DR. WILNER:
Because schizophrenia is rarely a single-episode illness, reducing relapse and non-adherence to medication has remained a large priority for physicians, especially since 8 out of 10 patients experience a relapse of symptoms after initial treatment. So how can we help reduce the frequency of relapse in our patients?
Welcome to NeuroFrontiers on ReachMD. I'm Dr. Andrew Wilner, and joining me to talk about the use of long-acting injectable antipsychotics for schizophrenia treatment is Dr. Jose Rubio, psychiatrist at Long Island Jewish Medical Center and Assistant Professor at the Donald and Barbara Zucker School of Medicine at Hofstra Northwell. Dr. Rubio, welcome to the program.
DR. RUBIO:
Hi. Thank you very much for inviting me.
DR. WILNER:
To start us off, Dr. Rubio, can you give us some background and how prevalent relapse and non-adherence is among our schizophrenia patients?
DR. RUBIO:
Sure. So unfortunately, schizophrenia is a chronic condition. And in most of the cases, and we were talking about 80% of the cases, there are going to be multiple relapses. This has been known for a long time. And studies that followed up patients over periods of time, up to five years, they found now that most patients have relapses and very often they have many of them. So this is very prevalent, and it’s very impactful. Every time that someone experiences a recurrence of their symptoms, that means that if they were working towards recovery, that work is wasted in many cases. Someone may have been trying to recover, trying to go back to work, go back to study, go back to building up relationships. And if symptoms come back, it may be difficult to get the job the second time you have a psychotic episode, it may be difficult to go to school, it may affect your relationships with other people. So it is very prevalent, but also it is very, very impactful. And that's why in my mind, this is something that should be a priority of schizophrenia.
DR. WILNER:
So with that in mind, let's turn our attention to long-acting injectable antipsychotics, or LAIs for short. What are they, and how do they compare to oral medication?
DR. RUBIO:
So long-acting injectable antipsychotics have been around for a long time. And now in the market, we have LAI products for a good amount of the second-generation antipsychotics that are sold as an oral compound. These are essentially the same drugs. The only thing that changes is how they get in the system. So that means that individuals will take the medication by an intramuscular injection; the range of the frequency is between two weeks and six months. And one of the good things about it is that patients don't have to worry about taking meds every day. They don't have to worry about “did I remember to take it, did I not remember to take it.” And it guarantees drug delivery for the period of time that the patients are receiving treatment for. So that's one of the advantages.
But not just that. We know that LAIs are used for longer than the oral counterparts. We did this study in all of the patients with schizophrenia in Finland, who were followed up over two decades. And in this very large cohort, we found that there was a very strong effect of being on the LAI versus the oral drug in terms of how long did it take for that patient to stop treatment. So one, they are used for longer.
DR. RUBIO:
There are some studies coming from Finland that suggest that they are about one-third more effective in preventing relapse than the oral counterparts. And that shouldn't be a surprise because if you think about it, it's very counterintuitive to have to take meds every day. We are not programmed, we are not wired in such a way. So non-adherence is very common. And if you don't take your medication, obviously, you're not going to have the effect for it.
DR. WILNER:
Now, Dr. Rubio, if we zero in on the use of LAIs, what kind of impact do they have on the frequency of relapse and non-adherence in patients? In other words, are patients cured now? Or is it just some improvement?
DR. RUBIO:
That's a good question. I wish that I could say that they are cured, but unfortunately they are not. These drugs are not miracle drugs. These drugs do quite well treating what we call psychotic symptoms. These are mostly things like delusions or hallucinations. They are not that great treating negative or cognitive symptoms.
But people may still relapse despite being on a long-acting injectable. That's what we call breakthrough psychosis. You respond to a treatment, you will stay on it, and we know that you stay on it because you're taking it on long-acting injectable, but yet, the symptoms come back. And that is obviously much less frequent than symptoms coming back after a drug discontinuation, but still it does happen. We calculate that about 20% of individuals may experience that. So by no means that's a silver bullet. But it is much, much better than the alternative, which is to not use an antipsychotic. So it's the best that we got.
DR. WILNER:
For those just tuning in, you're listening to NeuroFrontiers on ReachMD. I'm Dr. Andrew Wilner, and I'm speaking with Dr. Jose Rubio about long-acting injectable antipsychotics for schizophrenia treatment.
So given that it's pretty clear that these long-acting injectables are the best option, why are they underused?
DR. RUBIO:
That's a million-dollar question. And actually, more than a million-dollar question because there are a lot of people who are interested in expanding the use of LAIs. We know that they are very effective. We know that they would save a lot of costs in terms of suffering due to relapses. They would help recovery for those who suffer schizophrenia.
Unfortunately, they are not more used. And there are many reasons for that. One of those reasons is that they are difficult to roll out in the real world in part because there are obstacles that begin with how difficult it is to get a prior authorization for these drugs. Often, they require much more work by the prescriber in order to obtain prior auth. You need to get with a pharmacy that will carry the medication, you have to, in some cases, administer the drug yourself. So that's a lot much more work, in addition to talking to patients about LAIs.
If you are seeing patients every 15 minutes, it takes time to do a high-quality discussion about LAIs with patients. In some cases, you may say do you want to take a shot, the answer may be straight, yes. That doesn't always happen. You may have to discuss it, in some cases, over multiple visits. And, you know, if you're seeing patients every 15 minutes, you may not have the bandwidth to do them. So that's one reason. And also you may not have the bandwidth to be on the phone for a long time with an insurance company to do the prior authorization.
Or also you may not have the availability to store the drug if the drug needs to be refrigerated. So there are many obstacles. But I think that those are addressable in some degree. For instance, I think that there are an increasing amount of materials that are online that can be used to train clinicians on how to talk about LAIs. Very often, we may tend to focus on the shot, the fact that it's an injection. But that's not the point. The point is it's a drug that's very effective preventing relapse. And that's been very well demonstrated. So the discussion should be about the efficacy, not about the fact that it comes in the shot. That's secondary to me. So things like that are important and also may facilitate how patients respond to whenever they are offered a long-acting injectable.
DR. WILNER:
Well, before we close, Dr. Rubio, do you have any final thoughts you want to leave our listeners on how we can better utilize long-acting injectables with our patients?
DR. RUBIO:
Yes, I will say that long-acting injectables, in my view, are highly beneficial for patients who need to be on treatment with an antipsychotic. And it's tricky sometimes to use them. There are obstacles that we may not face whenever we are using an oral instead. However, I think it's a worthwhile investment. It's an investment on the health of our patients. And if you're interested in learning more about how to talk to patients about LAIs, there are resources online that are very helpful. For instance, SMI Adviser has a lot of materials about LAIs, and they even have consultation services. So there are a lot of resources online that can facilitate. And yes, it's true that it's a very difficult task. But I think it's a very worthwhile investment for patients who have this condition.
DR. WILNER:
Well this has been an interesting look at a potential option for our patients living with schizophrenia. I want to thank my guest, Dr. Jose Rubio, for sharing his insights on long-acting injectable antipsychotics. Dr. Rubio, it was a pleasure speaking with you today.
DR. RUBIO:
Likewise, thank you very much.
DR. WILNER:
For ReachMD, I'm Dr. Andrew Wilner. To access this and other episodes in our series, visit ReachMD.com/neurofrontiers, where you can Be Part of the Knowledge. Thanks for listening.
