From the Guidelines
Long-acting injectable antipsychotics are recommended over oral medications for outpatient adherence due to their ability to eliminate daily medication administration and reduce relapse rates by 20-30%. This recommendation is based on the most recent and highest quality evidence available, including guidelines from the British Journal of Psychiatry 1 and case vignettes that illustrate the benefits of long-acting injections in patients with a history of non-adherence 1.
Key Points to Consider
- Long-acting injectable antipsychotics, such as paliperidone palmitate, risperidone, aripiprazole, and haloperidol decanoate, provide steady plasma levels and reduce side effects, leading to improved adherence.
- Patients should be stabilized on the oral version of the medication before transitioning to the injectable form, and most LAIs require initial loading doses followed by regular maintenance injections.
- Regular contact with healthcare providers for injections creates opportunities for intervention if problems arise, and LAIs may be particularly beneficial for patients with a history of recurrent relapses related to partial or full non-adherence.
- However, LAIs may not be suitable for all patients due to cost considerations, needle phobia, or personal preferences for autonomy in medication management.
Implementation and Monitoring
- Healthcare providers should consider long-acting injection antipsychotic medication for patients who have a history of non-adherence or recurrent relapses, as it can be a valuable treatment option to improve adherence and reduce relapse rates.
- Patients should be closely monitored during the transition to LAIs, and regular follow-up appointments should be scheduled to assess treatment efficacy and address any concerns or side effects.
- As noted in the guidelines, depot preparations should be offered as a treatment option where a service user expresses a preference for such treatment because of its convenience or as part of a treatment plan in which avoidance of covert non-adherence to the antipsychotic regimen is a clinical priority 1.
From the Research
Long Acting Injectable vs Oral Outpatient Adherence
- Long-acting injectable (LAI) antipsychotic medications can help improve treatment adherence in patients with schizophrenia and bipolar disorder 2.
- Rates of adherence to treatment in patients with schizophrenia and bipolar disorder are low, and individualizing care can help improve this 2.
- A personalized intervention to address adherence barriers combined with LAI can improve recovery outcomes in high-risk individuals with bipolar disorder 3.
- The proportion of missed medications in the past week significantly improved from 50.1% to 16.9% when using LAI antipsychotic medication plus customized adherence enhancement in poorly adherent individuals with bipolar disorder 3.
Comparison of LAI and Oral Formulations
- There is little evidence on comparisons between LAIs and their oral mother compounds, and even less concerning effectiveness comparisons between different depots 4.
- LAI antipsychotics have a clear advantage over placebo regarding relapse prevention and symptom reduction, but their effectiveness compared to oral formulations is not well established 4.
- Paliperidone, a second-generation antipsychotic, has demonstrated efficacy in the reduction of acute schizophrenia symptoms and clinical benefits were maintained also in the long-term treatments, both as an extended-release (ER) oral formulation and a long-acting injectable paliperidone palmitate (PP) formulation 5.
Adherence and Outcomes
- Improving adherence to antipsychotic medication is crucial for achieving better outcomes in patients with schizophrenia and bipolar disorder 2, 3.
- Customized adherence enhancement approaches can help improve adherence and outcomes in high-risk individuals with bipolar disorder 3.
- The use of LAI antipsychotic medication can help reduce the risk of relapse and improve symptom reduction in patients with schizophrenia and bipolar disorder 4, 3.