Use of Oral Therapy for the Management of Schizophrenia

Transcript: John M. Kane, MD: We have a broad range of oral medications. There are many that have been approved by the Food and Drug Administration. They differ largely in their adverse effect profile. They’re similar in terms of efficacy with the exception of clozapine, which is approved by the FDA for the treatment of treatment-resistant schizophrenia and patients with suicidality. The other nonclozapine drugs are similar in efficacy. We would make some distinctions based on adverse effects and the individual patient, what adverse effects are they vulnerable to and are most concerned about?

There are many challenges in using oral medicines. The most significant is the fact that patients have a difficult time taking oral medicine on a long-term basis. That’s true in any chronic illness, not just schizophrenia, whether we’re talking about diabetes, hypertension, epilepsy, or asthma. Everyone has trouble taking medicine on a regular basis, and when we use oral medicine, we’re not sure whether our patient is taking them. I’m a believer in the use of long-acting formulations because we can feel more comfortable in the knowledge that the patient is getting the medicine.

With oral medicines, we don’t know. The way we try to find out is by asking the patient if he or she is taking the medicine, and they’re not always in a position to report accurately. I know when I’ve been taking medicine, there are times when I’m not sure whether I took it that morning or not. I forget, so imagine someone who is struggling with an illness like schizophrenia, it becomes more of a challenge.

One of the biggest challenges with oral medicine is that we don’t know exactly how adherent the patient is, and that leads to confusion to determine is the medicine working or not? Is the patient having any [adverse] effects or not? That can happen if someone stops taking their medicine for a few days and then decides to go back on it again, suddenly they have an [adverse] effect they didn’t have before and it can get confusing. Those are some of the challenges with oral medication.

Christoph Correll, MD: Dose adjustments and frequency of oral medications have a relationship to adherence. We know the more complex a treatment is, the more doses per day are needed, the more complex it is for the patients to follow, who often have cognitive problems, who may be ambivalent about taking the medication, and may not have a caregiver with them when they need to take the medication. The less medication that needs to be taken, and the less often, the better. Long-acting injectable formulations reduce the ingestion of medication from 3 times, 2 times, or once daily to once every 2, 4, 6, 8, or even every 12 weeks.

The simplicity of long-acting injectable medication treatments reduces the time that patients can be ambivalent, or reject or forget, so the adherence is higher with long-acting injectables than with oral medications. Patients have to only consider whether they want or don't want to take the medication every 2, 4, 6, 8, or 12 weeks. Since nonadherence is immediately visible to both the patient's prescriber, but also to family members, if they can be reached, patients can be brought back before relapse occurs, and adherence is more likely assured, even in patients who are trying to stop the medication.

Transcript Edited for Clarity