Some Experts Urge More Use of Long-Acting, Injectable Antipsychotics

With studies showing schizophrenia to be treatment refractory in one-fifth of those affected, psychiatrists are exploring options for the delivery of effective treatment. At APA’s Institute on Psychiatric Services in San Francisco this fall, experts in psychopharmacology led a symposium on the benefits of long-acting injectable (LAI) antipsychotic medications.

“Psychiatrists who were trained during my time of training think that long-acting, injectable antipsychotics should be used for the most refractory, noncompliant, and difficult-to-treat patients,” Steven Potkin, M.D., director of clinical research at the University of California, Irvine, said at the symposium. However, “there is accumulating evidence that very early in the course [of illness], this should be offered as an option, since half of the patients with first-episode psychosis discontinue medication after they are discharged from a hospital.”

Research on LAI antipsychotics was presented by Keith Nuechterlein, Ph.D., a distinguished professor of psychiatry at the University of California, Los Angeles, who led a randomized study comparing LAI risperidone with oral rispiderone in 83 individuals who had a first psychotic episode within the two years prior to the study.

The results showed that after one year of treatment, participants who received the daily oral form of risperidone had a 33 percent relapse rate, compared with 5 percent in those treated biweekly with LAI risperidone. In addition, individuals in the oral risperidone cohort were four times more likely to be hospitalized than were those taking the LAI version.

“We were struck [by the fact] that these were among the most dramatic results that have occurred for long-acting injectables—and it was in first-episode patients,” Nuechterlein told Psychiatric News. He added that not only did patients experience advantages regarding outcomes associated with LAIs, but the patients accepted LAI medication quite readily. The study was funded by the National Institutes of Health and Janssen Pharmaceuticals, which manufactures the Risperdal brand of risperidone.

Another randomized study was described by Larry Alphs, M.D., Ph.D., therapeutic area leader for psychiatry at Janssen Scientific Affairs, which showed that patients who took once-monthly injections of paliperidone palmitate were 43 percent less likely to experience treatment failure over a 15-month time span than those taking oral daily antipsychotics (Psychiatric News, June 17). Average time for treatment failure in the paliperidone palmitate group was at approximately 14 months, compared with eight months in the oral antipsychotic group. The most common adverse effect reported was pain at injection site.

In an interview with Psychiatric News after the session, Potkin said that the symposium was an invitation for psychiatrists to rethink when it is appropriate to offer patients long-acting injectable medication. “Should it be reserved only for refractory patients, or should it be offered to people earlier in the course [of illness] … or at any stage of illness? Of course, LAIs are not for everyone, but our patients should definitely be given options,” he concluded. ■