From QAAPAPLE 1 to QAAPAPLE 2: how do we move from one algorithm to another one with Long Acting Antipsychotics (LAIs)

ABSTRACT

Background

In 2011, the authors published an algorithm summarizing practice guidelines related to the use of long-acting antipsychotics (LAIs) called the Québec Algorithme Antipsychotique à Action Prolongée (QAAPAPLE), and proposed that it be revised every 5–10 years to update it according to most recent scientific knowledge. Therefore, a re-evaluation of the algorithm was conducted to determine which recommendations were still relevant and which needed modification.

Methods

The authors conducted a two-fold approach: a review of the literature to include new evidence since 2011 (controlled trials, meta-analyses, and practice guidelines); and a participatory component involving electronic surveys, conferences, encounters with opinion leadres, and patients’ representatives.

Results

Overall, prescribers tended to make decisions based on personal experience and conversations with colleagues rather than consulting evidence-based guidelines. To test if the algorithm was useful worldwide, it was presented in the United Arab Emirates, where the feedback was in agreement with the algorithm and its limitations.

Conclusions

Since its initial publication, the QAAPAPLE algorithm has been updated to guide clinicians on the use of LAIs. The new algorithm has also been assessed outside Canada to test its generalizability worldwide, and indicated its flexibility, efficiency, and user-friendliness in order to guide clinicians on the use of LAIs.

KEYWORDS:

• Antipsychotics
• long-acting injections
• psychosis
• algorithm
• QAAPAPLE

Article highlights

• LAIs remain an underused therapeutic modality, an updated algorithm can help clinicians to find their way around treatment options to facilitate use.

• The injection frequency palette allows intervals of 2 weeks to 3 months, which allows adjustment to the patient's needs in terms of clinical stability and frequency of contact.

• Observational studies show that LAIs reduce relapses, re-hospitalizations and excess mortality.

• An algorithm needs to be revised every 5 or 10 years and a useful algorithm can be modified and improved.

Acknowledgments

The authors thank the department of psychiatry of University of Montreal for funding the project for QAAPAPLE2 and the CHUM Foundation.

Declaration of interest

E Stip received fees for lecturing, advisory board work, and traveling and MA Roy received fees for lecturing from Janssen-OtsukaCanada, Lunbeck Canada. E Stip, MA Roy, S Grignon, and D Bloom received fees from the AMPQ for the first version of the QAAPAPLE. E Stip and MA Roy received funding from CIHR and FRQS. D Arnone has received travel grants from Jansen-Cilag and Servier and sponsorship from Lundbeck. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

A peer reviewer on this manuscript has received honoraria from most companies manufacturing second-generation antipsychotics, including LAIs. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

Intramural funds were available to support this research by the Department of Psychiatry of University of Montreal for logistics of meeting the experts, and publication fees.