Authors: Emma E. Nelson, PharmD; Lauren M. Hynicka, PharmD, FCCP, BCPS; Jill A. Morgan, PharmD, BCPS, BCPPS, FNAP; Chelsea N. Di Polito, PharmD, BCPP; Gloria M. Reeves, MD; Megan J. Ehret, PharmD, MS, BCPP, FAAPP
Learning Objective: Describe key clinical and patient factors that influence expert recommendations for long‑acting injectable antipsychotic (LAIA) use in pediatric schizophrenia.
Background Schizophrenia is a chronic psychiatric disorder often emerging in adolescence, with early onset linked to worse outcomes such as cognitive deficits, social dysfunction, and increased relapse and hospitalization. Timely, consistent pharmacologic treatment is key to improving prognosis.
Oral antipsychotics are the standard of care, but pose adherence challenges in pediatric patients, contributing to relapse and higher rates of healthcare use. LAIAs may improve adherence by reducing dosing frequency. Although LAIAs are increasingly used off-label in pediatric patients, they remain unapproved by the U.S. Food and Drug Administration (FDA) for individuals under 18, and supporting evidence is limited to small observational studies and case reports.
Objective To develop consensus-based recommendations for LAIA use in pediatric schizophrenia, including agent selection and dosing.
Methods A three‑round Delphi process was conducted using an online survey tool to gather input from physician and pharmacist experts. Experts were identified through guideline authorship, employment at pediatric psychiatric facilities, and participation in professional associations. Eligible participants were required to have at least five years of post‑graduate experience in pediatric psychiatry or to provide care for ten or more pediatric patients with schizophrenia annually, as well as experience recommending LAIAs. The study aimed to recruit a panel of 30 experts. Round 1 consisted of free‑response questions, Round 2 used a Likert‑scale format, and Round 3 presented patient cases to verify the Round 2 findings. Consensus was defined as at least 70% agreement among participants.
Results Results show consensus on key indicators for LAIA use, including relapse after missed oral doses and patient willingness to receive injections. Experts agreed that established efficacy or tolerability with the corresponding oral agent supports LAIA selection. Consensus was also reached for avoiding certain agents in younger patients or those with extrapyramidal symptom risk. Several clinical factors, including oral overlap strategies and some age‑related considerations, did not reach consensus.
Conclusions Experts reached consensus on several key indicators for the use of LAIAs, including relapse following missed oral doses and patient willingness to receive injections. Agreement was also achieved regarding the appropriateness of initiating an LAIA when effectiveness has already been demonstrated with the corresponding oral formulation. However, several areas showed considerable variability and did not reach consensus. This lack of uniformity underscores that many clinical scenarios lack a clearly preferred agent, reflecting the complexity of real‑world pediatric schizophrenia management. Overall, these findings highlight an important need for head‑to‑head comparative trials to better inform LAIA selection in pediatric populations.
Self‑Assessment Question Which factor reached expert consensus as strongly supporting the use of a long‑acting injectable antipsychotic in pediatric schizophrenia? A. Concern for injection volume B. Patient willingness to receive injections C. Placement in foster care D. Age under 14 years
