Institutional Best Practices for Treating Schizophrenia - Episode 10
Rahn Bailey, MD, DFAPA, and Henry Nasrallah, MD, review how early long-acting injectables should be started in patients with schizophrenia.
Peter Salgo, MD: How early should the LAIs [long-acting injectables] be started?
Henry Nasrallah, MD: As early as possible.
Peter Salgo, MD: I knew it.
Rahn Bailey, MD, DFAPA: As early as possible.
Henry Nasrallah, MD: Let me tell you why.
Rahn Bailey, MD, DFAPA: I’ll show you our process. Very often in a midlevel hospital, which we are, we don’t have an ER [emergency department]…. If we saw someone with a first break and had some treatment, no treatment at all, or they’ve been on treatment in the past in and out where they worked, we are very comfortable—we teach our trainees that LAIs absolutely are and can be first-line treatment, and we use a fair amount of each across the board in that regard.
One of the struggles is that often junior faculty and trainees tend to think you’re going to use the LAI that’s identical to what oral medicine they responded to in the past. It’s another unfortunate axiom of what’s been problematic, because if you hadn’t taken anything that worked very well for you in the past, docs keep trying to put you on another oral rather than thinking you could start with the LAIs. Those are some barriers. I used the term reculturate earlier to keep talking about repetitive messaging to work through.
To answer your question, the reality is here at Kedren hospital and where I was in the past. I was at a long-term state hospital in Alabama before, which is our ideal setting to start somebody initially on LAI. You could make the argument that parenthetically, it’s best for the majority of the patients that we see.
Peter Salgo, MD: Henry, if you want to start LAIs as early as possible, what I’m hearing is if somebody presents for the first time, start them right away on an LAI. I’ll ask you the other question. Would there ever be a reason not to start someone on an LAI but to start on an oral agent first?
Henry Nasrallah, MD: I do always. I always start patients on oral, especially when they come into the hospital first episode. We want to make sure they’re not allergic to it, and we want to make sure they can tolerate it, so we always start with oral. The good nurses on the inpatient unit make sure the patient is swallowing it. That’s why they start getting better. Orals work perfectly well on the inpatient unit because it’s being monitored and the patient is swallowing, not cheeking it and throwing it away. Once they improve, then we start planning. Discharge planning includes educating the patient, educating the family. I do multiple lines of convincing for the patients to get them to agree and give them that injection before they leave the hospital.
That is the best time, in my opinion, to manage schizophrenia and get the best outcome possible. There are many studies showing that, and basically initiating the dose. Switching to an injectable is seamless on the inpatient. If you start with the risperidone, you can switch to either risperidone or paliperidone at discharge. If you start with aripiprazole, you can switch them to aripiprazole, first episode.
For patients who are chronic and have taken other medications, you can tell that they’ve been exposed to these medications in the past, I can switch them to an LAI right away. No need to test them for allergic reaction, etc.
Here’s why I start with the first episode: Study after study shows that the outcome is incredibly better. I’ll give you 2 examples. Dr Robin Emsley of South Africa was the first to give first-episode patients long-acting risperidone. He used risperidone back then. It was only available second generation. He didn’t want to use first generation. He got 50 patients and he gave them long-acting risperidone, and he published a 2-year study. Patients signed up for it, and he presented it in 2008—65% of the patients went 2 full years without a single relapse. Their insight came back, they went back to school, they went back to work, and they resumed their life. The other 35% included either partial responders or nonresponders who should go to clozapine. Another vastly underutilized drug in psychiatry is clozapine, which should be given to at least 25% to 30% of patients who don’t respond to dopamine antagonist, the standard antipsychotic therapy, and only 4% or 5% are getting clozapine when about 25% to 30% should get it. There is this epidemic of lack of use of effective treatment in psychiatry by psychiatrists. They keep doing the same old, same old.
There’s another study from UCLA, published in JAMA Psychology, a very prestigious journal, and they took 100 patients with their first episode. They used risperidone for some reason. At the time of discharge half of them were kept on oral risperidone, the other half were getting injectable. They followed them up for a whole year, counted the number of relapses. What did they report in that paper? It’s really stunning, and many clinicians probably never bothered to read it: 650% higher relapse rate in the oral group compared with the injectable group. Give me a break—how can you read a well-done study like that and not use a long-acting? If my family member becomes psychotic, that’s what I would do for them, and I want to treat my patients like a family member. That’s what I tell them. I tell them, “I want to treat you like a family member.”
Peter Salgo, MD: 650% gets your attention.
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Transcript Edited for Clarity