Optimizing Management of Schizophrenia with LAIs - Episode 17
John M. Kane, MD: Henry, what patient factors do you consider when choosing an LAI [long-acting injectable]?
Henry A. Nasrallah, MD: There are many factors. I regard every patient with acute psychosis as a candidate for long-acting injectable [therapy] for at least a year. I never tell my patient, “You are going to take it for life.” I say, “Let's try for a year and stabilize you, and I’ll see you frequently. Then we make a decision at the end of the year.” During that year I do education, therapeutic alliance, and the patient develops trust with me and they recognize they're doing much better.
If you have a patient who commits a crime, or has violent behavior at the first episode, that patient is going to become violent every time they relapse. You recapitulate the same symptoms with relapse from the first episode. I immediately protect them from harming others and getting into trouble with the law. I give it to patients with substance abuse, in the first episode. Most patients are young, aged 18 to 25, and oftentimes into marijuana and other drugs. Prescribing them the long-acting injectable is vital because they are exacerbating their psychosis with many of the drugs they take.
There is research showing that injectable antipsychotic blunts dopamine continuously, not off and on with oral nonadherence. There is a continuous blunting of dopamine, which will reduce the pleasure, because dopamine is the reinforcement, reward, and neurotransmitter. They tend to stop abusing the drugs. I’ve seen it in my own patients. It’s not an approved indication by any means. But it is a side benefit of the injectable. I give it to patients because substance use with oral medication is a terrible combination. I use it for patients with no insight; 90% of patients with a first episode deny they are sick and don’t think they need medication…. Those patients, they're going to stop their medication within a few days of leaving the hospital, and they're going to relapse. I do my best to convince them to take the injectable.
Patients with severe cognitive deficits are candidates for injectables. This includes at least 90% of patients. Many of you have done research in this area. I try to spare them the forgetfulness. Patients with severe negative symptoms, which is about 50%, are likely not to adhere. Those are candidates. There is a cluster of patients who definitely deserve, and need long-acting [medication]. My bias is that I give it to everybody for the sake of relapse prevention in general, not just because they are vulnerable.
Erin C. Crown, PA-C: Considerations should include what does their physical health look like? What is their metabolic picture? I take into consideration their age and their level of sexual activity. Some of these medications are more likely to be friendly in that area than others. If you give a young person something that is going to completely destroy their libido or cause them to be unable to achieve an erection or an erection suitable for penetration, or if they can't ejaculate, they're not going to want to continue the medication. Considering those factors, practical life matters, are important.
Henry A. Nasrallah, MD: Hyperprolactinemia can occur with every antipsychotic because of prolactin. It is a class warning, but especially with paliperidone and risperidone. However, some people focus on it as a sexual [adverse] effect, and some patients get galactorrhea and gynecomastia. I've seen it in some patients, not everybody, and that is considered a negative. We can address that very easily by giving the patient 1 dose, 5 mg a day of aripiprazole, which has a partial agonist and can reduce the prolactin.
I remind my patients that there are many data showing that prolactin is extremely good for the brain. It actually regenerates the brain, rebuilds the white matter extensively and it's good for your brain. It's not just the sexual [adverse] effects. Unfortunately, some patients have that. But it has 12 neuroprotective benefits that I put on a slide to teach my residents. The most important one is oligodendrocytes, which make myelin every day, with prolactin they multiply; they are very low in schizophrenia. They make more myelin. Without myelin, the brain doesn't work.
I remind patients that MS [multiple sclerosis] is a white matter disease. If a woman who has severe pain and weakness with MS, gets pregnant, she goes into full remission, no pain, no weakness, she gets her life back because her prolactin goes sky high. If she breastfeeds, she continues to be in remission. Once she stops breastfeeding, relapse occurs when the prolactin goes away. So there are definite lines of evidence that prolactin is good for the brain of the patient and it's not just an [adverse] effect. But I completely agree with you that we should address the sexual [adverse] effects.
Erin C. Crown, PA-C: It may alter the complexity of our treatment choice. I'm not suggesting that I wouldn't give a young male or a female who's sexually active something that might elevate their prolactin levels. I do it every day. But it’s something I need to educate them on, give them the open door to come to me if they are experiencing an [adverse] effect, so we can talk about it. I then share with them what options we have to address the problem and keep them stable.
Transcript Edited for Clarity