Atypical Anti-psychotics (long-acting injectable)
Atypical Anti-psychotics (long-acting injectable) - Index
Medications listed in the tables and non-FDA approved indications included in these retrospective criteria are not indicative of Texas Vendor Drug Program formulary coverage.
- Revision history
- Oct. 13, 2023
- Oct. 22, 2021
- Sept. 2019
- Initially developed
- Sept. 2017
1. Dosage
1.1. Adults
Long-acting injectable (LAI) second generation (atypical) antipsychotics are FDA-approved drugs to treat psychiatric disorders. All of the LAI atypical antipsychotics are used to treat schizophrenia1-14 . Invega Sustenna has an additional indication
for treating schizoaffective disorder 1-3. Both Abilify Maintena, Abilify Asimtufii, Risperdal Consta, and Rykindo have an additional indication for treating bipolar I disorder1,2,4-7. Invega Hafyera is approved for the management of schizophrenia in adult patients, and it is administered every six months1,2,12. Perseris is a monthly injection of risperidone approved for the management of schizophrenia in adults1,2,14. Aristada Initio was approved for the initiation of Aristada, and is only given once in combination with single 30 mg oral dose of aripiprazole1,2,9,10. Recommended treatment dosages for LAI atypical antipsychotics are summarized in Table 1.
| Drug Name | Available Dosage Strengths | Treatment Indication | Maximum Recommended Dosage |
|---|---|---|---|
| Aripiprazole (Abilify Asimtufii) | 720 mg, 960 mg intramuscular (IM) injection | Schizophrenia, bipolar I disorder (maintenance therapy) | 960 mg IM once every two months |
| Aripiprazole (Abilify Maintena) | 300 mg, 400 mg intramuscular (IM) injection | Schizophrenia, bipolar I disorder (maintenance therapy) | 400 mg IM once monthly |
| Aripiprazole lauroxil (Aristada, Aristada Initio) | 441 mg, 662 mg, 675 mg, 882 mg, 1064 mg IM injection | Schizophrenia | 1064 mg IM every two months |
| Olanzapine (Zyprexa Relprevv) | 210 mg, 300 mg, 405 mg IM injection | Schizophrenia | 300 mg IM every two weeks or 405 mg every 4 weeks |
| Paliperidone palmitate (Invega Hafyera) | 1,092 mg, 1,560 mg IM injection | Schizophrenia in patients who have been treated on Invega Sustenna for at least four months or Invega Trinza for at least one three month cycle | 1,560 mg IM every 6 months |
| Paliperidone palmitate (Invega Sustenna) | 39 mg, 78 mg, 117 mg, 156 mg, 234 mg IM injection | Schizophrenia, schizoaffective disorder | 234 mg IM once monthly |
| Paliperidone palmitate (Invega Trinza) | 273 mg, 410 mg, 546 mg, 819 mg IM injection | Schizophrenia in patients who have been treated on Invega Sustenna® for at least four months | 819 mg IM once every 3 months |
| Risperidone (Perseris) | 90 mg, 120 mg IM injection | Schizophrenia | 120 mg IM every month |
| Risperidone (Risperdal Consta) | 12.5 mg, 25 mg, 37.5 mg, 50 mg IM injection | Schizophrenia, bipolar I disorder (maintenance therapy) | 50 mg IM every 2 weeks |
| Risperidone (Rykindo) | 25 mg, 37.5 mg, 50 mg IM injection | Schizophrenia, bipolar I disorder (maintenance therapy) | 50 mg IM every 2 weeks |
| Risperidone (Uzedy) | 50 mg, 75 mg, 100 mg, 125 mg, 150 mg, 200 mg, 250 mg subcutaneous (SubQ) injection | Schizophrenia | 125 mg SubQ once monthly or 250 mg SubQ every 2 months |
Abilify Maintena and Abilify Asimtufii dosages must be modified in patients prescribed CYP3A4 or CYP2D6 inhibitors, or in those patients identified as CYP poor metabolizers. Abilify Maintena and Abilify Asimtufii should be avoided in patients prescribed CYP3A4 inducers concurrently1,2,4,5. Abilify Asumtufii should be avoided in patients taking CYP2D6 and CYP3A4 inhibitors concurrently. Recommended Abilify Maintena and Abilify Asumtufii dosages when prescribed concurrently with CP450-modifying medications are summarized in Table 2.
