Which LAI antipsychotics are best for people with nonaffective psychoses?

Long-acting injectable (LAI) formulations of paliperidone (3-month formulation), aripiprazole, olanzapine, and paliperidone (1-month formulation) have the highest effect sizes and certainty of evidence for relapse prevention and acceptability in patients with nonaffective psychoses, a recent study has shown.

The databases of Medline, Embase, PsycINFO, Cinahl, Central, and online registers were searched for randomized controlled trials published until June 2020. Random-effects pairwise and network meta-analysis were utilized to pool relative risks and standardized mean differences.

The authors then rated the quality of eligible studies using the Cochrane Risk of Bias tool and measured the certainty of pooled estimates using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Eighty-six trials were identified, of which 78 (n=11,505) were included in the meta-analysis. Most of the 12 LAIs included outclassed placebo in terms of relapse prevention.

The largest point estimates and best rankings of LAIs relative to placebo were observed for paliperidone (3-month formulation) and aripiprazole. Moderate to high GRADE certainty for superior relapse prevention compared with placebo was also noted for risperidone, followed by pipothiazine, olanzapine, and paliperidone (1-month formulation). Only haloperidol was inferior to aripiprazole, fluphenazine, and paliperidone in head-to-head comparisons of LAIs.

With regard to acceptability, most LAIs bested placebo, with moderate to high GRADE certainty for zuclopenthixol, followed by aripiprazole, paliperidone (3-month formulation), olanzapine, flupenthixol, fluphenazine, and paliperidone (1-month formulation). In head-to-head comparisons, only LAI aripiprazole had superior acceptability to other LAIs, namely bromperidol, fluphenazine, paliperidone (1-month formulation), pipothiazine, and risperidone.

“Results from this network meta-analysis should inform frontline clinicians and guidelines,” the authors said.