Navigating Schizophrenia: Role of Long-Acting Injectable Antipsychotics

Brief Summary

This video, the first in a four-part series on navigating schizophrenia, focuses on the role of long-acting injectable antipsychotics (LAIs) in treatment. The speakers discuss what LAIs are, which ones are currently available, where they fit within a treatment plan, how to switch from oral medication to LAIs, and how to monitor patients on LAIs. The experts advocate for the early and thorough consideration of LAIs in treating schizophrenia, highlighting their benefits in improving adherence, reducing relapse, and potentially mitigating brain damage associated with the illness.

• LAIs offer a guaranteed delivery mechanism for antipsychotics, bypassing the variability of oral medication absorption.
• Current guidelines recommend considering LAIs earlier in the course of schizophrenia, not just as a last resort.
• Transitioning to LAIs involves careful consideration of dosing, potential overlap with oral medications, and patient-specific factors.
• Monitoring patients on LAIs is crucial to manage potential adverse effects and ensure treatment effectiveness.

Introduction

The video introduces a four-part series on navigating schizophrenia, with a focus on the role of long-acting injectable antipsychotics (LAIs). The speakers, including Kristofh Coral, Dr. Leslie Citrome, and Dr. Rebecca Roma, express their belief in the importance of considering LAIs early and thoroughly in the treatment of schizophrenia. The discussion will cover what LAIs are, their place in treatment plans, how to transition to them from oral medications, and how to monitor their effects.

What are Long-Acting Injectable Antipsychotics (LAIs)?

Long-acting injectable antipsychotics (LAIs) are designed to create a drug depot at the injection site, allowing for extended release of the medication. This approach aims to reduce the variability in drug levels seen with oral medications, where peaks and troughs can occur due to inconsistent absorption and metabolism. LAIs bypass the first-pass effect in the liver, leading to higher bioavailability and more predictable plasma drug concentrations. The absorption rate of LAIs depends on factors such as drug properties, particle size, water solubility, injection volume, and patient factors like body weight and fat distribution.

Currently Available LAI Formulations

Dr. Citrome describes LAIs as a guaranteed delivery mechanism for antipsychotics, crucial for patients with fluctuating insight or difficulty adhering to daily oral medication regimens. In the United States, first-generation LAIs like fluphenazine decanoate and haloperidol decanoate are available, but they are oil-based and associated with movement disorders. Second-generation LAIs are preferred, including the risperidone/paliperidone family (risperidone microspheres, paliperidone palmitate monthly/3-monthly/6-monthly, and subcutaneous risperidone), the aripiprazole family (aripiprazole monohydrate monthly/2-monthly and aripiprazole lauroxil monthly/2-monthly/6-monthly), and olanzapine pamoate (every 2-4 weeks). Olanzapine requires a three-hour observation period post-injection due to the risk of post-injection delirium/sedation syndrome (PDSS).

LAIs in the Treatment Plan

Dr. Roma emphasizes that LAIs should be considered earlier in the course of schizophrenia, not just as a last resort for non-adherent patients. The American Psychiatric Association recommends LAIs for patients who prefer them or who have a risk of non-adherence due to factors like changing treatment settings, comorbid substance abuse, or poor insight. Early use of LAIs may reduce brain damage, treatment resistance, and polypharmacy. Motivational interviewing can help address patient and family resistance.

Advantages and Disadvantages of LAIs

Advantages of LAIs include improved adherence monitoring, elimination of daily oral medication, reduced risk of overdose and rebound symptoms, and more stable serum concentrations. Disadvantages include the cost of second-generation LAIs, limited flexibility for dose adjustments, delayed time to reach steady state, potential for prolonged exposure to adverse effects, and the pain and logistical burden of injections.

Transitioning from Oral to LAI Formulations

Transitioning to LAIs involves three key steps: starting the LAI, discontinuing the oral treatment, and maintaining the LAI. It's important to ensure the patient is not allergic to the medication and to establish tolerability and efficacy with the oral formulation first. The oral-to-LAI dosing conversion is provided in the medication labeling. Some LAIs require an overlap with oral treatment, while others can be initiated with a loading dose or two injections. When discontinuing the oral medication, consider the potential for rebound effects and taper slowly, especially when switching from more sedating or dopamine-blocking drugs. Maintaining the LAI involves choosing the right injection interval and considering factors like injection site, duration of effect, and potential for PDSS.

Adverse Reactions and Monitoring Needs

Professor Citrome notes that the systemic adverse event profile of LAIs mirrors that of the oral formulation. Injection site pain is a common concern, but research suggests it is generally mild. Prescribers should not hesitate to use LAIs due to concerns about efficacy, as the guaranteed delivery can provide a clearer picture of the medication's effectiveness. Regular monitoring is essential to manage potential adverse effects and ensure treatment success.