Good resource for long acting injectables?

[shahseh22]

I'm taking over a clinic where there are several patients on Clozaril and LAI's. I am Child trained and even the work that I've been doing since fellowship has been mainly child focused. I really need a good resource to learn more about how many days to give oral and then stop after the injection for the different ones. Before in residency I would give Risperdal for 5-6 days at low dose and then send the pt out with Invega Sustenna after discharge.

For example, I had a patient today who was on Abilify 15 for past 2 weeks, tolerating well, father concerned about compliance so wants Long Acting Abilify, do I just give Abilif Maintenna 400 mg and then DC the oral abilify or do I continue for a couple of weeks?

I'm doing all of this via telepsych so I don't have the luxury of looking at the package insert.

thanks in advance! I feel like my knowledge of pharmacokinetics is severely lacking so appreciate any input.

---

Members don't see this ad.

 

[hallowmann]

I'm taking over a clinic where there are several patients on Clozaril and LAI's. I am Child trained and even the work that I've been doing since fellowship has been mainly child focused. I really need a good resource to learn more about how many days to give oral and then stop after the injection for the different ones. Before in residency I would give Risperdal for 5-6 days at low dose and then send the pt out with Invega Sustenna after discharge.

For example, I had a patient today who was on Abilify 15 for past 2 weeks, tolerating well, father concerned about compliance so wants Long Acting Abilify, do I just give Abilif Maintenna 400 mg and then DC the oral abilify or do I continue for a couple of weeks?

I'm doing all of this via telepsych so I don't have the luxury of looking at the package insert.

thanks in advance! I feel like my knowledge of pharmacokinetics is severely lacking so appreciate any input.

In your situation, I might invest into access to a service with up-to-date recommendations (e.g. DynaMed/Micromedex or UpToDate). Alternatively you could become affiliated loosely with some organization that already offers such a subscription (medical center, medical school, academic institution, etc.). Costs without something like that are going to be in the $300-$400/yr range, but you'll have access to basically endless changing info rather than having to do journal dives or finding resources for each individual topic. You could invest into a physical text as well that reviews current practices, but honestly, you'll have to periodically buy a new one of those as well. Alternatively, you could just use something free resources like epocrates (phone app or web) or similar if medications is your primary concern.

Regarding your example, per UpToDate:

"IM, ER injectable suspension (aripiprazole monohydrate): 400 mg once monthly (doses should be separated by ≥26 days). Note: Establish tolerability with oral aripiprazole prior to initiation of the ER injection; due to the prolonged half-life of oral aripiprazole, it may take up to 2 weeks to fully assess tolerability. Continue (overlap) oral aripiprazole or other oral antipsychotic for 14 days during initiation of the ER injection.

Dosage adjustment of ER injection for adverse effects: Consider reducing dose to 300 mg once monthly.
Missed doses of ER injection:
Second or third doses missed:
>4 weeks but <5 weeks since last dose: Administer next dose as soon as possible.
>5 weeks since last dose: Administer oral aripiprazole for 14 days with next injection; adjust oral dose as needed based on response and tolerability.

Fourth or subsequent doses missed:
>4 weeks but <6 weeks since last dose: Administer next dose as soon as possible.
>6 weeks since last dose: Administer oral aripiprazole for 14 days with next injection; adjust oral dose as needed based on response and tolerability."

Regarding your example, per epocrates:

"schizophrenia, maintenance tx
[400 mg IM qmo]Start: overlap oral antipsychotic tx x14 days; Info: give 300 mg IM qmo in poor CYP2D6 metabolizers; may decr. dose to 300 mg IM qmo; D/C if ANC <1000; consider D/C if unexplained decr. in WBC "

https://online.epocrates.com/drugs/6594/Abilify-Maintena

 

[thepoopologist]

Judging tolerability is an issue of peak plasma, half life/time to steady state

Judging overlap of PO with IM has to do with half life/time to steady state. What you are doing when you have them on oral, cut them off and send them out on a LAI is you are assessing their tolerability but not taking the drug plasma level into account. This isn't as much of a problem when you are talking about Abilify because the half life is so long that cutting them off and putting them on Maintena would not result in as big of a drop in plasma level while Maintena gets to steady state. If you are talking about an antipsychotic with a shorter half life, then you risk them decompensating if you don't do an appropriate overlap.

The protocols as you find them in Uptodate or Stahl or whatever rely on that. Anyway, I support you finding the protocols to use as a guide.

