Journal LogoColleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Pharmacological treatment is central to effective management of schizophrenia. Prescribing clinicians have an increasing array of options from which to choose, and haldol decanoate oral overlap antipsychotic polypharmacy is common in routine clinical practice. Practice guidelines recommend long-acting injectable LAI formulations, typically viewed anavar tablet monotherapeutic alternatives, for patients with established nonadherence.
Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Pharmacological treatment is central to effective management of schizophrenia. Prescribing clinicians have an increasing array of options from which to choose, and oral antipsychotic polypharmacy is common in routine clinical practice.
Practice guidelines recommend long-acting injectable LAI formulations, typically viewed as monotherapeutic alternatives, for patients with established nonadherence.
Yet there are limited data on the prevalence and nature of concurrent oral antipsychotic prescriptions in patients receiving LAIs. Our observational, claims-based study examined the frequency and duration of concurrent oral prescriptions in Medicaid patients receiving LAI therapy.
Specifically, we examined patients with a recent history of nonadherence and hospitalization for schizophrenia and included both first-generation antipsychotic depot medications fluphenazine decanoate, haloperidol decanoate and more recently available second-generation injectables LAI risperidone, paliperidone palmitate.
Of all patients initiated on LAIs, Patients receiving concurrent prescriptions were frequently prescribed an oral formulation of their LAI agent, but many first-generation LAI users received a concurrent second-generation oral medication. The lowest rate of concurrent prescribing Our findings highlight the need to further examine such prescribing patterns, to probe the reasons for them, and to clarify the optimal roles of different antipsychotic treatments in clinical practice.
Supplemental digital content is available for this article. The work cannot be changed in any way or used commercially. Antipsychotic medication use is a central treatment strategy for the management of schizophrenia , a chronic, disabling psychiatric disorder that incurs substantial human and monetary costs.
Many of these SGAs are now available in long-acting injectable LAI formulations, providing an increasing array of treatment options for prescribers and patients. It is well established that prescribing patterns in routine medical practice do not always correspond to clinical practice guidelines or precisely duplicate the medication protocols examined in controlled trials of antipsychotic medications. Yet there is some evidence that concurrent use of oral and LAI antipsychotic medication does occur, potentially representing another form of polypharmacy.
No differences in frequency of concurrent prescribing were observed by type of antipsychotic medication , although patients were more likely to receive a corresponding oral formulation of the LAI they were prescribed as opposed to a different medication ie, there was a high level of concordance between specific oral and LAI medications when concurrent prescribing occurred.
These studies provided valuable insights, but their generalizability is restricted by the limited data on concurrent oral antipsychotic use with SGA LAI medications and by their patient populations eg, uninsured patients treated at a single center. Given that almost one third of schizophrenia patients in the United States qualify for the low-income Medicaid program, 11 it is important to examine concurrent oral antipsychotic prescriptions in patients receiving LAIs who are covered by Medicaid.
This brief report provides new retrospective claims-based data on concurrent oral antipsychotic prescriptions with the routine use of LAI antipsychotics and builds on the existing literature in several key ways.
First, we examined a multistate sample of Medicaid patients using LAIs after discharge from a hospitalization for schizophrenia.
Third, we examined the percentage of patients with concurrent oral antipsychotic prescriptions and the total days of concurrent availability, both overall and by type of agent. Finally, because practice guidelines highlight the use of LAIs in patients with a history of nonadherence, we selected patients with documented nonadherence in the 6 months before their index hospitalization.
The database brings together administrative information from multiple state Medicaid programs and includes demographic and clinical information, inpatient and outpatient utilization data, and outpatient prescription data for Medicaid enrollees. All personally identifiable patient, provider, and facility data were replaced with fully de-identified markers before delivery for research use. No data were collected from human subjects.
Thus, institutional review board approval was not required. The primary inclusion criteria captured non-dual eligible Medicaid adults 18 years or older who 1 were discharged to the community after at least 1 hospitalization with a primary diagnosis of schizophrenia International Classification of Diseases, Ninth Revision, Clinical Modification code The proportion of days covered is a standard measure of adherence calculated from prescription claims by dividing the number of days that the patient has a days' supply of the medication available by the number of days in the time interval of interest.
The primary outcome measures were 1 the prevalence of concurrent oral antipsychotic prescriptions in the sample of LAI initiators, calculated based on the percentage of patients who had any oral antipsychotic medication available while on the LAI agent in the 6 months post-hospital discharge; 2 the number of days of oral and LAI medication overlap, for those patients with any overlap; and 3 the proportion of LAI-covered days where oral antipsychotic medication was also available, for those patients with any overlap.
Descriptive statistics were generated to characterize the sample as a whole and by subgroup ie, patients with and without concurrent oral antipsychotic use. For those patients with any overlapping LAI and oral antipsychotic availability, the mean number of days of overlap and the mean proportion of LAI-covered days with available oral antipsychotic medication were measured.
Overlap was measured for any oral antipsychotic medication as well as individual oral agents, among concurrent users of those agents. No hypotheses were specified a priori and thus the analyses were purely descriptive in nature. A total of patients met the study selection criteria. Fifty-five percent of the sample was African American, The most common diagnosed comorbid mental health condition was substance abuse Sixty-nine percent of patients had an index hospitalization stay of greater than 7 days.
