Long-acting injectable antipsychotics and the management of nonadherence

LAIs are underused in the US. Part of the reluctance to their routine use in place of oral therapy is uncertainty about the potential benefits to patient care and ultimate outcome. A starting point in this discussion is to review the potential patient populations where LAIs might be used and compare it with when they are actually used. This shows that only a narrow segment of he schizophrenia patient population- the revolving door patient - is considered a possible LAI candidate. The narrow use of LAIs for only this segment of patients shows a serious misapplication of adherence theory in pharmacologic practice. Initiating LAIs does not immediately change attitudes toward medication adherence, and LAIs are not usually accepted by patients who overtly refuse their current oral therapy. Rather, the advantage of LAIs is their superiority over oral therapy as an adherence tracking method. Failure to recognize nonadherence in day-to-day practice is very common and leads to significant complications in optimizing drug therapy. Furthermore, nonadherence to oral antipsychotics is often unintentional and related to difficulties with handling the daily complexities of an oral medication regimen. In this context, changing to LAI therapy has potential adherence benefits for this type of patient. Perhaps the reluctance of many clinicians can be traced to misunderstanding the potential role of a LAI in overall pharmacologic management. If the expectation is that LAIs will solve the adherence problem, clinicians will be disappointed. However, the benefits of LAIs may not be readily apparent until enough time passes to actually know the true adherence status of a patient. LAI therapy compels patients and cliniciansto enter honest discussions about medication adherence, which in the long run is healthier than the covert nonadherence often associated with oral therapy. Finally, the potential benefits of LAIs for relapse prevention do not happen overnight. Rather, these benefits may take a year or more to appear.