Comparison of long-acting antipsychotic injection and oral antipsychotics in schizophrenia

Projecting the Potential Budget Impact Analysis of Paliperidone Palmitate in Egyptian Adult Patients with Schizophrenia

Background: Schizophrenia is a serious mental disorder that has greater negative consequences on role functioning than many other severe chronic diseases. Objective: We evaluated the economic impact of long-acting injections of paliperidone palmitate (PP) vs daily oral antipsychotics to treat chronic schizophrenia from a societal perspective over a 2-year period. Methods: A static budget impact model was developed to compare PP with daily oral antipsychotics (risperidone, olanzapine, and aripiprazole) in the treatment of patients with chronic schizophrenia. Our study included treatments used during relapse and hospitalization, validated by an expert panel. The clinical parameters were extracted from the PRIDE trial. Direct medical costs and indirect costs were measured. The unit cost of drug acquisition for all medications was extracted from the public sector. One-way sensitivity analyses were conducted. Results: The target population in our model was estimated to be 142 incident patients. In the first year, the total drug costs in Egyptian pounds (EGP) for PP and oral antipsychotics were £2.7 million and £724 004, respectively, while the total medical costs for PP and oral antipsychotics were £3 million and £5.6 million, respectively. In the second year, the total drug costs for PP and oral antipsychotics were £2.7 million and £724 004, respectively, while the total medical costs for PP and oral antipsychotics were £3 million and £5 million, respectively. The total costs for PP (£11.6 million) over 2 years were less than those of oral antipsychotics without PP (£12.7 million). PP produced an estimated budget savings of £1 046 561 (budget savings per patient per year, £3667). In addition, PP resulted in the avoidance of 18 hospitalizations per year compared with the without-PP arm. Sensitivity analyses showed that the percent of hospitalizations for both oral antipsychotics and PP had the greatest impact on the results. Conclusion: The lower hospitalization rates associated with PP offset the increase in drug costs. PP may potentially be cost-saving compared with the standard of care in chronic schizophrenia in Egyptian representative healthcare settings. Policy makers may consider this approach to improve patient outcomes and budget sustainability.

Achieving long-term goals through early personalized management of schizophrenia: expert opinion on the role of a new fast-onset long-acting injectable antipsychotic

Definition of an appropriate and personalized treatment plan focused on long-term outcomes is crucial in the management of schizophrenia. Following review of the literature, a panel of six leading psychiatrists discussed the importance of clear and shared long-term goals when initiating antipsychotic treatment in light of their clinical experience. The importance of establishing shared and progressive treatment objectives was stressed, which should be tailored based on the patient's characteristics, goals, and preferences. Consensus emerged on the key role that therapeutic alliance and patient empowerment play throughout the course of treatment. Reduction in symptoms in the acute phase along with good efficacy and tolerability in the maintenance phase emerged as essential features of a therapy that can favor achievement of long-term outcomes. Long-acting injectable (LAI) antipsychotics enhance adherence to treatment compared to oral formulations and have been shown to be effective in the maintenance phase. Currently available LAIs are characterized by a delayed onset of action and require a loading dose or oral supplementation to achieve therapeutic concentrations. Risperidone ISM® is a novel LAI antipsychotic with fast and sustained release of antipsychotic, reaching therapeutic plasma levels within a few hours after administration without oral supplementation or loading doses. Risperidone ISM® has been shown to rapidly control symptoms in patients with an acute exacerbation of schizophrenia and to be effective and well tolerated as maintenance treatment irrespective of the severity of initial symptoms. It thus represents a valuable and novel therapeutic option in management of schizophrenia.

Comparison of prolactin level, sexual function, body mass index, and liver function tests in patients using depot antipsychotics

