Plan when LAI no longer working?

[surfguy84]

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Have an inpatient who is on maintena for at least several months but presented here with acutely psychotic and disorganized behavior. Drugs, organic causes have been ruled out as exacerbating factors. I think right now its clear the LAI isn't doing the trick. Would you give additional PO? Switch to another antipsychotic entirely and not give the next LAI dose? Any other thoughts?

 

[Sushirolls]

Nicotine... has it changed? It can impact blood level of antipsychotics.

 

[surfguy84]

Nicotine... has it changed? It can impact blood level of antipsychotics.

Good thought...but I thought smoking induced CYP1A2 primarily and not the CYP that metabolize Abilify.

But also no, no smoking reported.

 

[Sushirolls]

1) Back when I worked IP years ago, move up the dosage timing by 1 week if its a q4 week dosing?
2) Change med to different LAI
3) Adjunct with Haldol oral

*Pros/cons to each, adjuncting with 2nd is least desirable.

I'm rusty on those CYPs, not doing inpatient anymore.

 

[Jules A]

In general Abilify isn't my preference for acutely psychotic patients or those I know have been acutely psychotic in the past. The selection would depend on what other meds they have been on but I would most likely add PO of another antipsychotic with LAI option and plan to change over if helpful and tolerated.

 

[Sushirolls]

Yeah, I never got people going with abilify LAI. Usually started by colleagues on the unit and I followed through with their plan.
Risperdal / haldol / prolixin LAI were go to meds.

 

[Wheatbread]

Based on this info my opinion would be to switch to Invega. We use a ton here and I generally find it to be very effective. I agree with others that Abilify isn’t the best from an anecdotal perspective.

 

[Stagg737]

Have an inpatient who is on maintena for at least several months but presented here with acutely psychotic and disorganized behavior. Drugs, organic causes have been ruled out as exacerbating factors. I think right now its clear the LAI isn't doing the trick. Would you give additional PO? Switch to another antipsychotic entirely and not give the next LAI dose? Any other thoughts?

Were they ever doing well on it? If so, for how long? Or was it just keeping them out of the hospital? Is it having the wearing-off effect or is it just not working anymore? Can you bump it to 400mg or switch to Aristada? Any other factors like new meds? Need more info to help, but found an interesting article (note, I skimmed it but plan to read later) that might be helpful:

Psychopharmacology of Aripiprazole LAIs - Abilify Maintena & Aristada

Yeah, I never got people going with abilify LAI. Usually started by colleagues on the unit and I followed through with their plan.
Risperdal / haldol / prolixin LAI were go to meds.

Abilify has become much more convenient since you can give a loading dose and not have to bridge at all with POs. Imo Aristada also seems more effective for those getting q3month dosing than the other Q3month+ LAIs. Curious about others' experience with Hafyera and if anyone has used it successfully, as anecdotally I've heard poor things.

 

[surfguy84]

Based on this info my opinion would be to switch to Invega. We use a ton here and I generally find it to be very effective. I agree with others that Abilify isn’t the best from an anecdotal perspective.

I too don't like using abilify in the acute setting. ALso I believe I've read it takes 4 months for Maintena to get to steady state. So wouldnt it follow an accurate assessment couldnt be made until the patient has been on the LAI for 4 months?

If i were to start risperdal with intention of transitioning to invega, could I just start at the regular dose and titrate as normally would?

 

[Jules A]

Were they ever doing well on it? If so, for how long? Or was it just keeping them out of the hospital? Is it having the wearing-off effect or is it just not working anymore? Can you bump it to 400mg or switch to Aristada? Any other factors like new meds? Need more info to help, but found an interesting article (note, I skimmed it but plan to read later) that might be helpful:

Psychopharmacology of Aripiprazole LAIs - Abilify Maintena & Aristada



Abilify has become much more convenient since you can give a loading dose and not have to bridge at all with POs. Imo Aristada also seems more effective for those getting q3month dosing than the other Q3month+ LAIs. Curious about others' experience with Hafyera and if anyone has used it successfully, as anecdotally I've heard poor things.

I have been watching the additional Abilify offerings but haven't seen enough to form a reasonable anecdotal opinion. The name Hafyera makes me shake my head.

One of the inpatient units where I work has been using Perseris recently with a decent effect although most seem to need the higher dose.

 

[Stagg737]

I have been watching the additional Abilify offerings but haven't seen enough to form a reasonable anecdotal opinion. The name Hafyera makes me shake my head.

One of the inpatient units where I work has been using Perseris recently with a decent effect although most seem to need the higher dose.

