Healthcare Resource Utilization and Costs Among Patients With Schizophrenia Switching From Oral Risperidone/Paliperidone to Once-Monthly Paliperidone Palmitate: A Veterans Health Administration Claims Analysis.

BACKGROUND: Schizophrenia is associated with high health care resource utilization and treatment costs. OBJECTIVE: This study compared treatment patterns, health care resource utilization, and medical costs before and after a switch from oral antipsychotic drug (risperidone or paliperidone [RIS/PALI]) therapy to the long-acting injectable once-monthly paliperidone palmitate (PP1M) in patients with schizophrenia. METHODS: Data for adult patients (aged ≥18 years) with at least 1 diagnosis of schizophrenia who initiated treatment with oral RIS/PALI ≥6 months before switching and had continuous health plan enrollment during the study period before and after the switch were extracted from the Veterans Health Administration database. Treatment patterns, health care resource utilization, and costs were compared between the period 6 or 12 months before and after switching directly from oral RIS/PALI to PP1M. RESULTS: The analysis included 676 and 493 patients in the 6-month and 12-month cohorts, respectively. Adherence to oral RIS/PALI during the 12 months preswitch was 11.0% and 22.1% as measured by proportion of days covered and medication possession ratio ≥80%, respectively. During the 12 months postswitch, adherence to PP1M was 27.0% and 35.9%, respectively. Among patients treated with oral RIS/PALI, from 12 months pre- to 12 months post-PP1M switch, fewer all-cause inpatient stays (2.2 vs 1.1, respectively; P < 0.05) and a shorter mean length of inpatient stay (28.1 and 14.0 days, respectively; P < 0.05) were observed. This pattern was similar for both the number of mental health- and schizophrenia-related inpatient stays and length of stay. Compared with 12 months pre-PP1M switch, significantly higher mean numbers of all-cause outpatient visits and pharmacy visits were observed at 12 months postswitch. In line with health care resource utilization findings, at 12 months pre- versus 12 months post-PP1M switch we observed decreases in all-cause inpatient stay costs ($41,886 vs $20,489; P < 0.05) and increases in outpatient visit costs ($22,005 vs $29,069; P < 0.05). Findings for the 6-month cohort followed a similar pattern. CONCLUSIONS: Post-PP1M switch, a decrease in total medical costs fully offset an increase in pharmacy costs, resulting in similar total costs. The findings suggest potential economic benefits of switching patients with schizophrenia from oral RIS/PALI to PP1M in the Veterans Health Administration.

Aripiprazole IM depot as an option for the treatment of bipolar disorder.

Introduction: Long-acting injectable (LAI) antipsychotic drugs are developed to reduce daily intake need and to overcome treatment non-adherence. Aripiprazole IM depot refers to two long-acting aripiprazole formulations, once monthly monohydrate (AOM) and aripiprazole lauroxil. AOM has been approved for schizophrenia since 2012 and for bipolar disorder since 2017. Aripiprazole lauroxil is approved for schizophrenia, not for bipolar disorder.Areas covered: To assess the effect of AOM in bipolar disorder, the authors searched PubMed and ClinicalTrials.gov for randomized trials using AOM in patients with bipolar disorder. Included were four studies covering efficacy, functioning, quality of life, and safety/tolerability. Studies lasted 12 months.Expert opinion: AOM reduced symptoms of patients with bipolar disorder and a manic episode, increased functioning and quality of life, and protected from recurrence of manic episodes. It proved to be safe/tolerable, with only akathisia occurring in ≥10% of cases and more frequently than with placebo. However, there were only 143 patients receiving AOM in the considered studies. Included studies were backed in their conclusions by other literature, but they come from 2017-2018. No studies are expected or planned in the near future. Aripiprazole lauroxil has not applied for approval in bipolar disorder and there is no sign it will.

Head-to-head comparison of 1-year aripiprazole long-acting injectable (LAI) versus paliperidone LAI in comorbid psychosis and substance use disorder: impact on clinical status, substance craving, and quality of life.

