Discussing Long-Acting Injectable Antipsychotics for Patients with Schizophrenia

In this podcast, Psych Congress Steering Committee member Rakesh Jain, MD, MPH facilitates a Q&A session with Leslie Citrome, MD, MPH, Clinical Professor of Psychiatry, New York Medical College, Valhalla, New York and Georgia Stevens, PhD, APRN, PMHCNS-BC, Director, P.A.L Associates: Partners in Aging and Long-term Caregiving-Medication Management, Therapy & Consultation, Washington, DC, on their Psych Congress Regionals virtual series presentation titled “Long-Acting Injectable Antipsychotics: Practical Considerations and Impact on Adherence in Schizophrenia.”

Drs Jain, Citrome, and Stevens discuss suggestions for difficult LAI administration, how to discuss LAI as a treatment option for patients with schizophrenia, and when LAIs should be considered for treatment.

Read the Transcript:

Dr Jain:  Dr. Citrome and Dr. Stevens, it's nice to be with both of you. I have a lot of great questions. I will start with one of the most practical questions I have seen in a long time. I'll start with you, Dr. Stevens, if I may.

The question is, patients who have had a long history of LAIs for decades and have developed bilateral gluteal scar tissue, which makes administration of LAIs difficult in this patient, what are some of your suggestions for such a patient?

Dr Stevens:  We have choices. The reality is, we still can find areas in which to safely inject a gluteal injection. We do have choices where you have a choice of four sites, either the two deltoids or the two gluteals. You might want to think in that direction, as well as we also have a subcutaneous risperidone, which gives us another option in this case.

Dr Jain:  Les, I know there are some injectables where location is somewhat limited. Having said so, I like Dr. Stevens' suggestions. What would you add?

Dr Citrome:  I would add we're limited right now. Subcutaneous route to the abdomen for the current available risperidone subcutaneous injectable. Coming soon, I think, in a not too distant future is another subcutaneous formulation of risperidone that could be injected elsewhere. That's good. That would be welcome.

Off-label, you can inject anywhere you like with subcutaneous, but I like to go with what's initially recommended, because that's how it was studied.

Dr Jain:  This particular practical question and particular challenge our clinician is facing, thankfully, both of our presenters are offering you some options to consider.

Dr. Stevens, a question that I know is near and dear to your heart. Do you think LAIs should be considered earlier in treatment, or are you pretty satisfied with the American status quo of where we use LAIs?

Dr Stevens:  I won't hit my forehead on the keyboard, but no, I'm not satisfied with the American standard. We know that the relapse risk is five times greater after a first-episode person stops their antipsychotic medication. They do stop, and we know that they stop.

Earlier in the journey, we can protect people, and hopefully, they'll have less to lose if it's earlier in their journey as well as the fact that we might, if we do it early in the journey, reduce some of the stigma of the need for continuous medication.

Dr Jain:  Dr Citrome, I've known you long enough to know that you passionately agree with Dr Stevens' point here. You've also written quite a bit about how to practically, in a busy clinic, increase the yield in converting patients from oral to injectables.

Would you mind sharing perhaps the top three tips you might offer our audience on achieving exactly that goal?

Dr Citrome:  The most important thing is to get everyone on board that this is a good idea. There has to be a sense of urgency to consider long-acting injectables as a first choice.

That means being aware of the data that supports its use that provide ample evidence that it improves outcomes, in terms of avoidance of relapse, reduction of hospitalization, and so on because of the adherence angle to it. That's not enough. It's also very convenient for the patient, and we often lose sight of that.

The other aspect that's so appealing for LAIs is not only do we hopefully get better outcomes, but patients feel better served in their treatment and they feel better paid attention to, in many respects.

If you ask someone who's on an LAI, you'll find that surveys have shown that they prefer that LAI. Who knew? I would recommend think about LAIs earlier, more often, and as a choice.

The current guidance from the APA and the schizophrenic guidelines that were revised in 2020 suggest that, yes, it's good for people who have difficulty with adherence -- who doesn't? All of us do, in terms of chronic conditions and taking medicines -- but also on the basis of personal preference.

You have to get the buy-in so it's offered more frequently. Once you're fired up about it that this is a good idea and something I want to offer, there's all sorts of things we can do to make it more appealing to patients, such as putting it in a positive light.

"You don't want a shot, do you?” Is not the way to go, of course. You have to get everyone on the team on board. Some people may find, "Oh, injections. That's punitive, that's coercive." They need to be turned around, in terms of that kind of attitude.

All it takes is one naysayer on a treatment team to sabotage a treatment plan. We all have seen that time and time again. Get everyone on board, on the same page that this is a good intervention.