Amaç: Bu çalışmada uzun etkili antipsikotik ilaç formları (uzun etkili paliperidon palmitat, risperidon depo ve zuklopentiksol depo) kullanan hastalarda cinsel işlev bozuklukları, vücut kitle indeksi, karaciğer fonksiyon testleri ve prolaktin düzeylerinin karşılaştırılması amaçlanmıştır. Gereç ve Yöntem: Bu çalışmaya şizofreni tanılı ve uzun etkili antipsikotik tedavisi alan hastalar dahil edildi. Tüm katılımcılara demografik veri formu, Pozitif ve Negatif Sendrom Ölçeği (PANSS), Calgary Şizofrenide Depresyon Ölçeği (CŞDÖ) ve Arizona Cinsel Yaşantılar Ölçeği (ACYÖ) uygulandı. Ardından üre, kreatinin, karaciğer fonksiyon testleri, kolesterol ve prolaktin düzeylerini değerlendirmek için venöz kan örnekleri alındı. Bulgular: Çalışmaya 95 hasta dahil edildi. Dahil edilenlerin 79’u erkek (%83.2) ve 16’sı kadındı (%16.8). Tüm hastaların yaş ortalaması 36.77±10.24 yıl idi. Vücut kitle indeksleri ortalaması ise 27.06±4.95 kg/m2 idi. Gruplar arasında ACYÖ ve CŞDÖ skorları açısından farklılık saptanmadı. Prolaktin değeri paliperidon depo kullanan hastalarda zuklopentiksol depo kullanan hastalardan yüksek olarak hesap edilmiştir. Sonuç: Sonuçlarımıza göre cinsel işlevleri etkileyen prolaktin değerleri, hastalar semptom belirtmese de uzun etkili antipsikotik kullanan hastalarda göz önünde bulundurulmalıdır. Uzun etkili antipsikotik kullanımının hem prolaktin değerleri hem de diğer laboratuvar parametrelerine olan etkileri konusunda ileri araştırmalar yapılmalıdır.

Efficacy, Tolerability, and Acceptance of Long-Lasting Antipsychotics in Children and Adolescents: A Systematic Review

Objectives: While long-lasting antipsychotics (LLA) were specifically developed to address the problem of adherence in patients with chronic psychiatric disorders, their role in pediatric populations is not clear. Methods: To document the efficacy, tolerance, and acceptance of LLAs in children and adolescents, a literature search was conducted using several databases for published studies (PubMed, PsycINFO) from January 1965 to December 2020. Twenty-two studies were identified (16 case reports/series, 3 open label studies, 2 controlled studies, and 1 retrospective analysis of national database). Results: Demographic features were widely heterogeneous across studies (total N = 480, 58% male, mean age = 15.0 ± 1.8). Case reports/series presented positive therapeutic outcomes in noncompliant youths with severe mental illness. Three open-label one-arm studies supported the clinical efficacy of risperidone long-acting injection in patients previously stabilized with oral risperidone. One study showed lower clinical symptoms and higher functioning at 12 months in youths treated for an acute psychotic episode with paliperidone palmitate compared to oral risperidone. The types and rates of side effects of LLA were comparable to those observed for oral antipsychotics. Two studies suggested better metabolic and neurological tolerance of LLA compared to an oral form. Preliminary evidence supported a satisfactory level of treatment satisfaction in patients treated with LLA and their families, while concerns were raised regarding practical administration in outpatient services. However, the average quality of the evidence based on the RoB2 tool was low. Conclusions: The level of evidence was low for the efficacy of LLA in pediatric populations and very low for the tolerance and acceptance. It concerned mostly the effect of risperidone long-acting injection in adolescents with psychotic disorders. Randomized maintenance clinical trials using noninferiority analysis would be more appropriate for further research.

One-Month versus Three-Month Formulation of Paliperidone Palmitate Treatment in Psychotic Disorders: Patients', Relatives', and Mental Health Professionals' Perspectives

Purpose

Paliperidone palmitate is the only available long acting injectable (LAI) antipsychotic with a monthly and three-monthly formulation. LAIs may help battle non-adherence. Studies about the experiences of switching from the monthly (PP1M) to the three-monthly formulation (PP3M) of paliperidone are scarce. Therefore, the aim of this study is to evaluate the perspectives of patients, relatives, and mental health professionals on PP3M compared with PP1M.

Material and Methods

This was a multicenter, retrospective, non-interventional one-time questionnaire survey among patients with psychotic disorders who switched from PP1M to PP3M (n = 38), their relatives (n = 13) and mental health professionals (n = 38). General satisfaction and (un)desired effects were measured using the Medication Satisfaction Questionnaire (MSQ) and the Subjects' Reaction to Antipsychotics (SRA), respectively. Additional questionnaires assessed socio-demographic variables, preference, effectiveness, side-effects, and confidence in PP3M compared to PP1M.

