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Should Inverse Agonists Be Defined by Pharmacological Mechanism Or CNS Spectrums,(2019), 24 354 – 370. © Cambridge University Press 2018. This is an Open Access article, distributed under the terms , of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work. doi:10.1017/S1092852918001098 REVIEW ARTICLE Practical considerations for managing breakthrough psychosis and symptomatic worsening in patients with schizophrenia on long-acting injectable antipsychotics Christoph U. Correll ,1,2 Jennifer Kern Sliwa ,3* Dean M. Najarian ,3 and Stephen R. Saklad4 1 Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York 2 Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York 3 Janssen Scientific Affairs LLC, Titusville, New Jersey 4 College of Pharmacy, Pharmacotherapy Division, University of Texas at Austin, San Antonio, Texas With more long-acting injectable (LAI) antipsychotics available for treating schizophrenia, each with variable durations of action (2 weeks to 3 months), it is important to have clear management strategies for patients developing breakthrough psychotic symptoms or experiencing symptomatic worsening on LAIs. However, no treatment guidelines or clinical practice pathways exist; health-care providers must rely on their own clinical judgment to manage these patients. This article provides practical recommendations—based on a framework of clinical, pharmacokinetic, and dosing considerations—to guide clinicians’ decisions regarding management of breakthrough psychotic symptoms. Management options include ruling out/addressing medical illness or substance abuse/misuse as a contributing factor, addressing stressors, optimizing nonpharmacologic treatments, treating medical/psychiatric comorbidities, ensuring proper LAI administration technique, addressing missed LAI doses or lack of steady-state attainment, and increasing LAI dose directly or indirectly by shortening the injection interval (off-label). If these strategies do not work sufficiently with frequent monitoring, the LAI could be supplemented with a low dose of the corresponding oral formulation for fast symptom control (off-label). However, caution should be exercised with this strategy, because data on the safety of concomitant use of LAI and oral antipsychotics (OAPs) are limited, especially over extended periods. If symptoms abate, therapy optimization could be continued and slow discontinuation of the OAP could be considered. For persistent/worsening symptoms, the OAP should be increased to optimum effective dose while intensifying the initial steps used before it was added. If this fails, switching the OAP or LAI could be considered. We believe that these strategies will help clinicians manage breakthrough psychotic symptoms during LAI treatment and improve overall outcomes among those who can benefit from LAIs. Received 20 December 2017; Accepted 23 May 2018 ; First published online 27 December 2018 Key words: Antipsychotic, breakthrough symptoms, long-acting injectable, management strategy, schizophrenia, symptomatic worsening. Introduction antipsychotics were introduced; however, the use of LAIs has increased slowly in recent years since the introduc- The use of long-acting injectable (LAI) antipsychotics for tion of second-generation LAI antipsychotics.1,2 Earlier the treatment of patients with schizophrenia decreased data estimated that LAI antipsychotics were prescribed significantly after oral formulations of second-generation to between one-quarter and one-third of patients with schizophrenia in the United States, Australia, and * Address correspondence to: Jennifer Kern Sliwa, Neuroscience Europe3,4; more recent data (2016) from the United Medical Information, Janssen Scientific Affairs LLC, 1125 Trenton- Harbourton Road, Titusville, NJ 08560. States indicate that 11% of patients are prescribed LAI (Email: [email protected]) antipsychotics (data on file, Janssen). Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.93, on 26 Sep 2021 at 01:28:22, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852918001098 MANAGING BREAKTHROUGH PSYCHOSIS IN SCHIZOPHRENIA 355 LAI antipsychotics offer advantages over oral formu- approved before the implementation of such US Food lations,1 because they provide assured adherence for the and Drug Administration requirements), may either duration of the injection interval and beyond; this is preclude them as a viable choice for HCPs or make them particularly important for patients who have a history difficult to use. Patient-specific practical considerations of poor adherence, lack of insight into their illness, include access to care, needle size, or injection site or cognitive deficits that interfere with scheduled location.10 Thorough consideration of patient- and HCP- medication intake.1 Because patients receiving LAI specific preferences will help guide selection of the antipsychotics do not have to remember to take medica- appropriate LAI antipsychotic and potentially improve tion daily, there are fewer opportunities for missed adherence and effectiveness among patients. doses.1 With LAI antipsychotics, health-care providers Despite the many advantages that LAI antipsychotics (HCPs) are assured of continuous antipsychotic coverage offer over oral formulations,1 patients may experience during the dosing interval. In cases of patients failing to psychotic breakthrough symptoms or symptomatic wor- take their medication, there is a longer window for sening during treatment, such as psychosis-related social intervention, as the decrease of blood concentrations of withdrawal, anxiety, or depression; parkinsonian side antipsychotics is much more gradual after discontinua- effect–related secondary negative symptoms; or akathisia tion of LAI antipsychotics than after discontinuation of manifesting as agitation. Unfortunately, there is a paucity oral antipsychotics (OAPs).1,5,6 Patients also benefit from of data regarding management strategies in response to consistent bioavailability and potentially fewer peak patients experiencing breakthrough symptoms, with only concentration–related adverse events (AEs) observed three articles identified during a recent literature – with OAPs.7 Furthermore, clinicians are immediately search.11 13 There are currently no algorithms, treatment aware when medication nonadherence begins (i.e., guidelines, or clinical pathways to guide the management patients do not return for their scheduled injections).1 of LAI antipsychotic–treated patients who have break- Importantly, there is evidence that LAI antipsychotics through symptoms or who become acutely ill. Moreover, reduce the incidence of relapse compared with oral the only available guidelines for the therapeutic targets of formulations.1,2,7 This in turn can decrease the frequency LAI antipsychotics, produced by Arbeitsgemeinschaft für and duration of hospital stays associated with relapse, Neuropsychopharmakologie und Pharmakopsychiatrie thereby reducing the overall burden on the patient and (AGNP), are based on data from oral compounds.14,15 their caregivers, and on the health-care system.2,8,9 Therefore, HCPs must currently rely on their own clinical Given that there are several first-generation LAI judgment to manage patients with breakthrough symp- antipsychotics still on the market as well as an influx of toms or symptomatic worsening. Herein, we provide newly available second-generation LAI antipsychotics practical solutions based on a framework of clinical, (Table 1), it can be challenging to delineate which LAI pharmacokinetic (PK), and dosing considerations to help antipsychotic is most appropriate for a particular HCPs make well-informed decisions regarding manage- patient. However, there are several practical considera- ment strategies for patients presenting with break- tions that should be considered when selecting a specific through psychotic symptoms or symptomatic worsening LAI. Because each LAI has unique attributes, selection while being treated with LAI antipsychotics. should be tailored to match the unique needs of the individual. First, the HCP should consider the reason for General Factors That Contribute to Breakthrough using an LAI antipsychotic (e.g., patient preference, Psychosis and/or Symptom Worsening nonadherence, court order). The patient and the HCP should then discuss factors important to the patient, Breakthrough psychosis and/or symptom worsening may such as the expected or already experienced efficacy and occur for a variety of reasons, including psychotic AE pattern of the oral formulation of the same relapse, concurrent medical illness, substance abuse or antipsychotic, the frequency of administration, whether misuse, other psychiatric comorbidity, psychosocial an oral supplement is required upon initiation, and the stressors, suboptimal drug administration, incorrect financial cost or coverage of the treatment.10 One dosage, ineffective medication, use of other drugs potential disadvantage of LAI antipsychotics is the leading to pharmacodynamic (PD) or PK interactions, potential for delayed resolution of a distressing or severe poor adherence,
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