Long Acting Injectable Antipsychotic Medications 10/3/2019

Antipsychotic medication can be delivered through long acting injectable (LAI) formulation. While these treatments are not typically prescribed by primary care doctors, primary care patients, both adolescents and adults, may need them.

LAIs play a crucial role in treating psychotic symptoms. They can be used for individuals with schizophrenia, bipolar disorder with psychotic features, or other chronic psychoses. There are two key interrelated factors to consider. First, the medication can be administered once every 2-4 weeks, which can increase compliance. Second, recent research has shown use of LAIs can decrease rates of hospitalization and relapse of psychotic symptoms.

As our understanding of psychotic illness grows, it appears likely that the better the symptom control, the better the short AND long-term outcomes. In other words, LAIs allow people to have better compliance, leading to better symptom control, which clearly allows for more social connection and interaction, and likely decreases severity of disease progression. These can be even more important for adolescents who have shown significant psychotic symptoms and non-compliance with anti-psychotic medications. While these medications are not FDA approved for use in adolescents, research does support their use in selected situations.

There are a range of medications, but we will focus on the more common options, which fall into the category of second generation antipsychotics.

Paliperidone palmitate (Invega Sustenna) can be administered monthly, with maximum doses of 234 mg / month. There is typically a loading dose of 234 mg and a subsequent dose of 156 mg on Day 8, followed by monthly maintenance doses. The use of oral medications following the first dose is not required. Prior to initiation, tolerability of oral paliperidone (Invega) is recommended. Invega Trinza, a 3-month injection, is indicated for the treatment of schizophrenia in patients after they have been adequately treated with Invega Sustenna for at least four months.

Aripiprazole Maintena (Abilify Maintena) is typically initiated at 400 mg and does require 14 days of oral supplementation. Subsequent IM doses are given monthly and can be lowered to 300 mg if needed. Prior to initiation, tolerability of oral aripiprazole (Abilify) is recommended.

Risperidone Consta (Risperdal Consta) is started at 25 mg, and administered every two weeks. Oral risperidone should be given for the first three weeks of the treatment. Prior to initiation, tolerability of oral risperidone (Risperdal) is recommended

LAIs require monitoring of LFTS, lipids and white blood Cell count on a regular basis (every 3-6 months), which falls to the psychiatrist to manage. However, other physical findings such as elevated muscle tone, stiff neck or difficulty swallowing (dystonias), weight gain, increased waist to hip ratio, abnormal movements of the hands, lips and mouth or hips, can be associated with the medications, and primary care input may help to catch burgeoning side effects.

If dystonias arise, the administration of oral anti-cholinergic medication, such as benztropine may be required.

LAIs are currently an underutilized treatment in patients. In theory, any patient requiring long term treatment can be a candidate.   They can provide a sustained and steady state of the drug in the body, they have clinical efficacy in preventing relapse, they positively affect patient adherence and they can take away any treatment gaps.

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