Then, the rest falls into place, because we're able to convey to the patient, "This is really a better option for you, and unless you haven't responded to traditional antipsychotic treatment and thus you're a clozapine candidate, an LAI, you'd be far better off with."

This goes back to our discussion also about the ones who are earlier on in the disease course. As was mentioned, they have a lot to lose. If we can reduce the number of relapses that they experience in their lifetime, we have done them a service.

Dr Jain:  A major service. I agree with you. Dr. Stevens, I saw you nod your head a number of times when Dr. Citrome was speaking. The practical issue a colleague is bringing up, but what about the patient who says, "Injections hurt. I don't want the pain"? How do you in Washington, D.C., address such a question coming from a patient?

Dr Stevens:  In order to reinforce that we are collaborative, we have a collaborative relationship, they're bringing their expertise in terms of their lived experience, I'm bringing expertise in terms of disorders and treatments, go over the data.

Share the data from the studies about injection site pain so that they can see the scale as well as the magnitude that people have experienced. Talk about that, "It may be, but let's see. Let's see how it is for you individually, because people are individuals and it really makes a difference for the person, and that we can always change back."

Most important is we have to demystify both the information and the processes of the long-acting injectables.

Dr Jain:  I couldn't agree with you more. Les, do you have any practical tips on a patient who says, "But it's going to hurt"? How do you approach that?

Dr Citrome:  I approach it with data, and data that they can understand. Who doesn't understand a visual analog scale? One of the long-acting injectables was assessed in its development regarding injection site pain. Out of a scale of 0 to 100, patients, on average, rated the first injection site pain of 7, 7 out of 100.

I tell patients that, "7 out of 100, and the subsequent injections were 5 out of 100. You know what? It's like a flu shot. It's similar to that. The tattoos that you have, they hurt a lot more."

It's very different. I put a light touch to it, too. I do mention the tattoos, tattoos are very common today, and I don't think they're pain-free when you get them. People do remember that, and then the flu shots, they do remember that.

One tricky part, though, is that it is different from a COVID vaccine shot, which can hurt a whole lot more. I want to place it within the backdrop of, in the past, getting those flu shots. That can be tricky.

I know a psychiatrist in Brooklyn who carries with him a picture of himself getting a flu shot and shows it to the patient, "Here, it's like this." It normalizes it, destigmatizes it. Show them the needle. Show them what the size of it is and the size of the syringe.

It's not so scary once you see it, although some needles may be larger than others and you'd want to think this through first. Demystify so that they don't have in their mind that it's a needle this big.

The other demystification that's necessary is they understand it's a shot in the rear for some of them, and they think they have to drop their pants. They don't. We don't want them to drop their pants. It's the upper outer quadrant.

I tell them, "That's the part of your rear that I see all the time, because you wear your pants so low."

Dr Jain:  You're using a combination of humor and empowerment. Dr Citrome, I appreciate that. Dr. Stevens, you used the themes of empowerment and education.

If you bring those four elements together, surely, we will have greater success than contemporary psychiatry is having, in terms of converting more patients to LAI therapy, which, as the data shows, quite obviously, is very often in the patient's best interest.

Dear colleagues, sadly, we have run out of time. Thank you both very much for presenting. I do appreciate it. Hugely practical, clinically relevant presentation.

With that, great thanks to both of you. To my dear colleagues, all of the hundreds of colleagues listening into this presentation, I'm certain you, too, enjoyed it as much as I did.

Please join us now for our innovation theater. The title of that is "Considerations for Screening and Assessment of Tardive Dyskinesia in the Telepsychiatry Setting," which starts in 15 minutes. Click on the session in the live agenda to join us.

See you later. Take care, Dr Stevenson, Dr Citrome.

Georgia Stevens, PhD, APRN, PMHCNS-BC, is the Director of P.A.L Associates: Partners in Aging and Long-term Caregiving-Medication Management, Therapy & Consultation in Washington, D.C. She received her BSN from Duke University, MSN in psychiatric nursing from The Catholic University of America, and PhD from the University of Maryland at Baltimore. In addition to serving in numerous organizations, she is the recipient of the APNA Best Practice Award in the Treatment of Behavioral Disorders Associated with Dementia and an American Journal of Nursing Book of the Year Award.

Leslie Citrome, MD, MPH, is a Clinical Professor of Psychiatry at New York Medical College in Valhalla, New York. He graduated from the McGill University Faculty of Medicine and completed a residency and chief residency in psychiatry at the New York University School of Medicine. He serves as the editor-in-chief of the International Journal of Clinical Practice and is a member of the Board of Directors of the American Society of Clinical Psychopharmacology.