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Long-Acting Injectable Antipsychotic Medications and Conversion Dosing Practical Tips for Practice Long-Acting Injectable Antipsychotic Medications and Conversion Dosing: Practical Tips for Practice Loading Usual Starting Dose Target Dose Max Dose Dosing Interval Dose Oral or Other Overlap* Injection Site Special Notes Option 12.5-50 mg Continue oral, decreasing dose by half after Not Gluteal Z-track recommended4 Fluphenazine Decanoate1,2 12.5-25 mg IM/SQ (interval determined by 100 mg/dose Q 2-4 weeks first injection, d/c oral therapy after second established Deltoid Use dry syringe/needle patient response) injection1,3 100 mg/1st Z-track recommended4 10-15X daily PO dose Continue oral for the first 2 to 3 injections if not Gluteal Haloperidol Decanoate5 10-20X daily PO dose IM injection; 450 mg/ Q 4 weeks Yes Do not administer > 3 ml per IM Q 4 weeks using loading dose3 Deltoid 4 weeks injection site Risperidone Long-acting 25-50 mg IM Q 2 Oral risperidone (or other oral antipsychotic) 25 mg IM Q 2 weeks + PO Gluteal injection weeks (range 12.5-50 50 mg Q 2 weeks Q 2 weeks No should be given with 1st injection and None dose for 3 weeks Deltoid (Risperdal Consta®)6 mg) continued for 3 weeks Risperidone “extended release” 90 or 120 mg SQ Q 120 mg SQ Q Establishment of tolerability by prior oral Abdomen only 90 or 120 mg SQ Q month Q Monthly n/a Abdomen- SQ (Perseris®)7 month month administration is recommended Inject slow and steady Deltoid Deltoid Day 1 and 8 Inj.; 234 mg IM day 1, then 156 Gluteal Paliperidone Palmitate monthly 117 mg IM Q monthly Establishment of tolerability by prior oral Maintenance given deltoid or mg IM day 8 (both in 234 mg Q month Q Monthly Yes (after second (Invega Sustenna®)8 (range 39-234 mg) administration is recommended gluteal; administered 5 deltoid)# injection) weeks after first injection Used only after establishment of four months of Paliperidone Palmitate Paliperidone Palmitate Based on Paliperidone Use of Paliperidone Palmitate monthly for the once monthly injection (last 2 819 mg IM Q 3 Gluteal three month Palmitate once monthly Q 3 months No previous 4 months Inject slowly months with the same dose); months Deltoid (Invega Trinza®)9 dose (last 2 months with the same dose) dose based on Paliperidone Palmitate IM once monthly dose$ Post dose monitoring: at 150 mg or 210 mg or 300 mg 150 mg or 210 mg or 300 mg Q 2 least three hours; observe Olanzapine Pamoate IM Q 2 weeks; OR 300 mg IM Q 2 weeks Establishment of tolerability by prior oral weeks; 405 mg Q Q 2 weeks or Q 4 weeks Yes Gluteal for delirium and sedation; (Zyprexa Relprevv®)10 300 mg or 405 mg IM Q 4 OR 300 mg or 405 mg administration is recommended 4 weeks inject steady continuous weeks IM Q 4 weeks pressure Oral aripiprazole 10-20 mg/day (or other oral Aripiprazole Monohydrate 400 mg IM Q Gluteal 400 mg IM Q month 400 mg IM Q month Q Monthly No antipsychotic already in use) should be given Inject Slowly (Abilify Maintena®)11 month Deltoid after the first injection for 14 consecutive days Aripiprazole Lauroxil At initiation of Aripiprazole 30 mg oral aripiprazole in combination when Gluteal Rapid and Continuous nanocrystal technology 675 mg IM Single Dose Only 675 mg Lauroxil or if indicated for n/a initiating Aripiprazole Lauroxil and if indicated Deltoid Injection (Aristada Initio®)12 reinitiating Aripiprazole Lauroxil for reinitiating Aripiprazole Lauroxil 441 mg or 662 mg or 441 mg or 662 mg or 882 mg Gluteal (all doses) 882 mg IM Q monthly; Q monthly (441, 662, 882 mg) Oral aripiprazole should be given after the first Aripiprazole Lauroxil IM Q monthly; OR 882 mg 1064 mg IM Q 2 Deltoid Rapid and Continuous OR 882 mg IM Q 6 Q 6 weeks (882 mg only) Yes injection for 21 consecutive days if Aripiprazole (Aristada®)13 IM Q 6 weeks; OR 1064 mg months (441 mg dose only) Injection weeks; OR 1064 mg IM Q 2 months (1,064 mg only) Lauroxil nanocrystal technology not utilized IM Q 2 months Q 2 months *Prior establishment of tolerability recommended #Patients may be given the second initiation dose within a +4-day flexible window $Patients may be given the injection up to 2 weeks before or after the 3-month time point 1. Fluphenazine Decanoate Injection, USP [package insert]. Rockford, IL: Mylan Institutional LLC; August 2018. 