5. Antipsychotics and HIV/AIDS ‐ Continued
• Choice of antipsychotic must weight the pros/cons of the typicals/atypicals
in the context of HIV infection – both have potential for excellent
antipsychotic efficacy
– Typicals tend to result in greater EPS, tardive dyskinesia, and anticholinergic side effects
in HIV+ patients
– Atypicals may be better tolerated, but like the ARVs can contribute to metabolic
syndrome
– Interactions with ARVs and other medications, as well as consideration for other
underlying medical problems must be taken into account
EPS
Metabolic
Syndrome
QTc
Drug‐Drug
Interactions
Seizure
Disorder
Renal
Insufficiency
HCV
6. Long Acting Injectable vs. Oral Antipsychotics in
Schizophrenia
• Meta‐Analysis of Randomized Controlled Trials
– 2012 meta‐analysis by Kishimoto1 et al showed no significant benefit of LAIs compared with
oral antipsychotics in terms of preventing relapse of symptoms or hospitalizations
• Meta‐Analysis of Mirror Image Studies
– 2013 meta‐analysis by Kishimoto et al2 using mirrored image studies showed “strong
superiority of LAIs over oral antipsychotics in preventing hospitalization”, as well as in
decreasing the number and duration of hospitalizations
– Mirror image studies, though potentially biased (eg by expectation bias, natural illness course,
time effect) more likely reflect the average clinical patient population and real‐world
treatment than do RCTs which tend to include less sick patients, and which by their design
impose a structure that may improve adherence
1 Kishimoto T, Nitta M, Borenstein M. Long‐acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta‐analysis of
mirror‐image studies. J Clin Psychiatry 2013;74: 957‐965
2 Kishimoto T, Robenzadeh A, Leucht C et al. Long‐acting injectable vs. oral antipsychotics for relapse prevention in schizophrenia: a meta‐analysis
of randomized trials. Schizophrenia Bulletin; 2014;40:192‐213
7. Long Acting Injectable Antipsychotics
• Typicals
– Haldol decanoate
– Prolixin decanoate
• Atypicals
– Risperdal (risperidone) Consta
– Abilify (aripiprazole) Maintena
– Invega (paliperidone)
– Zyprexa (olanzapine pamoate) Relprev
• Things to keep in mind
– Side effects (EPS, akathisia, sedation syndrome)
– Frequency of injection (once vs. twice monthly)
– Drug‐drug interactions
– Need for an oral overlap period
– Cost/insurance coverage
11. Case 1: Mr. R ‐ Continued
• In 2/2013 Mr. R was admitted to the ID service for the treatment of
chronic pancreatitis
• He was incidentally found to have a right gluteal intramuscular collection
(7.0 x 2.3 cm) with rim enhancement on CT concerning for an abscess;
fluid was drained and found to be consistent with a non‐infected seroma
• Mr. R reported having received a Haldol Decanoate injection (150 mg) at
the site in question during an inpatient psychiatric admission elsewhere in
the city in 1/2013
15. Case 3: Mr. H
• Mr. H is a 44 y/o African American man with HIV (CD4 760, VL <20 – 77)
• Psychiatric history is significant for schizophrenia with lengthy period of
state hospitalization, past court mandated outpatient treatment, past
cocaine and marijuana use, and historic medication non‐adherence
• Though initially at least partially adherent to risperidone and valproic acid,
he decompensated in 4/2013 resulting in several psychiatric admissions to
various city hospitals
• During a 6/2013 admission he refused day treatment placement; return to
our clinic was contingent on his agreeing to a trial of LAI risperidone
• He received one injection prior to hospital discharge but did not follow up
as an outpatient
• Over the past year he has had several more psychiatric admissions, as well
as unstable housing; he has not returned to outpatient psychiatric care,
and only rarely follows with his medical provider
17. Case 4: Mr. J ‐ Continued
• Aripiprazole was titrated to 30 mg/day with profound effect on his
psychotic symptoms, including his delusions about HIV/AIDS and his
willingness to take ARVs
• Prior to discharge from inpatient psychiatry, Mr. J was given an injection of
Abilify Maintena 300 mg with the hope it would help combat past poor
adherence to both psychotropics and ARVs; he was also continued on oral
aripiprazole for the cross‐over
• He stopped the oral medication immediately, and returned to the ED 6
days after discharge from psychiatry with altered mental status
characteristic of delirium, as well as renewed paranoid delusions of having
been kidnapped; medically he was found to have a decubitus ulcer
• He was restarted on oral aripiprazole as well as on his ARVs and was
ultimately discharged to a skilled nursing facility; he has not subsequently
followed up in our clinic
21. Conclusions ‐ Continued
• Special considerations in the HIV/AIDS population
– Degree of illness: does severe immunocompromise place patients at a higher risk of
adverse effects?
• Infectious complications?
• Delirium?
• Other issues for consideration
– “Psychosocial issues” have been shown to have an effect on adherence; this was
observed in our case series as well
• Substance abuse/dependence
• Unstable support mechanisms, including housing
• Selectivity of non‐adherence?
– Non‐adherence to LAIs, and intermittent adherence with oral antipsychotics reflects
patterns seen in the general population of patients with SPMI
– However, despite non‐adherence to antipsychotics, some of these patients maintain
fairly good adherence to their ARVs