BACKGROUND: To overcome nonadherence in patients with psychosis switch to long-acting injectable (LAI) antipsychotic formulations is adopted. Most oral versus LAI comparisons showed similar antipsychotic responses. Psychoses often overlap with substance use disorder (SUD). Head-to-head LAI comparisons have hitherto focused only on non-comorbid populations. OBJECTIVE: The objective of this study was to compare two LAIs, administered for 12 months, in initially hospitalized patients with psychosis comorbid with SUD in their clinical and quality of life (QoL) outcomes. PATIENTS AND METHODS: Inpatients were recruited during 2016 and switched randomly to 400 mg intramuscular aripiprazole monohydrate (AM) (N=50) or to 100 mg intramuscular paliperidone palmitate (PP) once-monthly (N=51); patients were discharged and followed up for 12 months. Patients were rated at baseline and after 1 year through the Clinical Global Impression scale - severity (CGIs), substance craving intensity was rated through a visual analog scale for substance craving, and QoL through the World Health Organization (WHOQOL-BREF) scale. We addressed confounders with backward stepwise logistic regression and three-way analysis of variance. RESULTS: PP were older and had more cases of schizophrenia spectrum and less bipolar disorders than AM, but AM had a stronger craving for substances at baseline. Both LAIs were associated with significant improvements in all outcomes, with AM displaying stronger effect sizes than PP. The two groups did not differ on baseline WHOQOL-BREF scores in any domain, but at the 1-year follow-up, AM fared better on all domains. The two groups did not differ in final severity, but PP scored higher than AM in craving at the 1-year endpoint.Limitation: The CGIs is not a refined tool for severity and the substance craving may be subject to recall bias. CONCLUSION: 1-year AM and PP was followed by improved clinical status and QoL and reduced substance craving in a population with psychosis and SUD comorbidity. AM, compared to PP, improved craving and QoL at the 1-year follow-up.

Long-term Administration of Antipsychotic Drugs in Schizophrenia and Influence of Substance and Drug Abuse on the Disease Outcome.

BACKGROUND: Many schizophrenic patients with a long-term administration of antipsychotic drugs do not regularly adhere to the prescribed pharmacotherapy. Antipsychotic drugs constitute a palliative, but not a curative treatment, and the long-term effect of these drugs is not secure. Patients tend to consume nicotine and alcohol, as well as some patients consume drugs such as cannabis and amphetamines. OBJECTIVE: The objective of this mini-review is to examine the reasons for the high tendency of schizophrenic patients to consume alcohol, nicotine and drugs and in addition to suggest measures to reduce the abuse of substances and drugs. The effects of substances such as alcohol and nicotine and drugs such as cannabis and amphetamines on the disease outcome will be mentioned. METHOD: Previous reviews on the psychotic disorders and the pharmacological treatment were used to examine the effects of substances and drugs on schizophrenic symptoms and to investigate appropriate measures to improve medication adherence and the renouncement of consuming substances and drugs. RESULTS: A possible coherence between the function of single susceptibility genes and the alteration of neurotransmitters is mentioned. The mechanism of action of the most important secondgeneration antipsychotic drugs and their indications are described. The tendency of schizophrenic patients to consume alcohol and nicotine and in addition the effect of both substances to possibly worsen psychotic symptoms are pointed out. The effect of nicotinergic agonists to support smoking cessation is described. The different compounds of cannabis, tetrahydrocannabidiol (a psychotomimetic) and cannabidiol (exerts antipsychotic actions), are mentioned. Because a reduced adherence to the pharmacotherapy is frequently combined with the abuse of substances, additional drugs, psychoeducation and the administration of long-acting injectable antipsychotic drugs could reduce the abuse of substances and drugs; these strategies could help to maintain the antipsychotic administration. CONCLUSION: The abuse of drugs and substances might be combined with a reduced adherence to the antipsychotic pharmacotherapy. Drugs and substances might in some cases worsen the psychotic symptoms. Appropriate measures to reduce substance and drug abuse as well as to improve the adherence to the antipsychotic pharmacotherapy are cognitive behavioral therapy, psychoeducation and the administration of long-acting injectable antipsychotic drugs. Some new drugs, for example the cannabis compound cannabidiol that shows antipsychotic properties and ß-varenicline, a nicotinergic cholinergic agonist, might be administered when substance abuse (cannabis, nicotine) occurs.