Evidence-Based Reviews

Second-generation long-acting injectable antipsychotics: A practical guide

Current Psychiatry. 2020 March;19(3):24-32

References

1. Risperdal Consta [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2019.
2. Invega Sustenna [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2019.
3. Invega Trinza [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2019.
4. Abilify Maintena [package insert]. Rockville, MD: Otsuka America Pharmaceutical, Inc.; 2019.
5. Zyprexa Relprevv [package insert]. Indianapolis; IN: Eli Lilly and Co.; 2019.
6. Aristada [package insert]. Waltham, MA: Alkermes, Inc.; 2019.
7. Perseris [package insert]. North Chesterfield, VA: Indivior, Inc.; 2018.
8. Kishimoto T, Robenzadeh A, Leucht C, et al. Long-acting injectable vs oral antipsychotics for relapse prevention in schizophrenia: a meta-analysis of randomized trials. Schizophr Bull. 2014;40(1):192-213.
9. Kishimoto T, Nitta M, Borenstein M, et al. Long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis of mirror-image studies. J Clin Psychiatry. 2013;74(10):957-965.
10. Aristada Initio [package insert]. Waltham, MA: Alkermes, Inc.; 2019.
11. Jain R, Meyer J, Wehr A, et al. Size matters: the importance of particle size in a newly developed injectable formulation for the treatment of schizophrenia. CNS Spectr. 2019:1-8.
12. Carpenter J, Wong KK. Long-acting injectable antipsychotics: what to do about missed doses. Current Psychiatry. 2018;17(7):10-12,14-19,56.
13. US Food and Drug Administration. Approved Risk Evaluation and Mitigation Strategies (REMS) zyprexa relprevv (olanzapine). https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=IndvRemsDetails.page&REMS=74. Updated April 11, 2019. Accessed January 27, 2020.

Recommendations for missed doses

Each LAIA has specific recommendations for missed dosing. Carpenter and Wong¹² reviewed the recommendations for managing missed LAIA doses in Current Psychiatry July 2018. This article is available at mdedge.com/psychiatry/article/168776/schizophrenia-other-psychotic-disorders/long-acting-injectable.¹²

Consider patient preference

Patient preference for the type and location of the injection may factor into a clinician’s choice of LAIA (Table 5^1-7,10). Risperidone LAI for SQ is the only LAIA that is administered as an SQ abdominal injection.⁷ All other LAIAs are IM injections in the deltoid or gluteal muscle.^1-6 All doses of risperidone LAI, paliperidone palmitate 3-month LAI, aripiprazole LAI, and aripiprazole lauroxil 675-mg LAI can be administered in the deltoid or gluteal muscle.^1,3,4,10 Deltoid administration is required for the 2 starting doses of paliperidone palmitate monthly injection, but maintenance doses can be administered in the deltoid or gluteal muscle. Because administration into the deltoid results in a higher concentration of the drug compared with gluteal administration, administering the 2 starting doses of paliperidone palmitate monthly injection into the deltoid helps to rapidly attain therapeutic concentrations.² Olanzapine pamoate LAI should be administered only in the gluteal muscle.⁵ The 441-mg dose of aripiprazole lauroxil LAI may be administered in the deltoid or gluteal muscle, but all other doses of aripiprazole lauroxil LAI should be administered only in the gluteal muscle.⁶

Storage

Most LAIAs can be stored at room temperature^2-6; however, risperidone LAI and risperidone LAI for SQ need to be stored in the refrigerator. Both risperidone LAI and risperidone LAI for SQ may be kept at room temperature for up to 7 days. If they are not used within 7 days at room temperature, they should be discarded.^1,7

Clinical pearls for specific LAIAs

Aripiprazole LAI. The recommended starting and maintenance dose for aripiprazole LAI is 400 mg monthly, unless the patient has drug interactions or other factors that require dose adjustment. If patients experience adverse reactions to the 400-mg dose, a reduction to 300 mg monthly could be considered.⁴

Olanzapine pamoate LAI has a Risk Evaluation and Mitigation Strategy (REMS) due to the potential for post-injection delirium/sedation syndrome (PDSS). Prescribing clinicians, dispensing pharmacies, and administering health care facilities must all be certified to prescribe, dispense, or administer olanzapine pamoate LAI. The patient must also be enrolled in the REMS program.¹³ Patients must be observed by health care staff for 3 hours after receiving a dose of olanzapine pamoate LAI to monitor for signs and symptoms of PDSS.⁵

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