Optimizing Management of Schizophrenia with Long-acting Injectables - Episode 7

Advantages of Treating Schizophrenia with Long Acting Injectables

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Experts discuss the advantages of using the longest-acting injection formulation to treat schizophrenia, and whether there’s a need to discuss LAIs with patients from onset of illness.

Sanjai Rao, MD, DFAPA: You made many key observations. One of the biggest was just because you’re injecting them every 3 months doesn’t mean you have to see them only every 3 months.

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: In fact, you guys turned it into an opportunity to look at it in a different light. Because we don’t have to spend 5 or 10 minutes working out the mechanics of giving you an injection on these intervening visits, we can use that time to talk about other things.

Kimberly Garcia, DNP, CRNP: Talk about other things, exactly. Find out what’s important to them.

Sanjai Rao, MD, DFAPA: It’s time regained.

Kimberly Garcia, DNP, CRNP: Yes. It’s amazing how many of my patients who are on injectables. They’re able to get Social Security benefits, but they’re able to work part time too. It’s beautiful to experience that with them. They realize that it’s going to be very stressful, and for some of them it’s too stressful; they’re not able to do it. But it’s just nice to see our patients in a good spot. We’re able to think about more things than, “Did you take your medicine?”

Sanjai Rao, MD, DFAPA: I imagine, even just from the perspective of the clinic and your staff, that this is much less burdensome. Having to inject somebody one-third as many times as you were before.

Kimberly Garcia, DNP, CRNP: Absolutely, yes.

Sanjai Rao, MD, DFAPA: Circling back to your idea of letting us take care of it for you, when we can do this every 6 months then that’s the ultimate let us take care of this for you, right?

Kimberly Garcia, DNP, CRNP: Absolutely, yes. Recently I had a patient come in with her mom, and the patient is in her mid-20s. The mother said she has never been well since she had her first psychotic episode. The mother said, “I’m at wit’s end with her. She’s become very paranoid at home. She’s done damage to the property.” The mom and the patient are arguing. We talked about some options, and the mom said, “You know what, we need that 6-month injection.” I’m like, “We’re going to need to take a couple of steps to be able to get there, but let’s have that goal and start working on that now.” So day 1 we’re starting to think about what that’s going to look like and when that can happen. And the patient was invested: “Every 6 months?” It made a big difference.

Sanjai Rao, MD, DFAPA: It’s a great starting point, right?

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: When I’m talking to people about the monthly, I’ll often say, “Look, if you’re doing well on this, we can extend this to every 3 months.”

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: It’s a good thing for them to think that this will lead to something better.

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: I’m glad you mentioned that transition though because it’s important to talk about how you get these things started and the idea that for any of these injections, there’s typically some initiation regimen. For the older ones, it meant you had to oral overlap for a few weeks. For the newer ones, it means you have to give them 2 injections, either in rapid succession or over a few days. But there are a couple—specifically I’m thinking of the monthly subcutaneous risperidone—that don’t require that overlap but also are limited to a max dose of the equivalent of 4 mg. With every agent there’s going to be a little trade-off, but you do have to have this initiation regimen. For the longer-acting formulations, specifically 3 and 6 months, you can’t start with those. You have to start with the monthly and build up a steady state over at least 4 months. Then you have the option to convert them to 3 or 6 months when we have that available.

Kimberly Garcia, DNP, CRNP: Yes.

Sanjai Rao, MD, DFAPA: That’s an important thing to keep in mind. With the long formulations, there’s a process to get there, but it’s a very reasonable process. And getting there involves just being on the monthly for a while.

Kimberly Garcia, DNP, CRNP: Yes, and having those goals. I found that the majority of my patients are willing to put in the time and energy to get to that point. When we empower them to become active participants in their care, it’s a game changer because it’s no longer a punishment where the mom is like, “Take your medication.” It doesn’t seem as if it becomes as much of an issue. Patients are willing to come in to get their injections. Sometimes they even look forward to it. We’ll try to incentivize it whenever we can—we’d do a raffle or something for patients who would come in for their appointments, but we haven’t needed to do that. The patients have been internally motivated to comply with the routine and the regimen.

Transcript edited for clarity.