LAI offer & acceptance

Video transcript

Mary:

Navigating Long-Acting Injectable Conversations to Achieve Longer Dosing Intervals in Adult Patients With Schizophrenia, a virtual national broadcast for pharmacists in mental health. This video was developed from virtual sessions previously recorded in June, 2022. Any audience participation and or interactivity will not be enabled or be available as part of this presentation. Our guest speaker is Dr. Alberto Augsten, pharmacy clinical manager and board-certified clinical toxicologist at Memorial Regional Hospital in Hollywood, Florida.

Dr. Alberto Augsten:

As Mary said, let's go ahead and begin this very interesting discussion on navigating long-acting injectable conversations, to achieve longer dosing intervals in adult patients with schizophrenia. So once again, thank you and welcome to the program. It must be stated, this is a promotional educational activity brought to you by Janssen. It's not certified for continued medical education. I'm a paid speaker for Janssen, and we're presenting on behalf of Janssen, and must present information in compliance with the FDA.

Now, with that being said, pharmacists play a key role. We know we're delaying the start. Now what are the guidelines and guidance telling us? We're going to reflect on the APA and the National Council for Mental Wellbeing. And looking at the APA, really highlighting in orange, making a suggestion that LAIs may be suitable for adult patients with schizophrenia for the following reasons, that we know now to be true.

This is a recent update last year that came out with APA. If the patient prefers such treatment, that's important, because at the end of the day, the patient has a choice. The patient needs to be engaged in treatment. There needs to be a therapeutic alliance if we really want best outcomes. Now, if the patient has a history of poor adherence—another reason to use an LAI—and now we have plenty of data to suggest that's something that our patients face. Let's be honest, most of us struggle with adherence related to our own medications that we take orally. So this is an issue. Poor adherence plays a role.

If the patient is at risk for reduced adherence due to any one of the following reasons: One, transitioning between settings, such as inpatient, or released from a correctional facility. Those are the patients we're seeing in our practice. Those are the patients we're seeing on the inpatient side. Or they have a co-occurring substance use disorder. Or they have limited awareness of needing treatment. So various factors. Not this potential—they may have an adherence issue, they may end up with four different regimens and multiple relapses—no, these are clear, defined reasons of why your patient should be initiated potentially on an LAI, and educated about LAIs. So earlier discussion of LAI, should be considered for patients with limited awareness of co-occurring substance use disorders. Either one.

Now transitioning over to the National Council for Mental Wellbeing. And looking at the part in orange, to utilize an LAI as an earlier treatment option, rather than using them only after multiple negative outcomes, such as failed oral medications, multiple relapses or hospitalizations. Meaning: Why wait? Why are we waiting so long? And the discussion should be happening much sooner. So now we know we have this delay in start, and we have this guidance and guidelines saying we should be using LAIs much sooner in the disease course.

Now, transitioning over into the offer—because as pharmacists, we're involved in education. We mentioned the transition phase, why is that important? We mentioned that we're waiting too long to start. We mentioned the APA guidelines and the National saying, we need to have an early discussion. There's more patients you can identify that may be good candidates, and we have these longer-duration products available—INVEGA SUSTENNA^®, INVEGA TRINZA^®, INVEGA HAFYERA^®—but how do you offer correctly? What's the offer up like?

Now, this market research that was obtained by Janssen identified that 78% of the patients want their clinician to offer them a choice between daily orals or a once-monthly LAI (long-acting injectable), meaning they want to know and have the education, and have that ability to decide and choose. Further, which adds to this element, of those who want a choice, 74% would like to try a once-monthly LAI. So important information because as you integrate into your treatment team, as you're discussing this with the providers, the nurse practitioners, it's information that changes some of the dynamics, saying that your patients actually want to know that there are options. And of those that learn of the options, a high percentage of them actually would like to start a long-acting injectable antipsychotic.

Now, with that being said: So now we know that they want that option. They want to be educated and many want to start. But what are some elements to consider? So obviously, how do you present this to them? You have to confidently educate patients on how they work. Obviously, when you talk about efficacy, you must talk about safety. What are the potential risks and side effects you may incur? And at the end of the day, many of these patients accept the LAI once they understand the psychiatrist, nurse practitioner or pharmacist believe that it may be a good option for them, creating that therapeutic alliance. It provides a strong patient-centric rationale for the offer. You can build that relationship, and understand that the process can take several conversations. Don't expect that the first offer and first education that patients will get complete buy-in. It may take multiple times. So, obviously, use your best clinical judgment when talking to patients. You're the best judge of what elements are the most effective and appropriate in your setting.

This data here relates to how one offers the LAI, and it's a separate study. And to the left-hand side, you're looking at patient initial reaction to the LAI offer, regardless of the approach. 67% of the time it was favorable to neutral, to various styles of offering LAIs. Meaning whatever style or approach the healthcare provider offered that LAI, two-thirds of the time, you had a favorable or neutral related result to that LAI. Now, those folks, there were some folks that were asked if they can have follow-up in an interview, and 20 out of 33 agreed. And after a positive offer, geared towards positive offer, the way we approach it—96% of those patients were willing to try an LAI after the positive offer. So it's clearly a factor in how we discuss, how we educate, how we create that therapeutic alliance and the impact on a positive offer.

In front of you, you have a framework. It's called GAIN. GAIN can be a framework for any LAI conversation. It was originally… the publications on the bottom are originally from a 2009 publication, and the GAIN approach can help align clinicians and patients and their expectations. So when we discussed, what do we do during this longer duration, the idea came: We can create the therapeutic alliance and address specific needs for the patients. Right? Using the patient's own motivation for change, with goal-setting, some goals that they can attain, creating an action plan, initiating treatment, once they start the LAI. Now we're seeking to hopefully activate that actual plan, and nurturing the motivation. What you can do to increase the motivation, stay in their treatment with the medications and so forth, and the treatment team. So just using an approach that improves motivation with your patient. Just some ideas to utilize and implement.

As we further discuss this, the LAI acceptance hinges on two-way dialogues between the treatment team and the patient. And really bringing it down, each treatment team member brings their unique perspective and experience. Specifically, we're talking about, in this instance, the pharmacist, right? Lots of education, lots of knowledge, and we know that's important. A collaborative approach can help improve patient outcomes. We know this is true. Because everybody's on the same page, everybody's understanding, digesting what is being offered, the education and the goals of the patient, because it becomes a therapeutic alliance. And educating team members about LAIs, and encouraging those who support LAI use to speak with adult patients with schizophrenia, and help improve LAI acceptance—all about that discussion and education. Honest, clear messaging about LAIs from treatment team members, including pharmacists, is important when speaking with patients. Hopefully, this resonates with you, because we know that our pharmacist involvement in the treatment of patients is increasing. There's more integration, more involvement in the treatment team.