Fast/normal/slow metabolizing can be taken into consideration when observing their response.

 

[NickNaylor]

Frankly you don't even need UpToDate, just look up the package inserts. Most of the information from UpToDate is just the data from package inserts presented in a more friendly way. The package insert will provide guidance with respect to approximate oral-to-LAI conversions, recommendations for oral/LAI overlaps, etc.. Of course, you'll become more familiar with the protocols the more you use the medications.

 

[clausewitz2]

May still be possible to get UptoDate gratis of you connect via a VPN with a Portugese IP address. The Norway loophole has been closed unfortunately.

300-400 per year ain't cheap but when you think about the value as reference, source of copious CMEs, and easy justification as a business expense if you are doing 1099, it's a reasonable value proposition.

 

[soundnin]

Frankly you don't even need UpToDate, just look up the package inserts. Most of the information from UpToDate is just the data from package inserts presented in a more friendly way. The package insert will provide guidance with respect to approximate oral-to-LAI conversions, recommendations for oral/LAI overlaps, etc.. Of course, you'll become more familiar with the protocols the more you use the medications.

and to OP who said he can't look at the package because it's telehealth, the package inserts are freely available on the product websites.

 

[J ROD]

Missouri Society of Health-System Pharmacists - Pharmacist Continuing Education: Overview of Long-Acting Injectable Antipsychotics

 

[NickNaylor]

and to OP who said he can't look at the package because it's telehealth, the package inserts are freely available on the product websites.

Exactly - just Google “[drug name] package insert” and the first link will likely be a PDF on the FDA website.

 

[Armadillos]

I have ton of patients on LAIs, I agree completely about just googling for the package insert.

Also personally I think some people worry a little too much about trying to dial in exactly pharmacokinetic “correct” decisions related to LAIs, but you have to keep in mind at baseline they probably were only rarely taking their meds sporadically so just getting medicine in them is a huge win.

Obviously try to follow the package inserts best you can and don’t do something dangerous, but just as an example the single dose 30mg oral Abilify pill on first day of initio+aristada just seems kind of silly thing added to make the graphs prettier and I doubt has impact on clinic outcomes.

 

[parametric]

Not sure how much it addresses pharmacokinetics specifically, but SMI Adviser has some good posts on LAIs: LAI resources

 

[Ironspy]

I work with a lot of SMI patients and still google the package inserts. There are new formulations of LAIs and I often need to double check. In residency I made a spread sheet of the common LAIs I used and titration recs so that's an option too. It's long gone otherwise I'd offer to share it.

 

[shahseh22]

I work with a lot of SMI patients and still google the package inserts. There are new formulations of LAIs and I often need to double check. In residency I made a spread sheet of the common LAIs I used and titration recs so that's an option too. It's long gone otherwise I'd offer to share it.

if you ever come across it again, please share it.

 

[shahseh22]

Thanks guys for the info and for reviewing some package inserts online. Is this for instance what you are referring to:

https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/022264s023lbl.pdf

Switching to INVEGA SUSTENNA® (paliperidone palmitate) | HCP

Learn about switching patients from risperidone and paliperidone to INVEGA SUSTENNA®. See full prescribing & safety info, including boxed warning.

www.invegasustennahcp.com

I just wonder for instance, I see a lot of Medicaid patients (oral Invega isn't option as its not covered) so I have to have them on Risperdal, but how much dose and how long do I put them on Risperdal before giving first shot of Invega Sustenna? I know initial dose of Sustenna needs to be 234mg so do I get them to 6 mg of Risperdal (see if the tolerate it well), then give them a shot of Innvega Sustenna and discontinue the Risperdal immediately?

 

[clozareal]

SMI Adviser - What long-acting injectable (LAI) antipsychotic medications are available in the U.S.?

Was this Helpful ? YesNo

smiadviser.org

 

[thepoopologist]

Thanks guys for the info and for reviewing some package inserts online. Is this for instance what you are referring to:

https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/022264s023lbl.pdf

Switching to INVEGA SUSTENNA® (paliperidone palmitate) | HCP

Learn about switching patients from risperidone and paliperidone to INVEGA SUSTENNA®. See full prescribing & safety info, including boxed warning.

www.invegasustennahcp.com

I just wonder for instance, I see a lot of Medicaid patients (oral Invega isn't option as its not covered) so I have to have them on Risperdal, but how much dose and how long do I put them on Risperdal before giving first shot of Invega Sustenna? I know initial dose of Sustenna needs to be 234mg so do I get them to 6 mg of Risperdal (see if the tolerate it well), then give them a shot of Innvega Sustenna and discontinue the Risperdal immediately?