Results

Mean number of received PP3M injections was 4.2 (SD 2.5). The three study groups reported a high level of confidence in PP3M. High general satisfaction rates about PP3M among patients (69%) and mental health professionals (95%) were reported. The majority of patients, relatives, and mental health professionals reported similar or in some cases even greater effectiveness and similar or in some cases even less side-effects of PP3M compared to PP1M. Sixty-seven percent of the relatives reported less concerns about non-adherence after switching to PP3M.

Conclusion

Most patients, relatives, and mental health professionals prefer PP3M over PP1M. The positive attitudes of all parties may facilitate the more frequent use of PP3M and potentially the clinical outcomes.

Predictors of functioning and clinical outcomes in inpatient with schizophrenia on clozapine augmented with antipsychotics

OBJECTIVE

We aimed at exploring predictors of improvement in clinical and functional outcomes of patients on clozapine with chronic treatment-resistant schizophrenia admitted into rehabilitation wards.

METHOD

In a cross-sectional study of 62 patients on clozapine augmented with oral and parenteral antipsychotics, predictors of HoNOS (Health of the Nation Outcome Scales) scores were analysed using ordinal logistic regression.

RESULT

Augmentation with parenteral antipsychotics was associated with lower psychotic symptom scores (OR 0.38 [95%CI 0.15, 0.99]) and activity of daily living scores (OR 0.36 [95%CI, 0.13, 0.96]) compared with oral antipsychotics. Increased age was a predictor of behavioural disturbances, physical illness and cognitive problems for all clozapine patients, and female gender was associated with the increase in depression scores.

CONCLUSION

The addition of parental antipsychotics to clozapine in patients with treatment-resistant schizophrenia might have potential benefits for clinical and functional outcomes and needs a further investigation.

Time to rehospitalization in involuntarily hospitalized individuals suffering from schizophrenia discharged on long-acting injectable antipsychotics or oral antipsychotics

BACKGROUND

Involuntarily hospitalized individuals suffering from schizophrenia often have a poorer prognosis after discharge.

OBJECTIVE

This study aimed to analyze time to rehospitalization within 6 months of discharge in involuntarily hospitalized individuals suffering from schizophrenia discharged on long-acting injectable antipsychotics (LAIs) or oral antipsychotics (OAPs). In addition, temporal trends in LAI use at discharge were explored.

METHODS

Involuntarily hospitalized individuals suffering from schizophrenia discharged from the study hospital between 2006 and 2019 (n = 806) were included in the analysis. Survival analysis was used to compare time to rehospitalization within 6 months of discharge between individuals discharged on LAIs and OAPs, and between first-generation antipsychotic (FGA) LAIs and second-generation antipsychotic (SGA) LAIs. The Cochran-Armitage trend test was used to test whether a temporal trend existed for LAIs use at discharge during the study period.

RESULTS

The LAIs group (n = 231) had a significantly lower rate of rehospitalization and a significantly longer time to rehospitalization than the OAPs group (n = 575). Rehospitalization rate and time to rehospitalization were not significantly different between individuals discharged on FGA-LAIs and SGA-LAIs. LAIs use at discharge grew significantly from 16.77% in 2006 to 50.00% in 2019 (Z = 6.81, p < 0.0001). Among all LAIs, only use of SGA-LAIs at discharge increased significantly (Z = 5.74, p < 0.0001), but not FGA-LAIs.

CONCLUSIONS

LAIs were superior to OAPs in preventing rehospitalization. However, SGA-LAIs were comparable with FGA-LAIs in reducing rehospitalization risk. Use of LAIs increased significantly in discharged involuntarily hospitalized individuals during the study period, especially SGA-LAIs.

Patient subjective experience of treatment with long-acting injectable antipsychotics: a systematic review of qualitative studies

ABSTRACT Objective: To gain a better understanding of how long-acting injectable antipsychotic (LAI) therapy is perceived by patients. Methods: A search for qualitative studies has been carried out on PubMed, Google Scholar, PsycINFO and PsycArticles, yielding 11 studies suitable for a review of qualitative studies. The reporting approach chosen was meta-ethnography, following the ENTREQ statement recommendations. Key concepts common to the different studies were extrapolated and then analysed in a systematic and comparative way. Results: Some recurrent issues were associated with LAIs, such as fear of coercion, fear of needles and lack of knowledge about depot therapy. These topics are linked to each other and the patients most concerned about the disadvantages of LAIs are those who are less informed about them, or who have experienced coercion and trauma during hospitalisation. On the other hand, patients who had already received LAIs, and those who had a good therapeutic relationship with their healthcare providers expressed satisfaction with this form of treatment and its continuation. Conclusion: Long-acting injectable antipsychotics are a tool in the management of mental disorders, and a viable alternative to oral medication. Patients show curiosity towards this method of administration, but lack of knowledge is a common finding. Shared decision making about the use of LAIs antipsychotics requires that patients receive accurate information and support for their decision regarding medication.

