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Long acting anti-psychotic injections (For Schizophrenia)

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

I previously discussed long-acting antipsychotic injections Westmeath Examiner due to a query from a person who is prescribed them for schizophrenia. First-generation antipsychotic (FGA) long-acting injections were introduced in the 1960s. The first of the second-generation antipsychotic long acting injections (LAI) (risperidone LAI) became available in 2002 and since then Xeplion^® (paliperidone) injection has come on the market. For the purpose of this article I refer to long-acting injection versions of antipsychotics as LAIs. This article discusses second-generation antipsychotic LAIs in a little more detail than I did in my previous Examiner article on LAIs.

Why used?

According to studies, approximately 40–60% of patients with schizophrenia do not take their medication regularly and in many cases refuse to take it at all. Long-acting injections are often prescribed when a patient is not taking their oral medication as prescribed. Many decide to use them as they offer the convenience of not taking a tablet every day and in some cases where a tablet did not work. LAIs require the attendance to a clinic for regular injection every 1–6 weeks.  This ensures the medication is given regularly and allows regular review of treatment. LAIs do not guarantee the patient will not relapse but they greatly reduce the risk.

Comparing Long-acting injectable antipsychotics (LAIs) to oral antipsychotics

A 2011 study published in the New England Journal of Medicines found that, in high-risk patients with schizophrenia and schizoaffective disorder, long-acting injectable risperidone did not provide great improvements to key outcomes such as psychiatric symptoms, quality of life or functioning when compared with oral antipsychotics (tablet versions). However, other studies have shown that LAIs give very favourable results when compared to oral antipsychotics and that they reduce hospitalisations by up to 34% when compared to oral antipsychotics and reduce relapses by between 10 and 30% when compared to oral antipsychotics.

Second-generation long-acting antipsychotic injections

Risperidone was the first of the second generation LAIs to be licensed in the UK and Ireland. The drug will not reach a therapeutic level for a few weeks after injection; therefore it is essential that the patient receive supplementary antipsychotic medication (tablet form) during the initial period of treatment following the first injection. It is administered into the gluteus (buttocks) or deltoid (upper arm) muscle every two weeks.

Xeplion^® (paliperidone) injection is the newest LAI; it only needs to be administered once monthly. Paliperidone is effective in relieving both positive symptoms (hallucinations, disturbances of thought, hostility) and negative symptoms (lack of emotion and social withdrawal) of schizophrenia, whereas older antipsychotics are usually less effective against the negative symptoms Paliperidone also relieves 'affective symptoms' that are associated with schizophrenia, such as depression, guilt feelings or anxiety.

For more information, call into Whelehans for a free copy of Eamonn’s comprehensive article on injections used for schizophrenia; he also discusses the older first-generation antipsychotic LAIs (commonly called ‘depot’ injections) such as Zuclopenthixol (Clopixol^®) such as Flupenthixol (Depixol^®). The information is also available at www.whelehans.ie. We also have a comprehensive article on schizophrenia.

This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans

Medication used to treat

This is a continuation of last week’s article in which I discussed causes and symptoms of schizophrenia. Last week I described how antipsychotic drugs are the main class of medication used to treat schizophrenia and are broadly divided into two categories; older typical or newer atypical antipsychotics.

Choice of Drug

No one drug can be considered significantly better than the others, however one may be better for one individual than another. For example, some are more sedating than others so may be suitable for patients who are agitated or cannot sleep. If one does not work so well, a different one is tried until a good response occurs. A good response to antipsychotic medication occurs in about 70% of cases. For patients with only one episode of schizophrenia and remain symptom free for two years with treatment, the medication may then be discontinued slowly; closely monitored for relapse when medication is being discontinued.

Side effects of medication

Side effects of older schizophrenia drugs

Anticholinergic side effects are more common with the older typical anti-psychotics and include dry mouth, blurred vision, flushing and constipation. These tend to be worse at the start of treatment and often ease off. Drowsiness is also common but may be reduced by reducing the dose. Extrapyramidal side effects (movement disorders) can occur with typical antipsychotics. Chlorpromazine has a tendency to cause skin photosensitivity when exposed to sunlight. Sunscreen must be used if going out in strong sun while taking chlorpromazine.

Side effects of newer schizophrenia drugs

Reduced risk of movement disorders is the main reason atypical antipsychotic drugs frequently are first choice for treatment. Atypical antipsychotics have their own risks; particularly the risk of weight gain and this increases risk of developing diabetes and heart problems (due to raised cholesterol). Longer term blood sugars and cholesterol levels should be monitored regularly. Weight gain appears to be a particular problem with clozapine and olanzapine. Other medication sometimes used to treat schizophrenia include the likes of antidepressants and mood stabilisers (ask in store for longer version of this article which has more detail on these)

What is the outlook (prognosis)?

