were used to assess the effectiveness of risperidone: the number of hospitalizations, the number of manic, mixed, and depressive episodes leading to hospitalization, the mean duration of hospitalizations, time to relapse, treatment adherence, aggression and suicide attempts. The Clinical Global Impressions (CGI) was used for clinical relevance as well.

RESULTS

During the follow-up, there was a significant decrease in the number of hospitalizations per patient (Z-2.72 P < 0.006), in the number of manic or mixed episodes leading to hospitalization (Z-2.68 P < 0.007) but not in the hospitalizations due to depressive episodes, a decrease in the average length of hospitalization per patient (Z-3.27 P < 0.001), a significant increase in the time to any new episode (first relapse) (Z-3.28, P < 0.001), and significant improvements in treatment adherence (P < 0.0001) and hetero-aggressive episodes (P < 0.0001), but not suicide attempts (P = NS). At study endpoint 14 patients (48%) were very much improved according to the CGI.

DISCUSSION

This observational long-term study provides support to long-acting injectable risperidone being effective for the maintenance treatment of mania and improving treatment adherence, reducing relapses and re-hospitalization rates.

A descriptive, open-label, long-term follow-up survey of psychotic patients receiving risperidone long-acting injectable: Preliminary results

Objective. To assess clinical development in patients with psychotic disorders who received risperidone long-acting injectable (RLAI) in combination with psychosocial interventions as part of daily clinical practice in France. Methods. In this 18-month survey, patients were started on bi-monthly RLAI injections and integrated in a psychosocial treatment programme. Clinical progression was evaluated using the Clinical Global Impression of Severity (CGI-S) and Global Assessment of Functioning (GAF) scales. In addition, data on patient characteristics, adherence, RLAI dosage, concomitant medications and rates and durations of hospitalization were collected. Results. Of the total of 120 patients included in the survey, 95 (79.2%) had previously received other treatments. Non-adherence was the most frequently reported reason for changing to RLAI (93 patients, 97.9%). With RLAI treatment, mean CGI-S scores improved from 5.6±0.5 at baseline to 3.6±1.1 at 18 months, whilst mean GAF scores increased from 34.0±12.7 to 67±13.5 (both P<0.0001). Furthermore, patients had fewer and shorter hospitalizations during the 18 months of RLAI treatment, compared to the preceding 18 months. Conclusions. Patients with psychotic disorders benefited from RLAI treatment in combination with psychosocial interventions, as shown by improvements in their clinical status and functioning and reduced hospitalization rates.