Adherence to Oral Agents in Schizophrenia Management

John M. Kane, MD: We have seen some advances in medication development. We now have the so-called second-generation, or atypical, medicines, which are better tolerated in general. I think in some cases, patients are more likely to be adherent with those medicines, but it’s not enough. I think we have to find additional ways to assure that patients are getting the benefit of the medication. I believe there’s a big difference between administering a medication via a long-acting injectable formulation versus administering it via oral medication. There’s really a big difference in terms of preventing relapse, but also in giving the clinical team the knowledge that they need to make rational clinical decisions.

For example, we consider some patients to be treatment resistant. We might use a drug like clozapine, which is the only drug that’s approved for treatment-resistant schizophrenia. But in some of those cases, it may actually be that the patient wasn’t taking the medicine on a consistent basis and that’s why they appeared to be treatment resistant. We are recommending that before we consider someone to be treatment resistant, we actually implement a trial of a long-acting formulation so we can rule out the possibility that it’s simply a matter of adherence.

When we have a patient on oral medication, we try to determine the best dose. It’s a little bit of trial and error, and we have recommendations. We know what the clinical trials have shown in terms of the most efficacious and best-tolerated dose, so that’s probably where we’ll start. But we don’t know for sure if the patient’s taking the exact right amount of medication or if they’re missing some. We don’t have a good way to monitor that, because if we were to do a blood level, you can only do it so often, it’s expensive, and not every laboratory is going to have access to the technology to do a blood-level test. It’s not an easy solution.

The availability of digital medicine is something that’s very exciting. That’s using technology to put a small chip in the pill that you swallow. When it hits the gastric contents, it emits a signal that’s transmitted through bodily tissue, like a cardiogram signal, and is picked up by a small receiver that the patient wears in a patch on the torso, and that relays a message to a mobile device showing the medicine was, in fact, ingested. That digital medicine was approved by the FDA within the past year for the first time. It’s going to be very interesting to see what impact that will have.

I think that’s the first of many technological approaches that we’ll have. But in the meantime, I think the use of long-acting injectable formulations is one very powerful strategy to help us address this challenge of adherence. It is also helping in terms of bioavailability. If we give a medicine by injection, we have a much, much better control of how much is being absorbed and how bioavailable it is in comparison to taking oral medicine.