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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 21-24

Prescribing practice of long-acting injectable antipsychotics


1 Assistant Professor, Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2 Pharm D Intern, Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Date of Submission05-Jan-2020
Date of Decision06-Jan-2020
Date of Acceptance25-Feb-2020
Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Jisha M Lucca
Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_1_20

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  Abstract 

Introduction: Nonadherence to treatment is one of the main problems that prevent treatment outcomes in schizophrenia. Long-acting injectable antipsychotic (LAIA) simplifies the treatment process and improves the adherence and health-related outcomes. The prescription pattern of antipsychotics in psychiatric and nonpsychiatric wards is well studied. Whereas the patterns of long-acting injectable (LAI) are not yet documented. Hence, this study was aimed to assess the pattern and prescription of LAI in a university hospital in Saudi Arabia.
Materials and Methods: This single-centered, retrospective study was conducted in a university teaching hospital in Khobar city over a period of 6 months. Patients of all ages and either gender with a psychiatric diagnosis or received at least a single depot injection over a period of 1 year were included in the study.
Results: A total of 101 patients were included in the study; a male predominance was observed in (64%) our study patients. One half of the study patients have a long history (10 years and more) of psychiatric problems. Of the total 313 medications, 176 (55.7%) and 137 (43.3%) were psychotropic and nonpsychotropic medications, respectively. Zuclopenthixol (n = 48) and haloperidol (n = 10) were the commonly prescribed first-generation LAIAs, whereas risperidone (40) was the only one second-generation LAIA preferred in the study site. Befere the Initiation of LAIA ,majority (67%)of the patients received a trial of antipsychotices orally.
Conclusion: The study delivers the evidence of LAIA utilization in a psychiatric unit of a tertiary care teaching hospital in Saudi Arabia. LAIAs were the choice not solitary for schizophrenic-like ailments. The utilization pattern is similar to both-generation LAIs. More studies are required to focus the safety and efficacy concerns of LAIA.

Keywords: Depot injectable, long-acting injectable antipsychotics, prescription


How to cite this article:
Lucca JM, AlSumain G, Almousa M, Alkhalifa R. Prescribing practice of long-acting injectable antipsychotics. Arch Ment Health 2020;21:21-4

How to cite this URL:
Lucca JM, AlSumain G, Almousa M, Alkhalifa R. Prescribing practice of long-acting injectable antipsychotics. Arch Ment Health [serial online] 2020 [cited 2020 Oct 31];21:21-4. Available from: https://www.amhonline.org/text.asp?2020/21/1/21/288910


  Introduction Top


Globally, schizophrenia is one of the most frequent, troublesome, and detrimental psychiatric disorders in adults.[1],[2],[3] Antipsychotics are the mainstay of treatment of schizophrenia and are used to treat acute psychotic symptoms as well as for relapse prevention. Nonadherence to treatment is one of the major barriers for effective treatment outcomes in schizophrenia.[4],[5] It is reported that 25% of the schizophrenic patients were partially or completely nonadherent to the therapy by 10 days of discharge from the hospital. It will escalate up to 50% at 1 year and 75% at 2 years of treatment.[6] This increases the severity of the symptoms, relapses, suicidal attempts, and hospitalization.[7],[8] Inaccuracy in the long-term, day to day, self-administration of the medication and fear about the adverse effects were the top-listed reasons for nonadherence in schizophrenia.[9],[10] To overcome this, long-acting injectable antipsychotics (LAIAs) were developed. They simplify the treatment process, enhance the adherence as well as bioavailability problems, and reduce the risk of overdose.[10],[11] This, in turn, enhances the patients' social and professional reintegration and adaptation capacities.[6]

There exists a lacuna of accurate estimate of the prevalence of psychiatric disorders among the Saudi population. However, a few studies have been conducted in relation to specific mental disorders in different populations.[12],[13],[14],[15] The prescription pattern of antipsychotics in the psychiatric and nonpsychotic units is well studied. Whereas the patterns of long-acting injectable (LAI) are not yet documented. Hence, this study was aimed to assess the pattern and prescription of LAIs in a university hospital in Saudi Arabia.


  Materials and Methods Top


Study design and population

This single-centered, retrospective study was conducted in a university teaching hospital in Khobar city over a period of 6 months. Patients of all ages, either gender, with a psychiatric diagnosis, and who received at least a single LAIA over a period of 1 year were included in the study. Patients who changed the diagnosis or lost the treatment from the study site were excluded from the study.

