LAI injectable antipsychotics can improve clinical outcomes in serious mental illness population

Summary:

• Long-acting injectable (LAI) antipsychotics enhance adherence, reduce relapses, and improve outcomes in schizophrenia.
• They are recommended for chronic nonadherence, first-episode psychosis, and early-stage schizophrenia patients.
• They stabilize drug levels, reduce daily medication stigma, and allow better monitoring by healthcare providers.

The American Psychiatric Association’s practice guideline for treatment of patients with schizophrenia recommends the use of LAI antipsychotics in patients who prefer long-acting injectables or have a history of poor or uncertain adherence.⁴ LAI antipsychotics are commonly used in patients with chronic nonadherence or multiple relapses; however, experts suggest that patients with first-episode psychosis or early-stage schizophrenia may benefit most.^1,2

Early use of LAI antipsychotics may help increase treatment response, prevent relapse, and reduce structural neurologic changes in early disease. Patients at high risk for poor adherence or relapse should also be considered for LAI antipsychotics. When used in combination with cognitive and behavioral techniques that help patients understand their illness and need for treatment, LAI antipsychotics may help some patients break a cycle of multiple hospitalizations resulting from unstable illness.

Clinical benefits of LAI use include:

• Improved medication adherence: The biggest advantage of long-acting injectable antipsychotics is that they significantly improve medication adherence because they largely eliminate the need for daily pill taking.
• Stable drug levels: Long-acting injectables provide steady and controlled release of the medication, helping maintain consistent blood levels of the drug and may lead to better therapeutic consistency and fewer side effects.
• Monitoring: The use of long-acting injectables allows healthcare providers to better monitor treatment adherence, which can be vital in managing conditions like schizophrenia or bipolar disorder.
• Fewer relapses: Several studies have shown that using LAI antipsychotics can help patients avoid psychiatric hospitalizations and reduce the frequency of relapses.
• Less daily impact: A regular injection may be less disruptive or stigmatizing than taking daily oral medications, particularly if the injections can be administered at a general healthcare provider, rather than a psychiatric facility.
• No first-pass metabolism: Unlike oral medications, LAI antipsychotics bypass the gastrointestinal tract and first-pass metabolism in the liver so they can often be given in lower doses with similar therapeutic efficacy.

Typically, patients are transitioned to the LAI formulation of the same oral antipsychotic they responded to. However, it is important to consider other factors in the selection such as patient comorbidities and potential side effects. Like oral medications, second-generation LAI antipsychotics are favored because of their more favorable side effect profile.

See this table adapted from Guide to Long-Acting Medications.

LAI best practices:

1. Focus on member preference for treatment, empowering the member to take ownership and understanding of their treatment plan.
2. During administration use the proper injection technique and systematically rotate the injection site.
3. Discuss potential side effects and educate members on what to do in an emergency, such as if they are having suicidal thoughts.
4. Ensure maintained appointment availability in practice for patients and schedule follow-up appointments and subsequent injections before the patient leaves the current appointment.
5. Outreach patients who cancel appointments and reschedule as soon as possible to maintain medication adherence and continuity of care.
6. Obtain baseline diabetes initial screening, test again three to four months later, then order annually.
7. Order a yearly diabetes screening test for all patients on antipsychotic medication.
8. Include a family member or caregiver in discussions regarding treatment when able.

Quality impact — Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) HEDIS^® measure:

• SAA measure description: the percentage of members 18 years of age and older during the measurement year with schizophrenia or schizoaffective disorder who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.
• Inclusion criteria:
  • Members with either one acute inpatient encounter or two outpatient encounters with a diagnosis of either schizophrenia or schizoaffective disorder with at least two antipsychotic medication dispensing events
  • Members aged 18 and older covered under Commercial, Medicaid, or Medicare lines of business
• Exclusion criteria:
  • Members with dementia
  • Members over the age of 80 diagnosed with frailty
  • Members using hospice services at any time during the year
• A member passes the measure when their proportion of days covered (PDC) for their antipsychotic medications is at least 80% of their treatment period.