Guidance on the clinical understanding and use of long-acting injectable antipsychotics in Schizophrenia: Hong Kong Consensus Statements

AIMS

There is increasing evidence showing the importance of long-acting injectable antipsychotics in the management of schizophrenia, especially in terms of improving patient medication compliance. A panel of experienced clinicians in Hong Kong mapped out a set of consensus statements with an aim to facilitate the understanding and use of long-acting injectable antipsychotics among local physicians.

METHODS

Eight discussion areas regarding long-acting injectable antipsychotics were selected by the chairman of the consensus group. A series of meetings were held for the panelists to discuss the published literature and their clinical experience, followed by the drafting of consensus statements. At the final meeting, each consensus statement was voted on anonymously by all members based on its practicability of recommendation in Hong Kong.

RESULTS

A total of 12 consensus statements on the rational use of long-acting injectable antipsychotics were established and accepted by the consensus group.

CONCLUSION

The consensus statements aim to provide practical guidance for Hong Kong physicians on the use of long-acting injectable antipsychotics in schizophrenia patients. These statements may also serve as a reference for doctors in other parts of the Asia-Pacific region.

A Comparison of Long-Acting Injectable Antipsychotics With Oral Antipsychotics on Time to Rehospitalization Within 1 Year of Discharge in Elderly Patients With Schizophrenia

OBJECTIVE

The effectiveness of long-acting injectable antipsychotics (LAIs) in elderly patients with schizophrenia remains unclear. This study aimed to compare the effect of LAIs with oral antipsychotics (OAPs) on time to rehospitalization within 1 year of discharge in this population. Other factors potentially associated with time to rehospitalization and trends in LAI prescription rates during the study period were also investigated.

METHODS

Patients over 60 years of age with schizophrenia discharged between 2006 and 2017 were followed for 1 year under naturalistic conditions. Survival analysis was used in the comparison between LAIs and OAPs regarding time to rehospitalization. Covariates thought to affect time to rehospitalization were also analyzed. The Cochran-Armitage trend test was used to evaluate whether a time trend existed for LAI prescription rates.

RESULTS

The LAIs group had a significantly lower rehospitalization rate and a significantly longer time to rehospitalization within 1 year of discharge than the OAPs group. Other factors that were associated with a longer time to rehospitalization included a shorter index hospitalization during the time of the study and fewer previous hospitalizations. No significant time trend was found for LAI prescription rates during the study period. However, the prescription rate of second-generation LAIs grew significantly.

CONCLUSION

LAIs were found superior to OAPs in preventing rehospitalization. A continuous increase in second-generation LAI prescription rate may be due to the better side-effect profile of second-generation LAIs compared to first-generation LAIs. More studies investigating the effectiveness of LAIs in elderly patients with schizophrenia are needed in the future.

Time to Rehospitalization in Patients With Schizophrenia Receiving Long-Acting Injectable Antipsychotics or Oral Antipsychotics

BACKGROUND

This study aimed to investigate and compare time to rehospitalization in patients with schizophrenia receiving long-acting injectable antipsychotics (LAIs) after discharge with those receiving oral antipsychotics. Additionally, the trend of LAIs prescription rates was investigated.

METHODS

Patients with schizophrenia (n = 13 087), who were discharged from the study hospital from 2006 to 2017, were followed-up under naturalistic conditions in the year after discharge. The primary outcome was time to rehospitalization. Survival analysis was used in the comparisons between LAIs and oral antipsychotics and between FGA-LAIs and SGA-LAIs. Simple linear regression and Cochrane-Armitage trend test were used to test whether a time trend existed for LAIs prescription rates.