Hafyera is Invega, and the dosing schedule is exactly what one would guess, lol.

 

[G Sheb]

Change to a different antipsychotic unless there are drugs involved.
If he's been on another antipsychotic in the past, then clozapine is an option if the pt is a candidate.

 

[Wheatbread]

I too don't like using abilify in the acute setting. ALso I believe I've read it takes 4 months for Maintena to get to steady state. So wouldnt it follow an accurate assessment couldnt be made until the patient has been on the LAI for 4 months?

If i were to start risperdal with intention of transitioning to invega, could I just start at the regular dose and titrate as normally would?

If it was me, again not knowing the entire case, but I would give a one time 6mg oral invega test dose at the time of monthly maintena. If patient tolerates then give the loading 234mg dose without the booster. If patient is really psychotic I might start oral 3mg if the injection date is far off to control symptoms.

 

[When is graduation again?]

Abilify has become much more convenient since you can give a loading dose and not have to bridge at all with POs. Imo Aristada also seems more effective for those getting q3month dosing than the other Q3month+ LAIs. Curious about others' experience with Hafyera and if anyone has used it successfully, as anecdotally I've heard poor things.

I've wanted to use Hayfera for some time, but I also have heard of it wearing off. Also, I've had a run of bad lack in inheriting patients on invega having progressively worsening CKD/ESRD (wasn't caught previously because no one did labs for several years) causing nightmares for monitoring/switching to other LAIs. I'm probably going to trial it with my healthy, young patients, initially.

If it was me, again not knowing the entire case, but I would give a one time 6mg oral invega test dose at the time of monthly maintena. If patient tolerates then give the loading 234mg dose without the booster. If patient is really psychotic I might start oral 3mg if the injection date is far off to control symptoms.

Do you find that one dose is typically enough of a trial to switch most LAIs or is this specific to switching to invega? I've looked into switching to Haldol or Abilify from Invega, but I've seen recommendations for as much as a 2 week oral trial to establish tolerability.

 

[annoyedpsychiatrist]

Well i tend to not do LAIs unless they're doing well on the oral or they're at least improving. Some people don't respond well to certain antipsychotics, if they're unstable and you give them an LAI now its just more medication staying around in their body, and if its ineffective, now you have to add another antipsychotic. If you're going to give an LAI to an unstable person it would make more sense to do sustenna, because the levels are active without needing oral overlap.

I think abilify maintenna works fine for a lot of my patients in the past, i liked it. I tended to use invega sustenna, abilify maintenna, prolixin dec/haldol dec occasionally. I preferred abilify/invega the most.

if maintenna isnt working at all, then i think adding is pointless, you should replace it with something else. I would only consider adding low dose haldol if there was at least a partial response to abilify. If no response, then it doesnt make sense to continue it. I believe 400mg=20mg oral which is a fair dose, so if theyre not responding to that, they're probably not a good abilify canidate.

 

[Merovinge]

Given this patient was stable presumably on this medication for several months, did you check in with the OP/ACT team already to ensure they received the most recent dosage of the Maintena? I recall several instances when I was doing IP adult work where pt's were "on" an LAI and when our team got ahold of the pharmacy information they hadn't received the medication for 2-3 months.

 

[surfguy84]

Given this patient was stable presumably on this medication for several months, did you check in with the OP/ACT team already to ensure they received the most recent dosage of the Maintena? I recall several instances when I was doing IP adult work where pt's were "on" an LAI and when our team got ahold of the pharmacy information they hadn't received the medication for 2-3 months.

Following up on this at the moment...

 

[notamindreader]

Have an inpatient who is on maintena for at least several months but presented here with acutely psychotic and disorganized behavior. Drugs, organic causes have been ruled out as exacerbating factors. I think right now its clear the LAI isn't doing the trick. Would you give additional PO? Switch to another antipsychotic entirely and not give the next LAI dose? Any other thoughts?

Consideration for Clozapine? If they are in a hospital setting, the titration and monitoring is as ideal as it will ever be. Also, I've had plenty of patients on LAI Sustenna with oral Haloperidol with some limited benefit.

 

[surfguy84]

Consideration for Clozapine? If they are in a hospital setting, the titration and monitoring is as ideal as it will ever be. Also, I've had plenty of patients on LAI Sustenna with oral Haloperidol with some limited benefit.

Very unlikely to be able to meet the lab testing requirements. And he has a history of non-compliance. Starting a med like clozapine which would require re-titration after a short period of non-compliance seems like a contraindication for him.