Switching to Long-Acting Injectable Paliperidone is Not Cost-Effective in Stable Schizophrenia

A new analysis out of the College of Pharmacy at the University of Florida revealed that extended-release (ER) paliperidone tablets remain the most cost-effective medication regimen for adults with schizophrenia. This study, which was published recently in the Journal of Managed Care + Specialty Pharmacy, found that when patients with schizophrenia are stable on extended-release tablets, switching to long-acting injection (LAI) formulations improves their health outcomes, including reducing rates of relapses and hospitalizations. But the advantages might not sufficiently offset their substantial costs within a five-year timeframe.

Nearly 4 million individuals in the United States have schizophrenia, a chronic mental illness that hinders normal perception and thought processes. Providing care and support for individuals with schizophrenia is crucial because adults living with this condition face a higher risk of early death than the overall population. However, schizophrenia treatment is expensive. A 2019 report estimated an annual healthcare cost of more than $15,000 per year for a single patient with schizophrenia. One driving force behind rising treatment costs is relapses, which involve an acute worsening of symptoms and often result in hospitalization.

Paliperidone, an antipsychotic medication, works to manage symptoms of schizophrenia and prevent relapses. It comes in two formulations: extended-release oral tablets taken each morning and long-acting injectables, which may be administered every one, three, or six months, depending on the specific product. While the effectiveness and safety of these agents are well-established, little was known about the comparative cost-effectiveness of the different formulations.

With this in mind, a group of researchers from the University of Florida College of Pharmacy —led by Grace Hsin-Min Wang, Pharm.D., in the department of Pharmaceutical Outcomes & Policy in the College of Pharmacy — developed an analysis to better understand paliperidone's cost-effectiveness. Primarily, the team sought to understand the cost and implications of switching from one type of paliperidone to another.

To investigate, the researchers established a model to simulate 1,000 adults with schizophrenia, with each individual cycling through stages of schizophrenia treatment, including stable periods and relapses. A switch from paliperidone ER tablet to paliperidone LAI would occur during these stages. Then, the team investigated the cost of this change and the new regimen’s impact on disease outcomes and quality of life overall.

Ultimately, the results suggest that the LAI formulations of paliperidone improve quality of life and overall disease outcomes more so than oral paliperidone ER tablets. The study reflected increases in QALY (a scoring system designed to reflect changes in quality of life based on an intervention) compared with oral paliperidone tablets of 0.05, 0.14, and 0.15 for the one-month, three-month, and six-month versions of LAI paliperidone formulations, respectively. This suggests that the every-six-month version of paliperidone LAI provides the most benefit in reducing relapses, emergency room visits, and overall quality of life.

However, these changes resulted in considerable cost increases, as well. By changing from paliperidone ER tablet to the one-month, three-month, or six-month LAI during a stable schizophrenia period, costs increased by $49,433, $26,698, and $26,147, respectively.

Because of these high costs, it seems unlikely that switching to a LAI from oral paliperidone during stable schizophrenia periods is cost-effective.

However, this study revealed some interesting cost-effectiveness differences among the three LAI formulations. The six-month paliperidone LAI resulted in the greatest quality of life improvement and was associated with a lesser degree of cost increase compared with the other two formulations. Therefore, for individuals with schizophrenia currently receiving the one-month or three-month LAI version of paliperidone, switching to the six-month formulation is likely cost-effective.