The answer you are asking for is in the second link you posted, under "transitioning from Risperidone tablets"

 

[Jules A]

I believe Trinza requires 4 doses of Sustenna?

 

[shahseh22]

The answer you are asking for is in the second link you posted, under "transitioning from Risperidone tablets"

right, I see that no oral supplementation is required, but how do I get them to 6mg of Oral Risperdal quickly in an outpatient basis? So for instance, I saw a guy today and the family really wants to get him on a LAI to restore his competency to trial.

Do I do Risperdal 1 mg BID for 3 days, then 2 mg BID for 3 days and then 3 mg BID then give the shot after 10 days of the oral Risperdal and immediately dsicontinue?

Do I even have to do that much and can I just do Risperdal 1 mg BID for a week and then just give them 234 mg of Invega Sustenna?

Thanks

 

[NickNaylor]

right, I see that no oral supplementation is required, but how do I get them to 6mg of Oral Risperdal quickly in an outpatient basis? So for instance, I saw a guy today and the family really wants to get him on a LAI to restore his competency to trial.

Do I do Risperdal 1 mg BID for 3 days, then 2 mg BID for 3 days and then 3 mg BID then give the shot after 10 days of the oral Risperdal and immediately dsicontinue?

Do I even have to do that much and can I just do Risperdal 1 mg BID for a week and then just give them 234 mg of Invega Sustenna?

Thanks

I work in an inpatient setting so I will titrate medications to therapeutic doses aggressively (e.g., increasing the dose every couple of days). I will typically have someone on a medication for 5-7 days to make sure they tolerate it before giving the LAI. Obviously the half-life of LAIs is extremely long so it will take a while to reach steady-state - I would keep PO medications going for at least a couple of weeks to limit the risk of decompensation due to low plasma levels after the LAI is given.

 

[shahseh22]

I work in an inpatient setting so I will titrate medications to therapeutic doses aggressively (e.g., increasing the dose every couple of days). I will typically have someone on a medication for 5-7 days to make sure they tolerate it before giving the LAI. Obviously the half-life of LAIs is extremely long so it will take a while to reach steady-state - I would keep PO medications going for at least a couple of weeks to limit the risk of decompensation due to low plasma levels after the LAI is given.

I agree with you on Abilify as it is recommended to do oral for a couple of weeks, but I don't want to risk the patient going into NMS if I give too much antipsychotic. Should I taper the Risperdal 3 mg BID if I give 234 mg Invegga Sustenna? Or just abruptly discontinue? How many days do you recommend doing the Risperdal titration from 1 mg BID if on an outpatient basis?

I'm so frustrated because I'm doing all of this via telehealth and I can't see the patient. It would be nice if I could at least call them.

 

[clozareal]

I agree with you on Abilify as it is recommended to do oral for a couple of weeks, but I don't want to risk the patient going into NMS if I give too much antipsychotic. Should I taper the Risperdal 3 mg BID if I give 234 mg Invegga Sustenna? Or just abruptly discontinue? How many days do you recommend doing the Risperdal titration from 1 mg BID if on an outpatient basis?

I'm so frustrated because I'm doing all of this via telehealth and I can't see the patient. It would be nice if I could at least call them.

Invega Sustenna doesn't need an oral bridge after you give the first loading dose of Invega Sustenna. You can discontinue PO after first dose of Invega Sustenna because the release of paliperidone starts as early as day one after injection or you can lower the dose for a week and then completely discontinue after the second loading dose.

NMS is an idiosyncratic and not a dose-dependent phenomenon, although higher doses is a risk for developing NMS.

Abilify Maintena particles have low solubility so has slow and prolonged absorption. It takes about a week to get to the peak dose and the half-life is about 30 days for the 300mg dose and 45 days for the 400mg dose. Dosing with PO Abilify for 2-4 weeks as a bridge isn't going to confer a high risk of NMS unless they might not be a good candidate for an LAI (history of NMS, no outpatient follow-up). Also, given that it's a partial agonist, may have a lower likelihood for NMS.

 

[robellis]

Invega Sustenna doesn't need an oral bridge after you give the first loading dose of Invega Sustenna. You can discontinue PO after first dose of Invega Sustenna because the release of paliperidone starts as early as day one after injection or you can lower the dose for a week and then completely discontinue after the second loading dose.

