Earlier Use of Long-Acting Injectables in Schizophrenia
OCTOBER 31, 2019
Peter L. Salgo, MD: One of the rationalizations then for the early initiation of LAIs [long-acting injectables] is you ramp up and go as opposed to waiting till the cows come home.
John M. Kane, MD: Yes. Again, if we know that half of our patients are going to have trouble taking medicine…. There was a very seminal study that was published out of a national registry database in Finland where 2500 first episode schizophrenia patients were followed. Within 60 days of discharge from the hospital, half of them were not taking their medicine.
Peter L. Salgo, MD: Half.
John M. Kane, MD: Half.
Peter L. Salgo, MD: In Finland.
John M. Kane, MD: In Finland.
Peter L. Salgo, MD: OK, where people I suspect have their databases followed and people are very adherent. America’s the “Wild West” by comparison.
John M. Kane, MD: Well, it shows that even people in Finland are not so adherent.
Peter L. Salgo, MD: Apparently not.
John M. Kane, MD: I think it’s a worldwide problem, as I said.
Peter L. Salgo, MD: It’s human.
John M. Kane, MD: It’s human nature. People don’t want to take medicine for many different reasons. If we assume that half of our patients are going to have trouble taking their medicine, then why not offer the long-acting formulation to everyone and say that, “This is the way we treat your illness.” I think the problem is that many clinicians will wait until 2 years, 3 years, 4 years down the road after someone’s had multiple hospitalizations, and then they say, “Oh, gee, why don’t we try a long-acting formulation?”
Peter L. Salgo, MD: Let’s turn this upside down. It isn’t the patient who’s the problem.
John M. Kane, MD: Right.
Peter L. Salgo, MD: It’s the physician and the assumptions inherent in most physicians that they’re doing it right, their patients are better, and their patients are adherent—all of which we know is not entirely true, no?
John M. Kane, MD: I think so. I’m sure there are some patients out there who are very adherent, but it’s hard to identify them. I think if the long-acting formulations had more adverse effects or there was some reason not to use them, I could understand that. But there really is no evidence that they have more adverse effects. In fact, I believe that you can use a lower dose often with a long-acting formulation because you know exactly how much medicine the patient is getting.
Peter L. Salgo, MD: Got it.
John M. Kane, MD: Sometimes that will result in fewer adverse effects.
Peter L. Salgo, MD: There are no missed doses, so you don’t have to give enough to counter the odd day when they’re not taking it.
John M. Kane, MD: That’s right. You also don’t have a patient who decides, “OK, I’m going to skip my medicine over the weekend, and then I’m going to double the dose on Monday,” and then they come in with an adverse effect that you’re like, “Hey, what’s going on here?”
Peter L. Salgo, MD: Is there a way, short of these long awaited and often outdated guidelines, to encourage the clinicians to initiate injectables and long-acting injectables earlier?
John M. Kane, MD: Well, I think something we’re very interested in is how do you incentivize people to do this?
Peter L. Salgo, MD: Is that a verb?
John M. Kane, MD: I think this applies across all of medicine, right? How do we get those new findings implemented into clinical practice more quickly? Some of it is training, and some of it may be also access and payers. The payers could be doing more to provide incentives. Because 1 of the arguments that we hear from clinicians is that, “Well, it’s a hassle to do this. I have to find someone to give the injection. In some cases, it has to be refrigerated.”
Peter L. Salgo, MD: But so what?
John M. Kane, MD: Exactly.
Peter L. Salgo, MD: We do this for lots of diseases.
John M. Kane, MD: That’s right. So I think the hassle factor is not a good excuse.
Peter L. Salgo, MD: No.
John M. Kane, MD: But if it does take more time, maybe there needs to be some additional reimbursement for them.
Peter L. Salgo, MD: What about an institutional protocol? Does your institution have one that encourages LAIs?
John M. Kane, MD: We encourage it. We don’t have a protocol per se that says you must do this, but we definitely encourage it, and we have lots of in-service training about the use of long-acting injectables. We have a special clinic that provides injections where we have nurses available to give injections to the patient, so it makes it very convenient, very easy.
Peter L. Salgo, MD: We’ve discussed the way you approach a patient who may or may not be needle shy, for lack of a better phrase, to accept this therapy.
Transcript edited for clarity.