RESULTS

In the 1 year following discharge, patients in the LAIs group had a significantly lower rehospitalization rate and a significantly lengthened time to rehospitalization than those in the oral antipsychotics group. Rehospitalization rate and time to rehospitalization were not significantly different in patients receiving FGA-LAIs or SGA-LAIs. A significantly higher percentage of patients treated with FGA-LAIs received anticholinergic agents than those treated with SGA-LAIs. The LAIs prescription rate grew significantly from 2006 to 2017 by an average of 0.5% per year.

CONCLUSIONS

LAIs were significantly superior to oral antipsychotics in reducing rehospitalization risk, whereas SGA-LAIs were comparable with FGA-LAIs in reducing rehospitalization risk. However, use of concomitant anticholinergic agents was less frequent in the SGA-LAIs group than in the FGA-LAIs group. Increase in LAIs prescription rate may be due to growing experiences and success among clinicians in treating patients with LAIs.

Reasons associated with treatment non-adherence in schizophrenia in a Pakistan cohort

non-adherence in patients with schizophrenia is the most common reason for a relapse of psychosis. In a cohort of participants in Pakistan who suffered a relapse of psychosis, we aimed to identify the principal factors associated with non-adherence, including any culture specific factors that might not be as significant in other jurisdictions. Semi-structured interviews were undertaken at four psychiatric hospitals in the Peshawar region in Pakistan with 55 participants (44 male and 11 female) diagnosed with schizophrenia, who had suffered a relapse of psychosis subsequent to treatment non-adherence. The five principal documented reasons for treatment non-adherence were: 1) alternative treatment pathway chosen with a traditional faith healers (n=53, 96.4%), 2) lack of insight (n=36, 65.5%), 3) poor economic status (n=33, 60.0%), 4) adverse effects of medications (n=33, 60.0%) and 5) utilising psycho-active substances as an alternative to psychotropic medications (n=27, 41.1%). A number of identified factors associated with a relapse of psychosis are potentially modifiable including the provision of a range of pharmacological options including second generation antipsychotic agents, long acting injectable antipsychotics and psycho-therapeutic interventions including psycho-education. These interventions should prove cost effective and be associated with reduced relapse rates of psychosis.

Once-monthly injection of paliperidone palmitate in patients with recently diagnosed and chronic schizophrenia: a post-hoc comparison of efficacy and safety

BACKGROUND

The use of long-acting injectable antipsychotics in recently diagnosed schizophrenia remains less explored. We evaluated the efficacy and safety of paliperidone palmitate once-monthly (PP1M) treatment in adult patients with recently diagnosed vs. chronic schizophrenia.

RESEARCH DESIGN AND METHODS

These post-hoc analyses included two multicenter studies. Study 1 (NCT01527305) enrolled recently diagnosed (≤5 years) and chronic (>5 years) patients; Study 2 (NCT01051531) enrolled recently diagnosed patients only. Recently diagnosed patients were further sub-grouped into ≤2 years or 2-5 years. The primary efficacy endpoint was the change from baseline in Positive and Negative Syndrome Scale (PANSS) total score.

RESULTS

In Study 1, 41.5% patients had recent diagnosis (≤2 years: 56.8%; 2-5 years: 43.2%); 58.5% had chronic schizophrenia. In Study 2, 52.8% and 47.2% patients were grouped into ≤2 years and 2-5 years, respectively. PANSS total score showed significantly greater improvement in patients with recently diagnosed vs. chronic schizophrenia. Similar results were obtained for PANSS responder rate, improvements in PANSS, and CGI-S scores.

CONCLUSION

PP1M was efficacious in both recently diagnosed and chronic schizophrenia, with the benefits being more pronounced in patients with recently diagnosed schizophrenia. This adds to growing evidence recommending long-acting antipsychotic interventions at early stages of schizophrenia.

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.

Predictors of medication non-adherence in Bulgarian outpatients with schizophrenia

The purpose of this study is to assess the adherence status and to identify the risk factors for medication non-adherence in Bulgarian outpatients with schizophrenia. Variables with possible impact on adherence behaviour were assessed via a set of pre-determined clinical interviews and self-rating scales in a total of 226 patients with schizophrenia. As non-adherent were classified 55.8% of the participants. Differences between adherent and non-adherent patients were identified. A multiple regression analysis revealed three variables predictive for the medication adherence--attitudes toward medication, severity of positive symptoms and the ability to recognize psychotic symptoms. Interventions focusing on the identified predictive variables might be useful when aiming at improvement of medication adherence and outcome in schizophrenia.