NMS is an idiosyncratic and not a dose-dependent phenomenon, although higher doses is a risk for developing NMS.

Abilify Maintena particles have low solubility so has slow and prolonged absorption. It takes about a week to get to the peak dose and the half-life is about 30 days for the 300mg dose and 45 days for the 400mg dose. Dosing with PO Abilify for 2-4 weeks as a bridge isn't going to confer a high risk of NMS unless they might not be a good candidate for an LAI (history of NMS, no outpatient follow-up). Also, given that it's a partial agonist, may have a lower likelihood for NMS.

If a higher dose is a risk doesn’t it by definition mean dose dependent? Haldol 5 daily is less a risk for NMS than haldol 30 daily

 

[clozareal]

If a higher dose is a risk doesn’t it by definition mean dose dependent? Haldol 5 daily is less a risk for NMS than haldol 30 daily

Not necessarily. Dose dependence and risk with higher dose are related but distinct phenomena. A dose-dependent response is when you increase the dose, it reliably causes that effect. It's much more evident in toxicology where taking too much of a substance will cause an adverse effect. For example, serotonin syndrome (a better name is serotonin toxicity) is a reliable dose-dependent response. The intensity of clinical findings is thought to reflect the degree of serotonergic activity. If you get enough serotonin receptor agonism, then you will reliably get serotonin syndrome.

Another example is if you take enough amphetamine/methamphetamine/stimulant, you will reliably have a psychotic experience as it is dose-dependent.

Lots of people take haldol 30mg or more without ever getting NMS. NMS is not a toxic response but rather than idiosyncratic one. Overdoses on antipsychotics will also not reliably result in NMS and most cases of NMS actually occur within therapeutic doses. The speed of titration of dose may be more likely to cause NMS than actual total dosge. Also, people can get NMS on low doses at initiation whereas serotonin syndrome does not happen at low doses of SSRIs unless there's something else going on (drug interaction, neurodevelopmental disorders, etc).

 

[shahseh22]

Invega Sustenna doesn't need an oral bridge after you give the first loading dose of Invega Sustenna. You can discontinue PO after first dose of Invega Sustenna because the release of paliperidone starts as early as day one after injection or you can lower the dose for a week and then completely discontinue after the second loading dose.

NMS is an idiosyncratic and not a dose-dependent phenomenon, although higher doses is a risk for developing NMS.

Abilify Maintena particles have low solubility so has slow and prolonged absorption. It takes about a week to get to the peak dose and the half-life is about 30 days for the 300mg dose and 45 days for the 400mg dose. Dosing with PO Abilify for 2-4 weeks as a bridge isn't going to confer a high risk of NMS unless they might not be a good candidate for an LAI (history of NMS, no outpatient follow-up). Also, given that it's a partial agonist, may have a lower likelihood for NMS.

thank you so much for clarifying. I'm seeing medicaid patients so I have to establish tolerability with risperdal PO (Paliperidone PO isn't covered) and I'm doing it outpatient. I was wondering how quickly do you titrate Risperdal to get them to the 3 mg BID to make them suitable for Invega Sustenna 234 mg? Especially for an antipsychotic naieve individual, Do you do it Risperdal 1 mg BID for 1 week, then 2 mg BID, then 3 mg BID? then give them the first shot?

 

[clozareal]

thank you so much for clarifying. I'm seeing medicaid patients so I have to establish tolerability with risperdal PO (Paliperidone PO isn't covered) and I'm doing it outpatient. I was wondering how quickly do you titrate Risperdal to get them to the 3 mg BID to make them suitable for Invega Sustenna 234 mg? Especially for an antipsychotic naieve individual, Do you do it Risperdal 1 mg BID for 1 week, then 2 mg BID, then 3 mg BID? then give them the first shot?

Why would you start an LAI on an antipsychotic naive individual? Also, why would you want to also give them the highest dose of Invega for an antipsychotic naive individual? 3 weeks is definitely not enough time to establish efficacy and tolerability. Ideally, you want to be giving an LAI at a dose known to be effective orally and for antipsychotics, which takes about 12 weeks to determine the maximum benefit on the three domains of positive, negative, and disorganized symptoms.