2. Jann MW, Ereshefsky L, Saklad SR. Clinical pharmacokinetics of the depot antipsychotics. Clinical Pharmacokinetics 1985;10(4):315-333. 3. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/5432273; Accessed July 7, 2020. 4. McEvoy, JP. Risks versus benefits of different types of long-acting injectable antipsychotics. J Clin Psych. 2006;67[suppl 5]:15-18. 5. Haloperidol Decanoate Injection [package insert]. North Wales, PA: TEVA Pharmaceuticals, April 2019. 6. Risperdal Consta® [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; January 2020. 7. Perseris® [package insert]. North Chesterfield, VA: Indivior, Inc; December 2019. 8. Invega Sustenna ® [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; January 2019. 9. Invega Trinza ® [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; January 2019. 10. Zyprexa Relprevv ® [package insert]. Indianapolis, IN: Eli Lilly and Company; April 2020. 11. Abilify Maintena ® [package insert]. Tokyo, Japan: Otsuka Pharmaceutical Co.,LTD.; June 2020. 12. Aristada Initio® [package insert]. Waltham, MA: Alkermes, Inc.; February 2020. 13. Aristada® [package insert]. Waltham, MA: Alkermes, Inc.; February 2020. 1 LONG-ACTING INJECTABLE ANTIPSYCHOTIC MEDICATIONS AND CONVERSION DOSING How Supplied Need to Reconstitute Refrigeration Protect from Pre-filled Needles Needle Size Stability after Reconstitution (hrs) Needed* Light syringes Provided Fluphenazine Decanoate1,2 25 mg/mL; 5 mL multi-dose vial No No Yes No No 21 gauge or larger NA 50 mg/mL & 100 mg/mL; 1 mL Haloperidol Decanoate4 single-dose vials and 5 mL multi- No No Yes No No 21 gauge NA dose vials Risperidone Long-acting injection 12.5, 25, 37.5 & 50 mg dose packs Yes Yes (7 days Yes No Yes Gluteal: 20 gauge, 2” May be used up to 6 hours after (Risperdal Consta®)5 maximum at room Deltoid: 21 gauge, 1” suspended (store at room temp.); temp. not to resuspend if necessary before exceed 77°F) administering Risperidone “extended release” 90, 120 mg syringe kits Yes Yes (7 days No No Yes 18 gauge, 5/8” May be stored for up to 7 days in its (Perseris®)6 maximum at room unopened original packaging at room temp. not to temp. use within 7 days or discard; exceed 77°F) allow to come to room temp 15 mins Paliperidone Palmitate once 39, 78, 117, 156, & 234 mg kits No No No Yes Yes Gluteal all patients: 22 gauge, 1.5 “ Resuspend if necessary before monthly Deltoid: <90 kg: 23 gauge, 1” or administering (Invega Sustenna®)7 >90 kg: 22 gauge, 1.5” Paliperidone Palmitate 273, 410, 546, 819 mg kits No No No Yes Yes Gluteal all patients: 22 gauge, 1 ½” Resuspend if necessary before three months Deltoid: <90 kg: 22 gauge, 1” administering; shake 15 seconds (Invega Trinza®)8 >90 kg: 22 gauge, 1 ½” within 5 minutes of injecting Olanzapine Pamoate 210, 300, & 405 mg single-use kits Yes No No No Yes Non-obese: 19 gauge, 1.5” 24 hours after suspended; agitate (Zyprexa Relprevv®)9 (2” needle Obese: 19 gauge, 2” vial before withdrawing and inject not immediately included) Aripiprazole Monohydrate 300, 400 mg pre-filled syringes; Vials and Syringes (via No Yes (pre-filled Yes Yes Gluteal, non-obese pts or Deltoid, obese patients: Not stated, give injection immediately (Abilify Maintena®)10 300, 400 mg single-dose vials the dual chamber syringes) 22 gauge, 1.5” upon reconstituting; inject slowly, syringe kit)- Yes