Who’s on First: Accurate Recognition of Schizophrenia Candidates That Would Benefit From LAI Antipsychotic Therapy

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Dr. Citrome: 
Hello, I'm Dr. Leslie Citrome, Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York. The topic is the Accurate Recognition of People Who Would Benefit from LAI Antipsychotic Therapy, Who’s on First?

Well, let's base our decision on evidence-based medicine, which is actually patient-centered care. If we think about it, EBM consists of using our clinical judgment, together with our patients’ values and preferences, and incorporating relevant scientific evidence. It means using our brains and our patients’ brains, as well as keeping up with new information and making sense of it.

Research tells us that the evidence for LAIs is overwhelming actually. Studies have consistently demonstrated the importance of continuous medication treatment for people with schizophrenia in order to minimize the risk of relapse. That sounds pretty obvious, and it's actually replicated many, many times in research. There are also substantial challenges we face in adherence in people with chronic disorders. Research also tells us this is a problem. We have superior overall effectiveness of long-acting injectables compared to oral medicines, and that we have from research as well. You may not know that caregivers may actually prefer long-acting injectables, and so do patients, provided they're offered this means of treatment.

The American Psychiatric Association has practice guidelines for people with schizophrenia, and recommends the consideration of an LAI if people, of course, have a history of poor or uncertain adherence, but also if they prefer such a treatment. Now, how can they express a preference if we don't offer it to them? The Florida Best Practice Psychotherapeutic Medication Guidelines also talk about the use of LAIs, but also for initial treatment. So since when do we offer long-acting injectables to people in their first episode? Perhaps we should, and that may lead to better outcomes long term.

If we take a look at the guidance on long-acting injectable use across the world across different guidelines, it's pretty much universal. We need to consider it for first episode, we certainly can use it for maintenance treatment, we'll use it for those who are non-adherent, but will also consider patient preference.

Let's take a look at one example of how long-acting injectable antipsychotics can help. Here's a study that included over 75,000 patients hospitalized with schizophrenia over a 10-year period. LAIs reduced readmission rates by 29% compared with oral medication in the real world. Moreover, LAI use reduced the readmission rate by about 60% in patients with repeated admissions.

We can take a look at meta-analyses, and they consistently tell us LAI antipsychotics are associated with lower risk of hospitalization or relapse compared to their oral equivalents.

We can look at this through various study designs, not only randomized controlled trials, but also real-world design trials, such as before or after, amongst patients who we would ordinarily treat in our community settings. We can take a look at first episode or first hospitalization, LAIs lower the risk of rehospitalization after the first hospitalization for schizophrenia, based on a nationwide cohort in Finland. The adjusted hazard ratio of 0.36 is actually very impressive in terms of reduction of risk compared to oral medication; 0.36, that's a very important number.

Let's take a look at a prospective trial next, taking a look at prospective and randomized, I should say. And this is an instance where we can look at data comparing long-acting injectable risperidone versus oral risperidone in people who are early on in their disease course. This was a 12-month prospective study comparing 83 patients. It turns out that exacerbation or relapse was reduced in people randomized to long-acting injectable risperidone, compared to oral risperidone. And the mean time to relapse was significantly longer for long-acting injectable compared to oral.

The consensus is that we should use LAIs in a broader array of patients, including patients with poor insight, those who are homeless or have unstable housing situations, history of multiple hospitalizations, but also if they prefer such a treatment.

In the end, the principal obstacle to long-acting injectable antipsychotic use is us. We're not offering it to as many patients as we should or earlier on in the disease course.

I hope this has been helpful to you and you'll be considering long-acting injectables for your patients.

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