By Gina Shaw
Side effects and tolerability ranked as the most important clinical concerns for psychiatric clinicians selecting a long-acting injectable antipsychotic (LAI) to prescribe for their patients with schizophrenia, and the dosing frequency preferred was once per month or less often, according to results from the Determining Clinician factors for Implementing LAIs and Defeating Barriers (DECIDE) survey, presented at Psych Congress, in Nashville, Tenn.


Although LAIs improve adherence and reduce schizophrenia relapse rates compared with oral antipsychotics, they remain underused in clinical practice, with some data suggesting prescribing rates can be as low as 10% in the United States (Ther Adv Psychopharmacol 2014;4[5]:198–219).

In DECIDE, psychiatric clinicians were surveyed regarding their preferences when selecting and initiating LAIs for schizophrenia. DECIDE surveyed 380 practitioners across the United States, including 295 physicians and 85 nurse practitioners/physician assistants. Clinicians were analyzed by LAI use (high [≥31% of their patients using LAIs] versus low [≤14% using LAIs]) and attitude toward LAI archetypes (early LAI use, severity reserved, adherence reserved, LAI-hesitant).

Across these groups, options for multiple injection sites, smaller needles and price made at least two-thirds of clinicians somewhat or much more likely to use a particular LAI. In addition, 63% to 82% of clinicians, regardless of subgroup, reported being somewhat/much more likely to select an LAI dosed once monthly or less often, compared with 8% for an LAI dosed once every two weeks.

“Despite recent evidence, expert opinion and increasingly ‘LAI-friendly’ guidelines advocating for broadening LAI use, a large percentage of clinicians still feel LAIs are only reserved for adherence issues and more severe patients,” said study lead author Dawn Velligan, PhD, the Henry B. Dielmann Chair of the Department of Psychiatry and the director of the Division of Community Recovery, Research and Training at the University of Texas Health Science Center, in San Antonio. Among DECIDE survey respondents, 68% agreed that LAIs are reserved for patients with adherence issues, and 37% agreed that they were reserved for patients with more severe symptoms.

The survey also found that clinicians tend to underestimate patient nonadherence to oral antipsychotics (OAs) in their own practices. Overall, most survey respondents agreed that nonadherence to OAs is a problem nationwide, but although most estimated that 53% of patients nationwide are nonadherent, they considered only 26% of their patients taking OAs to be nonadherent.

“When we broke the survey respondents down into subgroups, we also found that people who prescribe fewer LAIs underestimate nonadherence in their practices even more,” Dr. Velligan noted. Clinicians who were high LAI users estimated that 32% of their patients were nonadherent to OAs, whereas low LAI users thought that just 21% of their patients were nonadherent.

Clinicians with low LAI use were also more stressed or burned out with managing schizophrenia in their practices, the survey found. While 42% of low LAI users said managing patients with schizophrenia increases their levels of stress, only 13% of high LAI users said the same. Of low LAI users, 17% said they felt burnt out, compared with 11% of high LAI users.

“The survey also found that LAI-hesitant clinicians were motivated to increase their LAI-to-OA use ratio—46% were dissatisfied with their LAI-to-OA use ratio and thought their OA use was too high,” Dr. Velligan said. “But they lacked the confidence” to increase LAI use.

Dr. Velligan reported consulting positions and/or advisory board relationships with Alkermes, Boehringer Ingleheim, Indivior, Janssen, Otsuka and Teva Pharmaceuticals.

 

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