Concurrent Oral Antipsychotic Drug Use Among Schizophrenia Patients Initiated on Long-Acting Injectable Antipsychotics Post-Hospital Discharge

Abstract

Pharmacological treatment is central to effective management of schizophrenia. Prescribing clinicians have an increasing array of options from which to choose, and oral antipsychotic polypharmacy is common in routine clinical practice. Practice guidelines recommend long-acting injectable (LAI) formulations, typically viewed as monotherapeutic alternatives, for patients with established nonadherence. Yet there are limited data on the prevalence and nature of concurrent oral antipsychotic prescriptions in patients receiving LAIs. Our observational, claims-based study examined the frequency and duration of concurrent oral prescriptions in 340 Medicaid patients receiving LAI therapy. Specifically, we examined patients with a recent history of nonadherence and hospitalization for schizophrenia and included both first-generation antipsychotic depot medications (fluphenazine decanoate, haloperidol decanoate) and more recently available second-generation injectables (LAI risperidone, paliperidone palmitate). Of all patients initiated on LAIs, 75.9% had a concurrent oral antipsychotic prescription in the 6 months post-hospital discharge. Patients receiving concurrent prescriptions were frequently prescribed an oral formulation of their LAI agent, but many first-generation LAI users received a concurrent second-generation oral medication. The lowest rate of concurrent prescribing (58.8%) was found with paliperidone palmitate, whereas the highest rate was with LAI risperidone (88.9%). Overlap in oral and LAI prescriptions typically occurred for a substantial period of time (ie, >30 days) and for a notable percentage of the days covered by LAIs (often 50% or more). Our findings highlight the need to further examine such prescribing patterns, to probe the reasons for them, and to clarify the optimal roles of different antipsychotic treatments in clinical practice.

Prevalence of and factors associated with antipsychotic polypharmacy in patients with serious mental illness: Findings from a cross-sectional study in an upper-middle-income country

“…25 Often, oral medication is used as initial lead-in dosing for the first few weeks after LAI initiation while waiting for LAI plasma levels to reach steady state. As there is evidence that eventual discontinuation of the oral medication in such cases is often deferred and may even continue beyond its original purpose as lead-in medication, 36 an important implication for clinical practice and treatment planning would include instructions to community clinics to taper and stop such medications, as well as audits of whether such processes are in fact carried out. The majority of combinations found in our study remain unsupported by strong evidence, with the possible exception of clozapine augmentation strategies.…”

Efficacy and safety profile of paliperidone palmitate injections in the management of patients with schizophrenia: an evidence-based review

“…The lowest rate of concurrent oral prescribing (58.8%) was found with PP, whereas the highest rate was with RLAI (88.9%). 50 …”

Analysis of the management of antipsychotics in a group of prisons

“…Given the high prevalence of mental illness, the use of antipsychotics in the prison milieu is widely extended. In recent years there has been an increase in the use of long-acting antipsychotic injectables (LAI), in parallel with the increased use of this therapy outside prison 7,8 . However, no differences in efficacy between the oral and injected formulations have been observed 9 .…”