Long-acting injectables (LAIs) are often used in patients with chronic schizophrenia who have frequent relapses accompanied by marked social and occupational disabilities,¹ including patients who have been non-adherent to other antipsychotics (APs).²

At the American Psychiatric Association Annual Meeting in 2022, Dr. Jose Rubio (Assistant Professor of Psychiatry at the Zucker School of Medicine at Hofstra/Northwell, New York) discussed the utilization of LAIs in other patient groups, including those with first-episode psychosis (FEP).

LAIs in FEP

LAI therapy has consistently been associated with a delay in time to first hospitalization. In one study of 489 participants receiving an LAI or the clinician’s choice of therapy, the mean time to first hospitalization was 613.7 days vs 530.6 days, respectively.³

Rate of relapse was assessed in a separate, prospective study of 83 patients with FEP, comparing patients randomly assigned to receive an LAI or oral AP.⁴ In the LAI group, fewer patients experienced a psychotic exacerbation and/or relapse and the mean time to relapse was higher, compared with the oral AP group.⁴ In a pooled analysis, LAIs were associated with a significantly lower risk of rehospitalization compared with their equivalent oral formulation (adjusted hazard ratio=0.36, P=0.007).⁵

Listen to Dr. Rubio discuss data supporting the use of LAIs early in disease: 

Expert considerations for LAIs in schizophrenia

Surveys of research experts and prescribers with extensive experience of using LAIs have found that many experts consider LAIs to be usually or extremely appropriate as a first-line therapy in several scenarios, with the highest ranking by ≥50% of respondents being:⁶
– People with poor insight into their illness and need for treatment
– People who are homeless or have an unstable housing situation
– Those with a history of multiple hospitalizations for psychotic relapses
– People with a history of violence to others

Other groups considered appropriate for treatment with an LAI include people with a comorbid substance use disorder or a history of attempting suicide, young adults, and those with cognitive impairment.⁶ 

Listen to Dr. Rubio discuss the groups which may benefit from LAI treatment: 

Guideline recommendations for LAIs in schizophrenia

Some evidence-based guidelines recommend LAIs for use beyond non-adherence. Guidelines from the American Psychiatric Association (APA) suggest that, as well as in cases of poor or uncertain adherence, patients may receive treatment with an LAI if they prefer such treatment.⁷ Patients may prefer an LAI if they find them more convenient, if treatment gives them a subjective sense of better symptom control, or if it reduces conflict with their family members or support groups.⁷ Discussion to consider LAI treatment may also occur due to a lack of response to an oral AP, when transitioning between care settings, when the patient has limited awareness of their need for treatment, or when the patient has a co-occurring substance use disorder.⁷ 

Other guidelines suggest LAIs could be given as an initial treatment. The Florida Best Practice Psychotherapeutic Medication Guidelines recommends initial monotherapy with a second-generation AP (SGA) other than clozapine – either oral, or oral AP followed by the same SGA-LAI (if tolerable and sufficiently efficacious).⁸

Listen to Dr. Rubio discuss the APA guidelines for LAI treatment and how physicians should present LAIs as a treatment option to their patients: 

In summary, it is a myth that LAIs are appropriate only for patients who have demonstrated non-adherence. You can listen to Dr. Rubio make the case for using LAIs proactively rather than reactively by viewing his full presentation at APA 2022 here. 

To download Dr. Rubio’s presentation slides, visit: https://uscnsb.tevapharm.com/scope-engage/

References

1. Correll CU, Citrome L, Hadadd PM, et al. The use of long-acting injectable antipsychotics in schizophrenia: evaluating the evidence. J Clin Psychiatry 2016;77:3.
2. Kane JM, Kishimoto T, Correll CU. Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies. World Psychiatry 2013;12:216–26.
3. Kane JM, Schooler NR, Marcy P, et al. Effect of long-acting injectable antipsychotics vs usual care on time to first hospitalization in early-phase schizophrenia. JAMA Psychiatry 2020;77:1217–24.
4. Subotnik KL, Casaus LR, Ventura J, et al. Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia: a randomized clinical trial. JAMA Psychiatry 2015;72:822–9.
5. Tiihonen J, Haukka J, Taylor M, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry 2011;168:603–9.
6. Sajatovic M, Riss R, Legacy SN, et al. Identifying patients and clinical scenarios for use of long acting injectable antipsychotics – expert consensus survey part 1. Neuropsychiatr Dis Treat 2018;14:1463–74.
7. American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. 2020. Available from: https://doi.org/10.1176/appi.books.9780890424841. Accessed July 2022.
8. 2019–2020 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults. 2020. Available from: floridamedicaidmentalhealth.org. Accessed July 2022.

NPS-US-NP-01129

Dr. Rubio full APA presentation: NPS-US-NP-01073