Slightly less than half The most frequently initiated LAI in our sample was haloperidol decanoate About a quarter No eligible patients were initiated on olanzapine pamoate.
Patients were covered on the initiated LAI therapy for an average of Patients receiving haloperidol decanoate had the lowest mean number of days on treatment Mean days on treatment for those initiated on fluphenazine decanoate Descriptive statistics comparing patients with and without concurrent oral antipsychotic prescriptions revealed no significant differences in regard to age, race, Medicaid plan type, cardiometabolic or mental health comorbidities, length of index hospitalization stay, or the mean treatment duration on the initiated LAI see online Supplementary Table A, Supplemental Digital Content 1, http: However, patients with concurrent oral antipsychotic prescriptions were more likely to have a history of oral olanzapine and quetiapine use, as well as a history of other mental health medication use, in the 6 months before the index hospitalization.
By individual LAI medication, concurrent oral antipsychotic prescription rates were When examining which oral antipsychotic medications were most frequently prescribed in conjunction with each individual LAI, it was evident that most patients were receiving an oral formulation of their LAI medication Table 1.
This same-drug overlap was highest for LAI risperidone Table 2 displays the mean number of days with overlap in availability of oral and LAI antipsychotics for the patients who had any such concurrent prescriptions, as well as the mean percentage of LAI-covered days where such overlap occurred. Oral agents overlapped with LAIs for an average of Paliperidone palmitate users with concurrent prescriptions of any oral antipsychotics had the lowest Further examination of the extent of concurrent use of individual oral antipsychotic agents across each group of LAI users revealed that in most of the cases, the mean number of days of overlap exceeded 30 days range, For patients with overlapping prescriptions of the same oral formulation as their LAI medication, the extent of overlap was also substantial.
Fluphenazine decanoate users also receiving oral fluphenazine prescriptions had overlapping coverage for an average of Both haloperidol decanoate and LAI risperidone users with same-drug overlap had such overlap for almost two thirds of their LAI-covered days.
Haloperidol decanoate users also receiving oral haloperidol prescriptions had overlapping coverage for a mean of LAI risperidone users also receiving oral risperidone had a mean of Although the proportion of paliperidone palmitate users with the same-drug overlap was lower than other LAI users, when overlap with oral paliperidone prescriptions did occur, it was for a mean of Extent of overlapping use of other SGA oral antipsychotic medications was also substantial among users of fluphenazine decanoate and haloperidol decanoate.
In keeping with prior research in other study populations, these analyses revealed a high proportion of LAI users with concurrent oral antipsychotic prescriptions. Moreover, overlap in oral and LAI prescriptions often occurred for a substantial period of time and for a notable percentage of the days covered by LAIs. There was substantial variability in the rate of concurrent oral prescriptions across individual LAI medications.
The lowest rate was found with paliperidone palmitate For example, more patients receiving fluphenazine decanoate had concurrent coverage with an SGA oral medication than with oral fluphenazine. These medication combinations merit additional investigation. Given the frequency, amount, and type of concurrent oral and LAI antipsychotic prescriptions observed in our analyses, it does not seem that such prescribing is being done on a transitional basis.
Although the prescription claims used in this study do not permit assessment of the reasons for such high levels of concurrent prescriptions, several explanations are possible. Concurrent oral medication may also allow for more flexible dose increases that can be discontinued and reversed more quickly should adverse effects or adverse reactions occur. Certain antipsychotics may also be used off-label for other symptoms, such as sleep difficulties.
Finally, some of the theoretical rationales put forth for combining different oral antipsychotic agents 4 may apply to concurrent prescribing with LAIs, although a comprehensive review found no support for the use of antipsychotic polypharmacy in patients without a history of treatment resistance to multiple trials of monotherapy and only limited evidence for use in treatment-resistant patients.
This study has several limitations. The information available in prescription claims data allows for identification of the presence and duration of overlap between LAI and oral antipsychotic medications but, as noted earlier, administrative claims do not provide details on why additional antipsychotics were prescribed or documentation of whether or how the concurrent oral antipsychotic medication was taken.
In keeping with other studies, 9 analyses included all concurrent prescriptions rather than setting a threshold for overlap eg, a minimum of 10 days , so this may overestimate actual concurrent use.
However, the findings on number of days of overlap suggested that in most cases the overlap was substantial. Finally, because this study focused on the Medicaid population, these results may not generalize to individuals with other types of insurance coverage.
Despite these limitations, these data highlight the need for stronger connections between controlled research trials and day-to-day clinical care, given that there is insufficient formal evidence to support the pharmacological strategies observed in this study. The cost-effectiveness of such practice is also unknown. Numerous studies, including both physician surveys and claims-based studies, have documented antipsychotic polypharmacy prescribing practices in routine care that conflict with both practice guidelines and expert recommendations.
Separate multiple e-mails with a ;. Thought you might appreciate this item s I saw at Journal of Clinical Psychopharmacology. Send a copy to your email. Some error has occurred while processing your request. Please try after some time.
August - Volume 35 - Issue 4 - p — Supplemental digital content is available in the text. Received December 31, ; accepted after revision April 1, This study was funded by Alkermes, Inc. Back to Top Article Outline. Atypical antipsychotics and the burden of disease. Am J Manag Care.