Guidelines for the use and management of long-acting injectable antipsychotics in serious mental illness

Abstract

BackgroundLong-acting injectable (LAI) formulations are not widely used in routine practice even though they offer advantages in terms of relapse prevention. As part of a process to improve the quality of care, the French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) elaborated guidelines for the use and management of antipsychotic depots in clinical practice.MethodsBased on a literature review, a written survey was prepared that asked about 539 options in 32 specific clinical situations concerning 3 fields: target-population, prescription and use, and specific populations. We contacted 53 national experts, 42 of whom (79%) completed the survey. The options were scored using a 9-point scale derived from the Rand Corporation and the University of California in the USA. According to the answers, a categorical rank (first-line/preferred choice, second-line/alternate choice, third-line/usually inappropriate) was assigned to each option. The first-line option was defined as a strategy rated as 7–9 (extremely appropriate) by at least 50% of the experts. The following results summarize the key recommendations from the guidelines after data analysis and interpretation of the results of the survey by the scientific committee.ResultsLAI antipsychotics are indicated in patients with schizophrenia, schizoaffective disorder, delusional disorder and bipolar disorder. LAI second-generation antipsychotics are recommended as maintenance treatment after the first episode of schizophrenia. LAI first-generation antipsychotics are not recommended in the early course of schizophrenia and are not usually appropriate in bipolar disorder. LAI antipsychotics have long been viewed as a treatment that should only be used for a small subgroup of patients with non-compliance, frequent relapses or who pose a risk to others. The panel considers that LAI antipsychotics should be considered and systematically proposed to any patients for whom maintenance antipsychotic treatment is indicated. Recommendations for medication management when switching oral antipsychotics to LAI antipsychotics are proposed. Recommendations are also given for the use of LAI in specific populations.ConclusionIn an evidence-based clinical approach, psychiatrists, through shared decision-making, should be systematically offering to most patients that require long-term antipsychotic treatment an LAI antipsychotic as a first-line treatment.

The Use of Continuous Treatment Versus Placebo or Intermittent Treatment Strategies in Stabilized Patients with Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with First- and Second-Generation Antipsychotics

“…Current guidelines and recommendations on schizophrenia consider LAAPs as drugs of choice for the treatment of schizophrenia patients with recurrent relapses related to non-adherence with antipsychotic medication [11,65,[152][153][154][155][156]. Recent reviews have never been more vocal about their use in early-episode patients for similar reasons (provided schizophrenia has been diagnosed or clinically highly suspected), as these patients ''have more to lose'' [134,[157][158][159][160][161][162][163][164][165][166][167][168][169][170]. LAAPs may, if presented correctly, be more effective for maintaining medication continuity, preventing relapse, reducing the number and duration of rehospitalizations and, when achieving remission, holding this status [161,166,168,169,[171][172][173][174][175].…”

Histoire des traitements antipsychotiques à action prolongée dans la schizophrénie

“…Avec les antipsychotiques de 2 nde génération, l'observance n'est pas seulement liée au fait que le médicament est injectable mais elle résulte aussi de la diminution maximale des effets indésirables (sédation, effets métaboliques, prise de poids, hyperprolactinémie, akathisie, effets extrapyramidaux) et des effets favorables sur les symptômes négatifs et sur la cognition. Des recommandations établies récemment par des équipes françaises indiquent que les antipsychotiques injectables à action prolongée ne devraient pas seulement être proposés à des patients qui n'observent pas leur traitement, mais de façon plus systématique à tous les patients chez qui un traitement de maintien est considéré [46]. Comme cela a été évoqué, les études randomisées contrôlées comparant des patients soignés par des antipsychotiques atypiques oraux par rapport à des patients soignés par APAP sont limitées quand il s'agit de prouver la différence en termes de rechutes et de ré-hospitalisations entre les deux groupes pour deux raisons :…”

Clinical Decision-Making in the Treatment of Schizophrenia: Focus on Long-Acting Injectable Antipsychotics

“…However, recent guidelines for the use and management of LAI antipsychotics in clinical practice evoke the possibility of using this formulation for patients with first-episode or recent-onset schizophrenia [8][9][10][11][12]. Although most clinicians regard them as effective, reported LAI antipsychotic prescribing rates are low [13] and vary widely between countries (6%-30%) [14].…”