Treating Schizophrenia in the Era of COVID-19 - Episode 6
Experts in the treatment of schizophrenia review the different frequencies of long-acting injectable medications and factors that affect the choice of agent.
Bryce Reynolds, MD: When you think of classes of long-acting injectables, give me your thoughts about the first vs second generation. Then we’ll talk about the frequency at which we’d give the injection.
Hannah Phillips-Hall, MSN, PMHNP-BC: I’ve been a nurse for about a decade and a prescriber for 6 years. My internal framework and what I’ve seen of the utilization of some of the first-generation agents was as a floor nurse. They were used as 1 of the last mechanisms to keep the patient from getting rehospitalized. They were reserved for patients who were there for their third or fourth time in the past 2 months. It felt like a last-ditch effort, and it was not something you felt delighted to give the patient.
I had 1 patient describe to me that the first-generation agent “took away his whimsy.” I loved the verbiage of the word whimsy, but it always felt a little punitive. This is not to say that 1 class is better than another, but this was my own personal perception due to the era in which I was a floor nurse. We did not have as many easily accessible choices of second-generation agents.
It’s been neat, especially because we know many of our patients are on oral forms of the second-generation medications, rather than first-generation oral medications. It’s an easier transition than into some other, newer long-acting injectables.
Bryce Reynolds, MD: I agree with you. I tend to always look at second-generation medications. I do have some patients on first-generation agents, but there are few. When I get a new patient who’s already on a first-generation medication, I try to switch them to a second generation. They’ve added a few different receptor bindings that may or may not—it’s all in theory, of course—have an impact on the client’s overall functioning. But my goal is to reduce the positive symptoms, the negative cognitive impacts, and new deficits that we may see.
I’m also aware that there are a lot of dosing options out there. You can give them every 2 weeks, 4 weeks, 6 weeks, 8 weeks, or 12 weeks. I think about the fact that we’re offering a medication just 4 times a year. That may be much more agreeable to the patient vs having to take a medication 365 days a year. I’ve actually had some patients who have said to me, “I won’t take a monthly injection, but I’ll take 1 that’s every 3 months.” In some cases, I might have to give them monthly for the first few doses, but they’ve agreed to do that. If I can offer somebody something, 6 or 4 times a year, they may partake of that more easily than doing it back in the days when we had to give medications every 2 weeks in some cases.
Hannah Phillips-Hall, MSN, PMHNP-BC: That’s a great point that you bring up, with posing frequency as the way to determine a treatment modality as well. That’s a great way to give the power back to the patient and allow them to choose the frequency at which they receive their medicine. It’s a great example.
Bryce Reynolds, MD: What other factors do you use, in terms of choosing a long-acting injectable?
Hannah Phillips-Hall, MSN, PMHNP-BC: Prior history of tolerability is used, because we know we always have to do that oral tolerability testing of any agents we’re going to be utilizing. I prefer some of the newer agents because, in the case that my injection nurse is out for the day, I am able to give them a bit more readily because of what they are providing for me in the box. In our little office, I don’t have any filtered needles, which I would technically utilize if I was handed a glass ampule of a Haldol decanoate. For me, it’s also the factor of convenience. What is going to be asked of me as a prescriber, as well as someone who administers these medications? I want it all in 1 package.
Bryce Reynolds, MD: I agree with you on that. I want convenience for me. Here I’m recommending an increased prescribing of long-acting injectables, but often we don’t necessarily get an increase in staff availability to give injections.
Spreading them out is the other thing I look for, as well as safety, tolerability, and contraindications. It is client choice. Their history very much comes into play. All those factors come into play, in terms of choosing a long-acting injectable.
At the same time, I want to recognize that there are some barriers in terms of long-acting injectable use in COVID-19 [coronavirus disease 2019] for staff. I’ve heard people say, “Well, I can’t send staff out into the community or have them give that.” One of the ways we’ve been able to counteract that is by saying, “Let’s talk about the safety factors. Let’s talk about PPE [personal protective equipment]. Let’s make sure the patient is not facing the staff directly.” We require our patients to wear a mask when they get an injection. That’s a protection we find to be necessary and important, not only for the patient but also for a staff member.
Hannah Phillips-Hall, MSN, PMHNP-BC: Absolutely. That would be critical to ensuring that the patients are able to continue to receive their services, as you said. That’s phenomenal to make the staff feel more comfortable in doing so.