I'm Dr. Leslie Citrome clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York. And with me is. Dr. Jonathan Meyer,
a voluntary clinical professor of psychiatry at the University
of California in beautiful San Diego. Let's go for this first one here. Do LAIs (long-acting injectable antipsychotics) prevent or delay hospital readmission? Well, one thing we understand
is that most people with chronic illnesses,
not just schizophrenia or non-adherence with oral medications,
not me, though, other people. Right. That being said, many studies have shown and there's
different types of methodologies. There are randomized studies. There are what are called mirror image
where has their own control. But the bulk of the literature
shows that the use of LAIs, particularly in patients with schizophrenia, reduces
the risk of relapse substantially. Does it reduce it to zero? It does not, because as many reasons, people may relapse even when they’re adherent with medication. But it's one of the best tools
for reducing the risk of relapse. Absolutely. You decrease the risk of relapse, you
decrease the risk of rehospitalization. This has been seen in patients
who've been hospitalized repeatedly as well as first episode patients. And I really want to add to the fact
that we now recognize that because non-adherence is such a prevalent problem,
and the consequences of nonadherence really may be irreversible,
meaning effects on the brain, which may make it difficult
to respond to antipsychotics. We think the state of the art these days
is when people have their first diagnosed with schizophrenia to preferentially
try and get them to respond to agents which have LAI options. Absolutely. We need to offer long acting injectables
to more people and earlier on in the disease course, people who are at the early stage
of their illness have the most to gain and the most to lose. Next question Do LAIs work better than oral antipsychotics? So it depends what you mean by better. If you had somebody who was 100% adherent with an oral medication,
I would say the answer is no. We are only providing a mechanism of delivery, which assures adherence. It does not necessarily
make the medication more effective. So overall, we would say LAIs are not more effective,
meaning if I have a certain reduction in symptoms on drug X
and I take that religiously, will I do better on the same LAI version? No, but from what I understand,
most people are not 100% adherent. No, The rate of partial or non adherence
in people with schizophrenia is about 50%. Now, before you start blaming people with schizophrenia as being,
you know, the trouble here, it's actually the same percentage
for those with bipolar disorder, major depressive disorder, anxiety disorder,
diabetes, hypertension and asthma. And last but not least, Do LAIs require a monthly injection? Well, we have a range now for LAIs
which go from as short of every two weeks up to every six months. And so you have a lot of options in a way
we never had in years past, each of which should be tailored to the particular
clinical situation for that patient. So, for example,
there's now a subcu form of risperidone where you could have a one
or two month option right off the bat. Why would you pick one or the other? Well, you know,
it depends also on patient preference and what would the patient actually like to receive something
every month, every two months. You would think the fewer
number of injections would be preferred. That's not always the case. And I've had patients who insist
on an injection every two weeks. Now, I'm not going to get in the way of their decision making
if that's what they really want. However, it's
nice to have a variety of options to offer the every month
or every two month option with risperidone that you talked about is injected under the skin subcutaneous
that's different from intramuscular And some patients may have a preference
as to what kind of injection they would prefer. They may also want a specific location
for the drug to be injected. And so some patients would prefer the arm. Others would prefer the gluteal muscle. Now, why would that be? Patients are human beings. Everyone has their own preferences. I think the most important thing
is to know all the options that are out there
and know how to use them effectively. Meaning if it is an agent that requires
oral overlap, make sure that's discussed with the patient.
If they don't take the oral overlap, they may be sub therapeutic
for many weeks. If it's a medication that has
an initiation regimen, know how to use it. If it's a medication with a loading
regimen, know how to use it. But the most important thing,
I think, with LAIs more than anything is that the conversation
should revolve around shared goals. What's important to the patient?
What are their concerns? What are their fears? And most importantly, rinse and repeat. It's not a one time discussion, is it? No. It could take a while before
someone goes and says, okay, I'll try it. One of the gambits I use is, you know,
let's try once if you don't like it next time you're scheduled
for an injection, we'll go back to pills. Well, when someone has experience
receiving injection, has the freedom from not having to take something orally
every day. They often are convinced. It's really one of our most effective
tools in psychiatry. And I think both of us would say,
learn how to use them learn how to have the conversation and know all the options out there
to get the best outcome for your patient. Thank you for joining us at NEI’s Autocomplete