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Why use of long acting injectables is an urgent issue

Long acting injectable antipsychotics are often withheld until later stages of schizophrenia, but should be offered to first-episode patients and those with early disease. Eric Achtyes (Michigan State University, Grand Rapids, USA) shared this clinical insight and the latest encouraging data from a very recent US study at ECNP Virtual 2020.

When compared with usual care, use of a long-acting injectable antipsychotic (LAI) in early-phase schizophrenia can significantly delay time to first hospitalization, according to results from the recent cluster-randomized clinical trial conducted in US.1

In the study, 39 mental health centers across 19 US states were randomized to two strategies:  encouraging use of an LAI to treat patients, or treatment according to clinicians’ usual choice of agent (which was allowed to include any LAI as well). 

 

Significant benefits from encouraging LAI use

Number Needed to Treat of 7, to prevent one additional hospitalization

The mean time to first hospitalization (the primary endpoint of the trial) was 614 days for patients from centers encouraged to use LAI and 531 days in control centers. 

The number needed to treat (NNT) to prevent one additional hospitalization was 7. Being treated by a center assigned to encourage LAI use was associated with a 44% reduction in incidence rate for first hospitalization and a 36% reduction in total hospitalization rate, Professor Achtyes reported.

In terms of the acceptability of the LAI, he pointed out that only 14% of patients eligible for the study at initial screening refused further participation, because they did not want to receive an LAI in principle. And 91% of eligible patients who entered the study after completing the interview and screening process received at least one long-acting injection.

Reduced hospitalization in centers randomized to encourage LAI helps both patients and healthcare costs

 

Implications and insights for practice

Given that relapse in schizophrenia has devastating consequences in terms of disease progression, treatment resistance, impaired functioning and reduced quality of life, 2,3 and the fact that medication non-adherence is a common cause of relapse,4 prescribers should increase their efforts to present LAIs as a treatment option early in the course of the disease, Professor Achtyes argued.

We should provide patients and their families with a solid understanding of the role of non-adherence in relapse and share the rationale for use of LAIs. Role playing in his experience is a helpful way to practice talking about the issues.

It also helps to identify patient’s treatment goals as part of shared decision making. Young people want education, jobs and relationships. Staying well will help them achieve those goals. Ensuring reliable medication is part of that, he said.

And, as a profession we can do better.

Assignment to LAI proved acceptable to patients

A discourse analysis of 33 conversations between a psychiatrist and patients with schizophrenia found that 91% of the content focused on the modality and only 9% on its benefits.5 Unsurprisingly, only a third of patients accepted an LAI. Yet a subsequent interview which presented the idea of an LAI more positively found that 96% were willing to try one.

 

Educational financial support for this satellite symposium at ECNP Virtual 2020 was provided by Otsuka Pharmaceutical Europe Ltd and H. Lundbeck A/S

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

This content does not necessarily represent the opinion of ECNP.
References

1. Kane JM et al. JAMA Psychiatry2020Jul 15;e202076

2. Olivares JM et al. Ann Gen Psychiatry 2013;12:32 

3.  Emsley R et al. Schizophr Res 2013;148:117-21

4. Caseiro O et al. J Psychiatr Res 2012;46:1099-1105

5. Weiden PJ et al. J Clin Psychiatry 2015;76:684-90.

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