| Factors | Dosage Adjustment |
|---|---|
| Abilify Maintena® 300 mg intramuscular administration | |
| Strong CYP3A4 or CYP2D6 inhibitor (greater than 14 days) | Reduce to 200 mg |
| CYP3A4 and CYP2D6 inhibitor together (greater than 14 days) | Reduce to 160 mg |
| CYP3A inducer (greater than 14 days) | Avoid use |
| Abilify Maintena® 400 mg intramuscular administration | |
| Strong CYP3A4 or CYP2D6 inhibitor (greater than 14 days) | Reduce to 300 mg |
| CYP3A4 and CYP2D6 inhibitor together (greater than 14 days) | Reduce to 200 mg |
| CYP3A inducer (greater than 14 days) | Avoid use |
| Abilify Maintena® in CYP2D6 poor metabolizers | |
| Known CYP2D6 poor metabolizers | Reduce to 300 mg |
| Known CYP2D6 poor metabolizer taking a CYP3A4 inhibitor | Reduce to 200 mg |
| Abilify Asumtufii® 960 mg intramuscular administration | |
| Concomitant use with strong CYP2D6 inhibitors | 720 mg once every 2 months |
| Concomitant use with strong CYP3A4 inhibitors | 720 mg once every 2 months |
| Concomitant use with strong CYP2D6 inhibitors and strong CYP3A4 inhibitors | Avoid use |
| Concomitant use with CYP3A4 inducers | Avoid use |
| Abilify Asumtufii in CYP2D6 poor metabolizers | |
| Known CYP2D6 poor metabolizers | 720 mg once every 2 months |
| nown CYP2D6 poor metabolizers taking concomitant CYP3A4 inhibitors | Avoid use |
Aristada dosages must be modified in patients prescribed CYP3A4 or CYP2D6 inhibitors as well as CYP3A4 inducers concurrently. Aristada Initio only comes in one dosage strength, and it should be avoided in patients who are known CYP2D6 poor metabolizers or taking strong CYP3A4 inhibitors, strong CYP2D6 inhibitors, or strong CYP3A4 inducers.1,2,9,10 Recommended Aristada dosages when prescribed concurrently with CP450-modifying medications are summarized in Table 3.
| Factors | Dosage Adjustment |
|---|---|
| Strong CYP3A inhibitor | Reduce Aristada dose to the next lowest strength; if patient is taking 441 mg, no dosage adjustment required |
| Strong CYP2D6 inhibitor | Reduce Aristada dose to next lowest strength; if patient is taking 441 mg, no dosage adjustment required |
| Known CYP2D6 poor metabolizer taking a strong CYP3A inhibitor | If patient is taking 662 or 882 mg, reduce the dose to 441 mg; if patient is taking 441 mg, no dosage adjustment required |
| Known CYP2D6 poor metabolizer taking a strong CYP2D6 inhibitor | No dose adjustment needed |
| Both a strong CYP2D6 inhibitor and CYP3A inhibitor | Avoid using in patients who are taking 662 or 882 mg; if patient is taking 441 mg, no dosage adjustment needed |
| CYP3A4 inducers | No dose adjustment is needed for the 662 mg or 882 mg dosages; if patient is taking 441 mg, increase dose to 662 mg |
Aristada Initio should be avoided in patients who are known CYP2D6 poor metabolizers or taking strong CYP3A4 inhibitors, strong CYP2D6 inhibitors, or strong CYP3A4 inducers.
1.2. Pediatrics
Safety and efficacy of LAI atypical antipsychotics for use in children younger than 18 years of age have not been established 1-14. The Psychotropic Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version) does not provide dosing recommendations for long-acting injectable atypical antipsychotics 14.
2. Duration of Therapy
If the patient is tolerating the LAI atypical antipsychotic, then there is no basis for limiting treatment length for approved psychiatric disorders as schizophrenia, schizoaffective disorder, and bipolar I disorder are chronic, lifelong diseases 1-13.
3. Duplicative Therapy
Co-administration of two or more LAI atypical antipsychotics is not justified due to limited additional therapeutic benefit and increased risk of adverse effects 1-13.
Patient profiles containing concomitant prescriptions for two or more LAI atypical antipsychotics will be reviewed.
4. Drug-Drug Interactions
Patient profiles will be assessed to identify those drug regimens which may result in clinically significant drug-drug interactions. Drug-drug interactions considered clinically relevant for LAI atypical antipsychotics are summarized in Table 6. Only those drug-drug interactions classified as clinical significance of severe or those considered life-threatening which have not yet been classified will be reviewed 1-13.