Study procedure

Patients who met the inclusion criteria were included in the study. “QuadraMed,” the hospital pharmacy database, was used to collect the data. Patients who visited or who were admitted to the psychiatric department during the period of 2016–2018 were reviewed. The study's clinical pharmacists perused the patient case records for any LAIA prescription. On identification of an LAIA prescription, all the study-specific details such as patient demographics, details of the LAIA, and duration of each drug prescribed were collected and analyzed systematically. Patients' comorbidity and coexisting medications were also noted.


  Results Top


Of the total 123 patients reviewed, 101 were included in the study. Majority (64%) of our study patients were male and geriatric population accounted only 8%. One-fourth of the study patients had at least one comorbid medical condition. Majority of the (55%) study patients had a long history (10 years and more) of psychiatric problem. The demographic details of the patients are summarized in [Table 1].
Table 1: Demographic of the study population

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Medical comorbidity

Diabetes mellitus (20%), hypertension (19%), and infectious disorders (15%) were the top-listed medical comorbidities found to be present in our patient population [Figure 1].
Figure 1: Common medical comorbidity

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Prescription medication

A total of 313 medications were prescribed for the 101 study patients. Of these, 176 (55.7%) and 137 (43.3%) were psychotropic and nonpsychotropic medications, respectively. Antipsychotics (n = 87) were the most prescribed psychotropic medication followed by mood stabilizers (n = 38). Among the nonpsychiatric medications, anticholinergic (n = 39) and glucose-lowering agents were (n = 28) the top most prescribed medications [Table 2].
Table 2: Commonly prescribed class of medication

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Details of long-acting injectable antipsychotics

Of the total 101 patients prescribed with LAIA, 60% of them received first-generation antipsychotics. Zuclopenthixol (n = 48) and haloperidol (n = 10) were the frequently prescribed first-generation antipsychotics, whereas risperidone (n = 40) was the only one preferred second-generation antipsychotic in the study site. One half of the schizoaffective disorders were treated with risperidone, whereas zuclopenthixol (53%) was the preferred choice for schizophrenia. The details of the diagnosis and preferred LAIA are depicted in [Figure 2].
Figure 2: Long-acting injectable antipsychotics versus diagnosis

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Trial of oral antipsychotic before long-acting injectable antipsychotic

Majority of the patients (n = 67) received an oral preparation of the same LAIA antipsychotic for few days prior to the depot injection [Figure 3]. In majority of the patients, flupentixol and haloperidol were administered in every 28-day interval, whereas risperidone was given for every 14 days. Similarly, zuclopenthixol was administered in every 14, 21, and 28 days of interval. Previous use of LAIA was observed only in 10% of the study patients.
Figure 3: Oral medication before the long-acting injectable

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  Discussion Top


A sustained pattern of LAIA prescription was observed in the study site. There was no change in the prescription pattern of LAIA when compared with first- and second-generation antipsychotics. Very minimal shift toward the initiation of second-generation LAIA was observed in this study, whereas a previous literature documented an increasing trend of second-generation LAIAs in recent years.[16] One of the reasons could be that during the study period, risperidone was the only one second-generation LAIA that was available in the study site. Other commonly prescribed LAIAs such as paliperidone and aripiprazole were not available in the study site. More than that, the risperidone frequency is every 14 days that limited its use when compared to the monthly prescribed first-generation LAIA.

Majority (89%) of the study patients had schizophrenic-like disorders. Other than this, bipolar disorder was one of the most frequent indications for the use of LAIA. Multiple evidence is available to prove the effectiveness of LAIAs in bipolar disorders.[17],[18] In this cohort, depression and anxiety are not observed. This is probably because depression and anxiety are considered off-label indications of LAIA in the study site, and the study site has a very strict policy for off-label use of the medication.

Approximately three-fourth of our study population received same oral antipsychotic, prior to the start of LAIA. Considering the guidelines and practices, it is recommended that LAIA should be started after stabilization with oral antipsychotics.[19] However, one-fourth of the study patients did not receive any oral stabilization dosage. This might be because some of the LAIAs such as zuclopenthixol not obviously recommend an earlier oral antipsychotic stabilization. Similarly, earlier oral administrations of the similar active principle medication may allow the testing of tolerability of medication.

There are few limitations associated with this study; the data were drawn from the database and additional clinical information was not collected. Furthermore, clinical improvement and adherence outcome were not studied. Additional research with lengthier follow-up and further comprehensive information is needed to assess the effective role of LAIAs in multifaceted recovery-oriented strategies of patient care.


