Explicit review of risperidone long-acting injection prescribing practice

What is known and objective: 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. Methods: 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. Results and discussion: 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. What is new and conclusion: 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.