Table 6: Select LAI Atypical Antipsychotic Drug-Drug Interactions
| Target Drug | Interacting Drug | Interaction | Recommendation | Clinical Significance Level |
|---|---|---|---|---|
| Aripiprazole | Citalopram | Increased risk of QT prolongation and serotonin syndrome because aripiprazole is a partial agonist of 5-HT1A and citalopram is a selective serotonin reuptake inhibitor | Avoid use | Major (DrugReax) 2-major(CP) |
| Aripiprazole | Strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole) | Increased risk of aripiprazole overexposure because aripiprazole is metabolized by CYP3A4 | Monitor patient closely and adjust aripiprazole dosages as needed | Major (DrugReax) 3-moderate (CP) |
| Long-acting injectable atypical antipsychotics (LAI AAs) | CNS depressants | Increased risk of respiratory and central nervous system depression due to additive pharmacologic effects | Use cautiously together; observe patients for enhanced CNS adverse effects | Major (DrugReax) 3-moderate (CP) |
| LAI AAs | Metoclopramide | Increased risk of extrapyramidal reactions or neuroleptic malignant syndrome | Avoid use | Contraindicated (DrugReax) 1-severe,2-major (CP) |
| LAI AAs | QT interval- prolonging medications (e.g. posaconazole) | Increased risk of QT interval prolongation | Avoid use; if combined use necessary, administer cautiously together and monitor closely | Contraindicated (DrugReax) 1-severe,2-major,3-moderate (CP) |
| Olanzapine | Agents that lower seizure threshold (e.g. clomipramine) | Increased seizure risk because psychotropic drugs may reduce the seizure threshold | Use caution when administered concomitantly | Major (DrugReax) 3-moderate (CP) |
| Atypical antipsychotics | CYP3A4 and CYP1A2 inducers (e.g. carbamazepine) | Concomitant use can lead to decreased serum concentrations of atypical antipsychotics | Monitor treat efficacy and adjust atypical antipsychotic dosages as needed | Major (DrugReax) 2-major (CP) |
| Olanzapine (CYP1A2 substrate) | CYP1A2 inhibitor (e.g. fluvoxamine) | Increased olanzapine serum concentrations | Monitor patient closely and adjust olanzapine dosages as needed | Major (DrugReax) 2-major (CP) |
| Risperidone | Serotonergic agents (e.g. linezolid) | Increased risk of serotonin syndrome | Monitor patients for serotonin syndrome | Major (DrugReax) 2-major (CP) |
| Risperidone, Olanzapine | Lithium | Increased extrapyramidal symptoms; encephalopathy and brain damage have occurred in case reports due to unknown mechanism | Monitor patients closely for symptoms and monitor lithium levels | Major (DrugReax) 3-moderate (CP) |
5. References
- IBM Micromedex® DRUGDEX® (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www-micromedexsolutions-com.libproxy.uthscsa.edu/ (cited: September 11, 2023).
- Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2023. Available at: http://clinicalpharmacology-ip.com.ezproxy.lib.utexas.edu/. Accessed September 11, 2023.
- Paliperidone palmitate extended-release injection suspension (Invega® Sustenna®) package insert. Janssen Pharmaceuticals, July 2022.
- Aripiprazole intramuscular extended-release injection (Abilify Asimtufii®) package insert. Otsuka America Pharmaceutical, Inc., August 2023.
- Aripiprazole intramuscular extended-release injection (Abilify Maintena®) package insert. Otsuka America Pharmaceutical, Inc., February 2023.
- Risperidone long-acting injection (Risperdal Consta®) package insert. Janssen Pharmaceuticals, Inc., February 2021.
- Risperidone extended-release intramuscular microsphere injection (Rykindo®) package insert. Shandong Luye Pharmaceutical Co., ltd., May 2023.
- Risperidone extended-release subcutaneous injection (Uzedy®) package insert. Teva Pharmaceuticals, Inc., May 2023.
- Aripiprazole lauroxil intramuscular extended-release injection (Aristada®) package insert. Alkermes, Inc., March 2021.
- Aripiprazole lauroxil intramuscular extended-release (Aristada Initio®) package insert. Alkermes, Inc., March 2021.
- Olanzapine extended release injectable suspension (Zyprexa® Relprevv™) package insert. Eli Lilly and Company, November 2021.
- Paliperidone palmitate extended-release injection suspension (Invega Hafyera®) package insert. Janssen Pharmaceuticals, August 2021.
- Paliperidone palmitate extended-release suspension (Invega Trinza®) package insert. Janssen Pharmaceuticals, August 2021.
- Risperidone long-acting injection (Perseris®) package insert. Indivior Inc., December 2022.
- The Parameters Workgroup of the Psychiatric Executive Formulary Committee, Health and Specialty Care Division, Texas Health and Human Services Commission. Psychotropic medication utilization parameters for children and youth in Texas public behavioral health (6th version). (June 2019) Available at: https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/facilities-regulation/psychiatric/psychotropic-medication-utilization-parameters.pdf. Accessed September 17, 2023.