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Objective To evaluate the long-term efficacy and safety of paliperidone palmitate once-monthly (PP1M) and once-every-3-months (PP3M) PP long-acting injectable antipsychotics in young adults with schizophrenia treated in routine Rwandan healthcare settings.Design This was a single-arm, open-label, multicentre interventional study consisting of two consecutive phases: an observation/run-in (OR) phase (weeks 1–24), during which participants received standard-of-care oral antipsychotics, and a lead-in/maintenance (LM) phase (weeks 25–66), during which participants first received PP1M for ≥17 weeks and subsequently transitioned to PP3M for maintenance treatment. For analysis, the full week 1–66 period was considered the follow-up (FU) phase.Setting/participants 93 adults aged 18–35 years with schizophrenia were enrolled across five Rwandan centres; 86 (92.5%) completed the 66-week study.Endpoints and measurements The primary endpoint was the change in Clinical Global Impression–Severity of Schizophrenia (CGI-SS) score from baseline (week 1) to the end of the study (week 66). Secondary endpoints included changes in CGI-SS and Personal and Social Performance (PSP) scores in both OR and LM phases. Safety was assessed through treatment-emergent adverse events (TEAEs), laboratory tests, vital signs, ECG and suicidality measured with the Columbia Suicide Severity Rating Scale.Statistical analysis Within-group changes were analysed using one-sample or paired Student’s t-tests, with a one-sided significance threshold of 0.025 for the primary endpoint. Descriptive statistics were used for safety outcomes.Results Over the 66 weeks FU period, CGI-SS improved significantly (mean change −1.4 (SD 0.69), 95% CI −1.50 to −1.22; p<0.001). Minimal improvement occurred during the OR phase (mean change −0.1), whereas the LM phase showed clinically meaningful improvements (mean change −1.2 (SD 0.67), p<0.001). PSP scores improved significantly during LM (mean+17.1 (SD 13.62), p<0.001) and across the entire FU period (mean+17.6 (SD 11.13), p<0.001). Overall, 75% of participants experienced ≥1 TEAE, mostly mild/moderate; the most common were asthenia (20.7%), nasopharyngitis (14.1%) and urinary tract infection (10.9%). Two deaths occurred during LM, neither related to study treatment.Conclusions Switching from oral antipsychotics to PP1M followed by PP3M resulted in significant improvements in symptom severity and psychosocial functioning over 66 weeks, with no new safety concerns in this real-world Rwandan setting.Trial registration number NCT04940039.