Gluteal, obese patients: 21 gauge, 2” resuspend if necessary before Deltoid, non-obese pts: 23 gauge, 1” administering Aripiprazole Lauroxil nanocrystal 675 mg pre-filled syringe No No No Yes Yes Gluteal: 20 gauge, 1 ½“, or 20 gauge, 2” N/A technology (Aristada Initio®)11 Deltoid: 21 gauge, 1” or 20 gauge, 1 ½“ Aripiprazole Lauroxil (Aristada®)12 441, 662, 882, or 1064 mg pre- No No No Yes Yes Gluteal all doses: 20 gauge, 1 ½“ or 20 gauge, 2” N/A filled syringes Deltoid (441 mg only): 21 gauge, 1” or 20 gauge, 1 ½“ * Prior to reconstitution 1. Fluphenazine Decanoate Injection, USP [package insert]. Rockford, IL: Mylan Institutional LLC; August 2018. 2. Jann MW, Ereshefsky L, Saklad SR. Clinical pharmacokinetics of the depot antipsychotics. Clinical Pharmacokinetics 1985;10(4):315-333. 3. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/5432273; Accessed July 7, 2020. 4. McEvoy, JP. Risks versus benefits of different types of long-acting injectable antipsychotics. J Clin Psych. 2006;67[suppl 5]:15-18. 5. Haloperidol Decanoate Injection [package insert]. North Wales, PA: TEVA Pharmaceuticals, April 2019. 6. Risperdal Consta® [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; January 2020. 7. Perseris® [package insert]. North Chesterfield, VA: Indivior, Inc; December 2019. 8. Invega Sustenna ® [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; January 2019. 9. Invega Trinza ® [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; January 2019. 10. Zyprexa Relprevv ® [package insert]. Indianapolis, IN: Eli Lilly and Company; April 2020. 11. Abilify Maintena ® [package insert]. Tokyo, Japan: Otsuka Pharmaceutical Co.,LTD.; June 2020. 12. Aristada Initio® [package insert]. Waltham, MA: Alkermes, Inc.; February 2020. 13. Aristada® [package insert]. Waltham, MA: Alkermes, Inc.; February 2020 2 LONG-ACTING INJECTABLE ANTIPSYCHOTIC MEDICATIONS AND CONVERSION
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  • CENTRAL NERVOUS SYSTEM DEPRESSANTS Opioid Pain Relievers Anxiolytics (Also Belong to Psychiatric Medication Category) • Codeine (In 222® Tablets, Tylenol® No

    CENTRAL NERVOUS SYSTEM DEPRESSANTS Opioid Pain Relievers Anxiolytics (Also Belong to Psychiatric Medication Category) • Codeine (In 222® Tablets, Tylenol® No

    CENTRAL NERVOUS SYSTEM DEPRESSANTS Opioid Pain Relievers Anxiolytics (also belong to psychiatric medication category) • codeine (in 222® Tablets, Tylenol® No. 1/2/3/4, Fiorinal® C, Benzodiazepines Codeine Contin, etc.) • heroin • alprazolam (Xanax®) • hydrocodone (Hycodan®, etc.) • chlordiazepoxide (Librium®) • hydromorphone (Dilaudid®) • clonazepam (Rivotril®) • methadone • diazepam (Valium®) • morphine (MS Contin®, M-Eslon®, Kadian®, Statex®, etc.) • flurazepam (Dalmane®) • oxycodone (in Oxycocet®, Percocet®, Percodan®, OxyContin®, etc.) • lorazepam (Ativan®) • pentazocine (Talwin®) • nitrazepam (Mogadon®) • oxazepam ( Serax®) Alcohol • temazepam (Restoril®) Inhalants Barbiturates • gases (e.g. nitrous oxide, “laughing gas”, chloroform, halothane, • butalbital (in Fiorinal®) ether) • secobarbital (Seconal®) • volatile solvents (benzene, toluene, xylene, acetone, naptha and hexane) Buspirone (Buspar®) • nitrites (amyl nitrite, butyl nitrite and cyclohexyl nitrite – also known as “poppers”) Non-Benzodiazepine Hypnotics (also belong to psychiatric medication category) • chloral hydrate • zopiclone (Imovane®) Other • GHB (gamma-hydroxybutyrate) • Rohypnol (flunitrazepam) CENTRAL NERVOUS SYSTEM STIMULANTS Amphetamines Caffeine • dextroamphetamine (Dexadrine®) Methelynedioxyamphetamine (MDA) • methamphetamine (“Crystal meth”) (also has hallucinogenic actions) • methylphenidate (Biphentin®, Concerta®, Ritalin®) • mixed amphetamine salts (Adderall XR®) 3,4-Methelynedioxymethamphetamine (MDMA, Ecstasy) (also has hallucinogenic actions) Cocaine/Crack