That dosing schedule sounds somewhat fast. In my experience with risperidone going slower typically is better tolerated from an orthostatic hypotension and EPS standpoint. For receptor antagonism, takes about 2-3 days for the alpha-1 receptors to up-regulate on the arterioles (where most of the smooth muscle in the systemic vasculature and therefore alpha-1 receptors are) which is also when the orthostatic hypotension tends to normalize.

I tend to start with 0.5mg at bedtime for a few nights, then 0.5mg BID, then increase the morning or night dose by 0.5mg every 3-4 days, but tend to stop around 2mg for the first episode for 8-12 weeks which is when the efficacy plateaus because that's where the evidence for the minimum effective dose is. If someone has more than one psychotic episode, then I would probably go up to 4mg/day and for the really refractory cases I would go up to 6mg but giving more sometimes isn't the answer. At that point, I would switch or consider clozapine.

 

[clausewitz2]

Why would you start an LAI on an antipsychotic naive individual? Also, why would you want to also give them the highest dose of Invega for an antipsychotic naive individual? 3 weeks is definitely not enough time to establish efficacy and tolerability. Ideally, you want to be giving an LAI at a dose known to be effective orally and for antipsychotics, which takes about 12 weeks to determine the maximum benefit on the three domains of positive, negative, and disorganized symptoms.

That dosing schedule sounds somewhat fast. In my experience with risperidone going slower typically is better tolerated from an orthostatic hypotension and EPS standpoint. For receptor antagonism, takes about 2-3 days for the alpha-1 receptors to up-regulate on the arterioles (where most of the smooth muscle in the systemic vasculature and therefore alpha-1 receptors are) which is also when the orthostatic hypotension tends to normalize.

I tend to start with 0.5mg at bedtime for a few nights, then 0.5mg BID, then increase the morning or night dose by 0.5mg every 3-4 days, but tend to stop around 2mg for the first episode for 8-12 weeks which is when the efficacy plateaus because that's where the evidence for the minimum effective dose is. If someone has more than one psychotic episode, then I would probably go up to 4mg/day and for the really refractory cases I would go up to 6mg but giving more sometimes isn't the answer. At that point, I would switch or consider clozapine.

Strongly agree with increasing every few days by 0.5 total. Racing to 6 in three weeks is a really good way to make sure you establish intolerability.

Also, I totally missed the suggestion that you were going to give an LAI to someone who had never taken antipsychotics before. First episode world is moving in the direction of more use of LAIs but this is still a conversation to be had only after you establish that the oral is useful in the first place! For first episode especially, more important than what medications you choose is continued engagement of some kind at all costs, and walloping someone with 6 mg of risperidone before the end of the month will likely torch that. These are people who are not socialized into the chronic patient role, they are much more likely to withdraw from treatment if they have a nasty side effect.

So agree with @clozareal about minimum effective dose. You might find this paper that defines minimum effective dosing for a number of agents helpful:

Dose Equivalents for Second-Generation Antipsychotics: The Minimum Effective Dose Method

Abstract. Background: Clinicians need to know the right antipsychotic dose for optimized treatment, and the concept of dose equivalence is important for many cl

academic.oup.com

Really, you could do worse than printing off a couple of the tables in that one and taping them to the wall next to whatever computer you are working from.

 

[shahseh22]

Why would you start an LAI on an antipsychotic naive individual? Also, why would you want to also give them the highest dose of Invega for an antipsychotic naive individual? 3 weeks is definitely not enough time to establish efficacy and tolerability. Ideally, you want to be giving an LAI at a dose known to be effective orally and for antipsychotics, which takes about 12 weeks to determine the maximum benefit on the three domains of positive, negative, and disorganized symptoms.

That dosing schedule sounds somewhat fast. In my experience with risperidone going slower typically is better tolerated from an orthostatic hypotension and EPS standpoint. For receptor antagonism, takes about 2-3 days for the alpha-1 receptors to up-regulate on the arterioles (where most of the smooth muscle in the systemic vasculature and therefore alpha-1 receptors are) which is also when the orthostatic hypotension tends to normalize.

I tend to start with 0.5mg at bedtime for a few nights, then 0.5mg BID, then increase the morning or night dose by 0.5mg every 3-4 days, but tend to stop around 2mg for the first episode for 8-12 weeks which is when the efficacy plateaus because that's where the evidence for the minimum effective dose is. If someone has more than one psychotic episode, then I would probably go up to 4mg/day and for the really refractory cases I would go up to 6mg but giving more sometimes isn't the answer. At that point, I would switch or consider clozapine.

