Expert Perspectives on the Clinical Management of Bipolar 1 Disorder - Episode 8

Long-Acting Injectables (LAIs) in Bipolar 1 Disorder

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Vladimir Maletic, MD, MS, and Andrew Cutler, MD, highlight the use of long-acting injectables (LAIs) as a treatment option for bipolar 1 disorder.

Vladimir Maletic, MD, MS: For maintenance purposes, we have different kinds of antipsychotic medications available to us, long-acting injectables.

Andrew Cutler, MD: Good point.

Vladimir Maletic, MD, MS: Can you tell us more about where you see the role of these agents? What are the advantages and disadvantages? When would you consider using them over oral options?

Andrew Cutler, MD: Let me start with an anecdote. I’ll never forget when I was first contacted to be an investigator on a study of long-acting risperidone, the microspheres preparation with every 2-week injection, for bipolar disorder, for maintenance. I thought that was kind of out there; I found that to be strange because I’d always associated the LAIs with schizophrenia and psychotic disorders. I thought I was going to have trouble recruiting for this study, frankly. I thought patients with bipolar disorder tend to be higher functioning. Are they going to want to have a shot? But I was surprised how many people with bipolar disorder, when given this option, accepted it. Those studies led to the FDA approval of risperidone long-acting microspheres preparation. We also now have an aripiprazole long-acting injectable, aripiprazole monohydrate. There are 2 long-acting injectable aripiprazoles, and one of them has been studied and is FDA approved for bipolar maintenance. The other one simply hasn’t been studied. That really changed my thinking. Sometimes I love when I’m proven wrong, when I’m flatfooted like that and don’t consider the options. It’s a failure of imagination on my part.

As I think about this, if we ask our audience, what is one of the biggest challenges you face in treating patients with bipolar disorder, near the top is going to be adherence. The fact is nobody wants to take medicine in general, and adherence is poor in all fields of medicine, diabetes medicine, hypertension medicine, and so on. But it’s especially bad in our field. I think some of it is that people don’t want to take medicine. Nobody wakes up in the morning and says, “Oh, I want to take an antipsychotic today.” But if you consider how this illness works, it is working on parts of the brain that have to do with insight and judgment. People with bipolar disorder are not often self-aware, they’re not good self-observers. They don’t always have the best insight and judgment, so they may think, “Well, it’s not that bad, I don’t need to take medication.”

So an option like this where you are guaranteed that they’re getting the medication, and you can tell right away if they don’t show up for their injection appointment that they’re becoming nonadherent, this can be an attractive option for some patients. Just like the APA [American Psychiatric Association] treatment guidelines for schizophrenia, they say a patient with schizophrenia should be managed with an LAI if they prefer such treatment. What that insinuates is that we offer it to them because how could we know if you prefer something if you don’t know about it? I think we should be offering them as a potential option because sometimes people don’t want to deal with the daily hassle of taking a medicine. Sometimes it’s more convenient to come in periodically and get an injection, and to not have to think about it, or not be in a situation where somebody can see you using a pill bottle and be stigmatized that you’re taking a medicine. These are some of the thoughts that go on in my mind now as opposed to before.

Transcript edited for clarity