Clinical Research & Resource Centre, Mental Health and Addictions, Waitemata District Health Board, Auckland, New Zealand.
J Clin Pharm Ther. 2011 Dec;36(6):651-63. doi: 10.1111/j.1365-2710.2010.01219.x. Epub 2010 Nov 5.
Long-acting injectable (LAI) antipsychotics are recommended for those people with a preference for this form of treatment and those who experience negative outcomes due to non-adherence with oral medication. LAI antipsychotics have been associated with improved outcomes and lower treatment discontinuation rates when compared with oral formulations. Risperidone long-acting injection (RLAI) treatment is effective and well-tolerated in clinical trials. The aim of this study was to review RLAI prescribing practice and compare prescribing to best practice recommendations (including indication, initiation, dose and co-prescribing) for adults receiving care from five clinical practice settings of New Zealand.
Patients starting publicly funded RLAI between 1 October 2005 and 31 October 2006 in five mental health services were included in the study. Data were retrospectively collected for 443 patients 1 year pre- and post-RLAI initiation at seven cross-sectional time-points (12, 6 and 3 months before; initiation; and 3, 6 and 12 months after). Patient characteristics (gender, age, ethnicity), DSM-IV-TR diagnosis, duration of mental illness, mental health act utilization, treatment setting and antipsychotic treatment (reasons for starting RLAI) were obtained from patient records.
The patients were mostly male (64,3%), of European background (42.9%) with a medium age of 34. In line with treatment recommendations, most had a diagnosis of schizophrenia or related psychoses, a history of medication adherence problems and previously been prescribed oral risperidone (72%). Treatment initiation also reflected recommended guidance; most were started on 25 mg/2 weeks (81.9%) and had treatment crossover (93.3%) until RLAI stabilized. For 58.3% of the group who continued for ≥ 12 months, mean fortnightly doses increased from 36.2 mg (3 months) to 41.3 mg (12 months); within the licensed range of 25-50 mg/2 weeks. Areas differing from recommended practice included high rates of antipsychotic co-prescribing at three cross-sectional time-points and ongoing at 12 months (12.3%). Patients prescribed higher RLAI starting doses were more likely to be prescribed higher doses 12 months later.
To our knowledge this is the largest multi-site explicit review of RLAI use in real world clinical practice. The review found that clinicians were using RLAI in clinical practice predominantly in accordance with best practice recommendations. However, high rates of antipsychotic co-prescribing with RLAI were identified which differ from practice reported in other small reviews of RLAI use and local studies of antipsychotic prescribing. We have demonstrated that clinical audit of practice is a powerful tool to identify areas of potentially poor practice, such as ongoing high rates of antipsychotic co-prescription cross-sectionally and 12 months after RLAI initiation and that this is an area of practice requiring further evaluation. Feedback to clinicians and stakeholders followed by re-audit of practice is needed in order to complete the audit cycle.
长效注射（LAI）抗精神病药推荐给那些喜欢这种治疗形式的人，以及那些由于不遵医嘱而出现不良反应的人。与口服制剂相比，LAI 抗精神病药已被证明能改善治疗效果并降低停药率。利培酮长效注射剂（RLAI）在临床试验中是有效且耐受良好的。本研究旨在回顾 RLAI 的处方实践，并比较五种新西兰临床实践环境中接受治疗的成年人的处方与最佳实践建议（包括适应症、起始、剂量和共处方）。
在五个精神卫生服务机构中，2005 年 10 月 1 日至 2006 年 10 月 31 日期间开始接受公共资助 RLAI 的患者被纳入研究。在七个时间点（开始前 12、6 和 3 个月；开始时；以及开始后 3、6 和 12 个月），对 443 名患者进行了回顾性数据收集。患者特征（性别、年龄、族裔）、DSM-IV-TR 诊断、精神疾病持续时间、精神卫生法使用、治疗环境和抗精神病治疗（开始 RLAI 的原因）均从患者记录中获得。
患者主要为男性（64.3%），欧洲裔（42.9%），平均年龄为 34 岁。与治疗建议一致，大多数患者患有精神分裂症或相关精神病、药物依从性问题史，并且之前曾服用过口服利培酮（72%）。治疗开始也反映了推荐的指导意见；大多数患者开始接受 25mg/2 周（81.9%）的治疗，并在 RLAI 稳定之前进行了治疗交叉（93.3%）。对于 58.3%的持续治疗≥12 个月的患者，平均两周剂量从 36.2mg（3 个月）增加到 41.3mg（12 个月）；在 25-50mg/2 周的许可范围内。与推荐实践不同的领域包括在三个时间点（横断面）和 12 个月时持续存在的高比率的抗精神病药共处方（12.3%）。开始时开更高 RLAI 剂量的患者更有可能在 12 个月后开更高剂量。
据我们所知，这是最大规模的多地点明确审查 RLAI 在真实世界临床实践中的使用情况。该审查发现，临床医生主要根据最佳实践建议在临床实践中使用 RLAI。然而，与其他小型 RLAI 使用综述和当地抗精神病药处方研究报告的实践不同，我们发现 RLAI 共处方的比率很高。我们已经证明，对实践进行临床审计是发现潜在不良实践领域的有力工具，例如在 RLAI 开始后 12 个月内和 12 个月内持续存在的高比率的抗精神病药共处方，这是需要进一步评估的实践领域。需要向临床医生和利益相关者提供反馈，然后重新审核实践，以完成审计周期。