Reason is that some of these patients are highly inconsistent with coming to the appointments and have a history (so not totally naieve) of receiving the meds in jail. I get a lot of push from the social workers to try to medicate them so they can achieve competency to stand trial.

Regarding the starting at 234mg, I thought that is the dose you are suppose to start with (loading dose)?

 

[clozareal]

Reason is that some of these patients are highly inconsistent with coming to the appointments and have a history (so not totally naieve) of receiving the meds in jail. I get a lot of push from the social workers to try to medicate them so they can achieve competency to stand trial.

Regarding the starting at 234mg, I thought that is the dose you are suppose to start with (loading dose)?

You don't take medication orders from social workers, judges, or anyone else. Your license is on the line and you need to do what is best (and safest) for your patient. Even more so for those who are in a vulnerable position where they aren't competent to stand trial, at which point, what's the rush since they're going to be in jail or a state hospital anyway where they can be forced to get IM medications if they refuse oral medications.

Remember that untreated schizophrenia can cause disorganized behavior and thought processes, negative symptoms, and positive symptoms, all of which can interfere with coming to appointments on a consistent basis. However, once they are taking the medication regularly, they can become much more consistent with coming to appointments. I would consider aripiprazole more strongly than risperidone if adherence is an issue as well because the half-life is so much longer and you don't need to reiterate if they miss a few doses. An easy way to cause harm is when a patient is nonadherent to risperidone for a few days and then takes their "regular" dose of 2-3mg and then becomes orthostatic and falls and hits their head.

If the patient is still inconsistent with coming to appointments, then you'll need a different approach—more intensive case managers, community conservatorships, assisted outpatient treatment, daily observed therapy for meds, stronger family engagement. In these cases, I tend to use Risperdal Consta since having an injection medication every 2 weeks will allow the staff to lay eyes on the patient more frequently, more closely monitor for decompensation, and offer more support to the patient if they need it.

Technically from the FDA label, it recommends only 2 weeks to establish tolerability but in real-world clinical practice, this is much longer. The starting dose is 234mg followed by 150mg a week later. Then the third injection (2nd month) is dosed based on the minimal effective dose although can take 8-12 weeks to determine what that is. The maintenance doses can goes as low as 39mg of Invega Sustenna (1mg/day of risperidone) up to 234mg of Invega Sustenna (5-6mg of risperidone). For those who are sensitive to higher doses of risperidone or have mild renal impairment or have any other reason why we shouldn't be using the max dose, we tend to use 156mg followed by 117mg a week later.

 

[shahseh22]

You don't take medication orders from social workers, judges, or anyone else. Your license is on the line and you need to do what is best (and safest) for your patient. Even more so for those who are in a vulnerable position where they aren't competent to stand trial, at which point, what's the rush since they're going to be in jail or a state hospital anyway where they can be forced to get IM medications if they refuse oral medications.

Remember that untreated schizophrenia can cause disorganized behavior and thought processes, negative symptoms, and positive symptoms, all of which can interfere with coming to appointments on a consistent basis. However, once they are taking the medication regularly, they can become much more consistent with coming to appointments. I would consider aripiprazole more strongly than risperidone if adherence is an issue as well because the half-life is so much longer and you don't need to reiterate if they miss a few doses. An easy way to cause harm is when a patient is nonadherent to risperidone for a few days and then takes their "regular" dose of 2-3mg and then becomes orthostatic and falls and hits their head.

If the patient is still inconsistent with coming to appointments, then you'll need a different approach—more intensive case managers, community conservatorships, assisted outpatient treatment, daily observed therapy for meds, stronger family engagement. In these cases, I tend to use Risperdal Consta since having an injection medication every 2 weeks will allow the staff to lay eyes on the patient more frequently, more closely monitor for decompensation, and offer more support to the patient if they need it.

Technically from the FDA label, it recommends only 2 weeks to establish tolerability but in real-world clinical practice, this is much longer. The starting dose is 234mg followed by 150mg a week later. Then the third injection (2nd month) is dosed based on the minimal effective dose although can take 8-12 weeks to determine what that is. The maintenance doses can goes as low as 39mg of Invega Sustenna (1mg/day of risperidone) up to 234mg of Invega Sustenna (5-6mg of risperidone). For those who are sensitive to higher doses of risperidone or have mild renal impairment or have any other reason why we shouldn't be using the max dose, we tend to use 156mg followed by 117mg a week later.

Thank you, I wish we would have had more training to LAI's in Residency.