  Conclusion Top


The study provides evidence of LAIA utilization in a psychiatric unit of a tertiary care teaching hospital in Saudi Arabia. LAIAs were the choice not solitary for schizophrenic-like ailments. Prior stabilization with oral antipsychotic therapy is not a mandatory requirement. Similarly, a comparable pattern of use has been observed with both-generation LAIs. More studies are required to focus the safety and efficacy concerns of the LAIA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sidhom E, Abdelfattah A, Carter JM, El-Dosoky A, El-Islam MF. Patients' perspectives on stigma of mental illness (an Egyptian Study in a Private Hospital). Front Psychiatry 2014;5:166.  Back to cited text no. 1
    
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Panayiotopoulos C, Pavlakis A, Apostolou M. Family burden of schizophrenic patients and the welfare system; the Case of Cyprus. Int J Ment Health Syst 2013;7:13.  Back to cited text no. 2
    
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Eglit GM, Palmer BW, Martin AS, Tu X, Jeste DV. Loneliness in schizophrenia: Construct clarification, measurement, and clinical relevance. PLoS One 2018;13:e0194021.  Back to cited text no. 3
    
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Popp BS, Manea MM, Moraru MO. Treatment adherence and social functioning in patients diagnosed with schizophrenia and treated with antipsychotic depot medication. Clujul Med 2014;87:109-12.  Back to cited text no. 4
    
5.
Gray R, Leese M, Bindman J, Becker T, Burti L, David A, et al. Adherence therapy for people with schizophrenia. European multicentre randomised controlled trial. Br J Psychiatry 2006;189:508-14.  Back to cited text no. 5
    
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Noordraven EL, Wierdsma AI, Blanken P, Bloemendaal AF, Mulder CL. Depot-medication compliance for patients with psychotic disorders: The importance of illness insight and treatment motivation. Neuropsychiatr Dis Treat 2016;12:269-74.  Back to cited text no. 6
    
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Leucht S, Heres S. Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia. J Clin Psychiatry 2006;67 Suppl 5:3-8.  Back to cited text no. 7
    
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Llorca PM. Partial compliance in schizophrenia and the impact on patient outcomes. Psychiatry Res 2008;161:235-47.  Back to cited text no. 8
    
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Weiden PJ, Kozma C, Grogg A, Locklear J. Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatr Serv 2004;55:886-91.  Back to cited text no. 9
    
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Sacchetti E, Grunze H, Leucht S, Vita A. Long-acting injection antipsychotic medications in the management of schizophrenia. Evid Based Psychiatr Care 2015;01:27-36.  Back to cited text no. 10
    
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Tiihonen J, Haukka J, Taylor M, Haddad PM, Patel MX, Korhonen P. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry 2011;168:603-9.  Back to cited text no. 11
    
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Becker S, Al Zaid K, Al Faris E. Screening for somatization and depression in Saudi Arabia: A validation study of the PHQ in primary care. Int J Psychiatry Med 2002;32:271-83.  Back to cited text no. 12
    
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Al-Khathami AD, Ogbeide DO. Prevalence of mental illness among Saudi adult primary-care patients in Central Saudi Arabia. Saudi Med J 2002;23:721-4.  Back to cited text no. 13
    
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Bassiony M. Substance use disorders in Saudi Arabia: Review article. J Subst Use 2013;18:450-66.  Back to cited text no. 14
    
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AbuMadini MS, Rahim SI, Al-Zahrani MA, Al-Johi AO. Two decades of treatment seeking for substance use disorders in Saudi Arabia: Trends and patterns in a rehabilitation facility in Dammam. Drug Alcohol Depend 2008;97:231-6.  Back to cited text no. 15
    
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Bossie CA, Alphs LD, Correll CU. Long-acting injectable versus daily oral antipsychotic treatment trials in schizophrenia: Pragmatic versus explanatory study designs. Int Clin Psychopharmacol 2015;30:272-81.  Back to cited text no. 16
    
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Chou YH, Chu PC, Wu SW, Lee JC, Lee YH, Sun IW, et al. A systemic review and experts' consensus for long-acting injectable antipsychotics in bipolar disorder. Clin Psychopharmacol Neurosci 2015;13:121-8.  Back to cited text no. 17
    
18.
Palomares N, Montes A, Díaz-Marsá M, Carrasco JL. Effectiveness of long-acting paliperidone palmitate in borderline personality disorder. Int Clin Psychopharmacol 2015;30:338-41.  Back to cited text no. 18
    
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Castillo EG, Stroup TS. Effectiveness of long-acting injectable antipsychotics: A clinical perspective. Evid Based Ment Health 2015;18:36-9.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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