How to Review LAI Continuation After Bipolar I Rehospitalization
How should clinicians use this study when deciding whether to continue or switch a long-acting injectable antipsychotic after rehospitalization in bipolar I disorder?
Patients with bipolar I disorder who relapse after discharge often return to the hospital on a changed medication plan. This study provides real-world data on how often LAIs are continued versus switched at first rehospitalization and whether continuation may be linked to fewer subsequent rehospitalizations.
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Check the patient's antipsychotic route at the index discharge
Start by identifying whether the patient had been discharged on an oral antipsychotic or an LAI at the index hospitalization. In this study, most patients discharged on oral antipsychotics remained on oral treatment at rehospitalization, whereas LAI-treated patients were much less likely to stay on an LAI.
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Recognize that LAI discontinuation at rehospitalization is common
Use the study's practice-pattern data to flag automatic switching away from LAIs as a common but not necessarily evidence-based pattern. Only 38.9% to 41.4% of patients discharged on any LAI and 35.4% to 37.0% of those discharged on a second-generation LAI were maintained on an LAI at rehospitalization within 30 to 90 days.
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Reassess the reason for switching before changing route
Before switching an LAI to an oral antipsychotic at rehospitalization, review whether the change is being driven by a clear clinical rationale rather than routine practice alone. The article highlights that clinician attitudes, knowledge, experience, patient preferences, and real-world practice factors may influence continuation and switching decisions.
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Consider continuation when the patient has already been started on an LAI
Use the exploratory findings to support a deliberate review of LAI continuation rather than reflexive conversion to oral treatment. The study found lower rates of second rehospitalization among patients who continued LAIs, including second-generation LAIs, at first rehospitalization compared with those who switched to oral antipsychotics, although most differences were not statistically significant.
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Interpret any continuation advantage cautiously
Treat continuation findings as hypothesis-generating rather than definitive protocol. The authors specifically describe these analyses as exploratory and note that most continuation-versus-switch differences for second rehospitalization did not reach statistical significance.
Clinical Considerations
- The continuation-versus-switch findings were exploratory and most differences in second rehospitalization were not statistically significant.
- The study did not capture important drivers of switching such as disease severity, prior treatment history, community care, formulary restrictions, clinician practice variation, or patient preferences.
- Because the database was limited to encounters within the same hospital system, medication use and services outside that setting were not fully captured.
- There was no information on LAI use during the 3-month baseline period before index hospitalization.
Bottom Line
At rehospitalization, do not assume an LAI should be stopped; review the reason for switching carefully, because continuation was common enough to be clinically relevant and was associated in exploratory analyses with fewer later rehospitalizations.
