What are important considerations for the use of long-acting injectable (LAI) antipsychotic medications in first-episode psychosis patients?

Compared to oral antipsychotics, LAIs are highly effective in preventing a second episode of psychosis (see reference). Achieving sustained remission is a critical treatment goal for first-episode psychosis patients who are trying to put their lives together after their first episode (e.g., finishing school).

Prior to initiating any LAI, tolerability needs to be established with the oral version of the antipsychotics; see this tip for more information. LAIs cannot be given to antipsychotic-naïve patients.  This is not a clinical problem as the initial stabilization of first-episode patients is often better done with oral medications due to more flexibility and easier dose adjustments. The treatment plan can then anticipate a switch to a LAI as soon as is feasible.

Clinicians who want to use LAIs in first-episode patients should do the following:

• Discuss LAIs as part of the overall treatment plan at the beginning of treatment, including outlining the planned switch to a LAI once tolerability and efficacy of the antipsychotic are established.
• Highlight the benefits from using LAIs in first-episode patients (reduced relapse risk compared to oral pills, convenience, less family strife over adherence, decreased risk of accidental and intentional overdoses).
  • Because there are no missed or doubling up on doses or variable dosing times commonly seen in patients taking PO meds, LAIs allow for better steady state medication plasma levels.
• Select an antipsychotic that can be transitioned to a LAI.
• If the patient is hospitalized, administer the first dose of the LAI prior to discharge or – if the stay is long enough, complete loading dose strategy if required for selected LAI.
• If the patient was started on a LAI on the inpatient side, communicate clearly to the outpatient team when the next injection is due and at what dose.

REFERENCES

• Subotnik, K.L., Casaus, L.R., Ventura, J., Luo, J.S., Hellemann, G.S., Gretchen-Doorly, D., … & Nuechterlein, K.H. (2015). Long-Acting Injectable Risperidone for Relapse Prevention and Control of Breakthrough Symptoms After a Recent First Episode of Schizophrenia. A Randomized Clinical Trial. JAMA psychiatry, 72(8), 822-9.
• Schreiner, A., Aadamsoo, K., Altamura, A.C., Franco, M., Gorwood, P., Neznanov, N.G., … & Hargarter, L. (2015). Paliperidone palmitate versus oral antipsychotics in recently diagnosed schizophrenia. Schizophrenia research, 169(1-3), 393-9.
• Kane, J.M., Schooler, N.R., Marcy, P., Achtyes, E.D., Correll, C.U., & Robinson, D.G. (2019). Patients With Early-Phase Schizophrenia Will Accept Treatment With Sustained-Release Medication (Long-Acting Injectable Antipsychotics): Results From the Recruitment Phase of the PRELAPSE Trial. The Journal of clinical psychiatry, 80(3), 18m12546.
• Kane, J.M., Schooler, N.R., Marcy, P., Correll, C.U., Achtyes, E.D., Gibbons, R.D., & Robinson, D.G. (2020). Effect of Long-Acting Injectable Antipsychotics vs Usual Care on Time to First Hospitalization in Early-Phase Schizophrenia. JAMA Psychiatry. Published online July 15, 2020.

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