In most cases there are recurring episodes of symptoms (relapses). Most people live relatively independently with varying amounts of support. Frequency and duration of each relapse can vary. Some people recover completely between relapses. Some people improve between relapses but never quite fully recover. Treatment often prevents relapses, or limits their number and severity.

Outlook is thought to be better if:

• Treatment is started soon after symptoms begin.
• Symptoms develop quickly over several weeks rather than slowly over several months
• The main symptoms are positive symptoms rather than negative symptoms.
• The condition develops in a relatively older person (aged over 25).
• Medication is taken as advised.
• There is good family and social support which reduces anxiety and stress.
• Abuse of illegal drugs or alcohol does not occur.

Newer drugs and better psychological treatments (discussed in more detail in my longer article) mean that prognosis is now better than it was in the past.

Whelehans Pharmacy, 38 Pearse Street, Mullingar. Tel 04493 34591. Eamonn’s full comprehensive article is available in Whelehans on request. Ask staff for a free copy.

Overview

For my detailed article on schizophrenia ask Whelehans staff for a free copy or log on to www.whelehans.ie.

Symptoms

Symptoms include hallucinations (seeing and hearing things), delusions (false ideas), disordered thoughts, and problems with mood, behaviour and motivation. It can cause a loss of touch with reality thus becoming unable to tell what is real and what is not. The cause is not clear. Symptoms can recur or persist long-term, but some people have just one episode of symptoms lasting a few weeks.

Positive and negative symptoms

The symptoms are classed as either positive or negative. Positive symptoms are abnormal mental functions while negative symptoms are a loss of normal mental functions.

Negative symptoms include loss of motivation (loss of interest in social activities and mixing with people, loss of concentration and inability to complete activities you previously had no problem completing), loss of a sense of pleasure, slow movements, lack of facial expression and low or flat mood. The person may neglect appearance and look unkempt. Negative symptoms of schizophrenia are similar to depression symptoms and can be misdiagnosed as depression

Positive symptoms are psychotic behaviours not seen in healthy people; they cause loss of touch with reality and include delusion, hallucinations, disordered thoughts and movement disorders

Incidence and prevalence

Schizophrenia occurs in about 1 in 100 people; this rate is the same for all ethnic groups. It occurs equally in men and women. It most often first develops between the ages of 15 to 25 in men and 25 to 35 in women. First diagnosis of schizophrenia is rare after the age of 45. The cause is not clear. It tends to run in families; 70% of the risk of schizophrenia is thought to be hereditary.

Treatment

People living schizophrenia often do not realise they have a mental illness and may not think they need help because they believe their delusions or hallucinations are real. Antipsychotic drugs are broadly divided into two categories; older typical or newer atypical antipsychotics.

Older typical antipsychotics

Sometimes called first generation antipsychotics; first appeared in the 1950’s. Examples include chlorpromazine (Largactil^®), trifluoperazine (Stelazine^®), haloperidol (Serenace^®), flupentixol (Depixol^® Injection, Fluanxol^® tablets), zuclopenthixol (Clopixol^® Injection), and sulpiride (Dolmatil^®). 30% of patients have a relapse during treatment with first-generation antipsychotic drugs compared with 80% without treatment.

Newer or atypical antipsychotics

Also known as second generation antipsychotics; first prescribed in the 1990’s. Examples are amisulpride (Solian^®), aripiprazole (Abilify^®), clozapine (Clozaril^®), olanzapine (Zyprexa^®), quetiapine (Seroquel^®) and risperidone (Risperdal^®). Atypical antipsychotics are often used first-line for newly diagnosed schizophrenia. This is because they demonstrate good balance between chance of success and the risk of side-effects.

Depot injections of an antipsychotic drug

Non-compliance can be a problem with schizophrenia. An American study showed that 74% of patients with schizophrenia discontinued medication within 18 months without consulting with their doctor leading to relapses. Non-compliance is similar for atypical and typical antipsychotics; therefore depot injections can be a solution where compliance is a problem. A depot injection is a long acting injection which is administered by a doctor or nurse and only needs to be administered typically every few weeks.

To be continued….next week I discuss treatment in more detail

Whelehans Pharmacy, 38 Pearse Street, Mullingar. Tel 04493 34591. Eamonn’s full comprehensive article is available in Whelehans on request. Ask staff for a free copy.