Long-acting injectable antipsychotics during COVID-19 How to determine if your patient should continue an LAI, and how to do so safely Kristina Schnitzer, MD ong-acting injectable antipsychotics (LAIs) are an essential tool Fellow, Public and Community Psychiatry Massachusetts General Hospital in the treatment of patients with psychotic disorders, allowing Boston, Massachusetts for periods of stable drug plasma concentration and confirmed L 1 Sarah MacLaurin, PMHNP-BC adherence. The current coronavirus disease 2019 (COVID-19) pan- Freedom Trail Clinic of North Suffolk Mental demic presents unique challenges for administering LAIs and requires Health Association a thoughtful and prospective approach in order to ensure continuity of Massachusetts General Hospital Boston, Massachusetts psychiatric care while minimizing the risk of infection with COVID-19. Oliver Freudenreich, MD, FACLP Ideally, patients should be seen in person as infrequently as clinically Co-Director, MGH Schizophrenia Clinical and prudent during this public health emergency; however, LAI administra- Research Program tion necessitates direct physical contact between patient and clinician. Associate Professor of Psychiatry Harvard Medical School Patients with serious mental illness (SMI), who comprise the majority Boston, Massachusetts of individuals who receive LAIs, are at heightened risk for cardiovascu- Disclosures lar and pulmonary comorbidities. These factors are the primary reason Dr. Freudenreich has received grant or research support the life expectancy of a patient with SMI is nearly 30 years shorter than from Alkermes, Avanir, Janssen, Otsuka, and Saladax, 2-5 and has served as a consultant to Alkermes, Janssen, that of the general population. The risk of health care workers becom- Neurocrine, Novartis, and Roche. Drs. Schnitzer and ing infected or inadvertently spreading COVID-19 is heightened when MacLaurin report no financial relationships with any companies whose products are mentioned in this article, working with patients in group living environments (ie, a shelter or or with manufacturers of competing products. group home), who have both increased exposure and increased risk of doi: 10.12788/cp.0087 further transmission.6 Additional patient populations, including older adults, immunocompromised individuals, and those with preexisting conditions, are at heightened risk for serious complications if they were to contract COVID-19.7,8 Thus, the questions of whether LAIs should be administered, and how to do so safely (both during the ongoing, acute phase of the pan- demic as well as during the subsequent recovery period until the pan- demic abates) need to be carefully considered. In this article, we provide concrete advice for clinicians and clinics on these topics, with the goal of Current Psychiatry GARY WATERS GARY Vol. 20, No. 2 9 Table 1 environment and health-vulnerability Considerations for LAI of the patient and the individuals living administration during COVID-19 with them. If the risk calculation does not point Should an LAI be continued? strongly towards a need for continuing Which LAI should be administered? the LAI, it may be prudent to temporar- When should the LAI be administered? ily transition the patient to the corre- LAIs during Where can the LAI be administered? sponding oral antipsychotic preparation. COVID-19 Who can administer the LAI? Table 2 (page 11) lists all LAIs available in the United States and their approximate What safety measures can be put in place to minimize risk to all parties? equivalent oral dosing. It is important to COVID-19: coronavirus disease 2019; LAI: long-acting note that such transitions are not without injectable antipsychotic clinical risk, to emphasize to the patient that the transition is intended as a tempo- rary measure, and to discuss a proposed timeline for re-initiating the LAI. Also, Clinical Point maintaining patients’ psychiatric stability emphasize to the patient and family that In some cases, it while protecting patients, health care work- this transition does not diminish the pre- ers, and the broader society from COVID-19 vious reasoning for needing an LAI, but may be prudent to infection. Table 1 summarizes the ques- is a temporary measure taken in light of temporarily transition tions regarding LAIs that clinicians need to weighing the risks and benefits during a the patient to the address during this crisis. While we focus pandemic. corresponding on outpatient care, inpatient teams should keep these considerations in mind if they oral antipsychotic are starting and discharging a patient on Which LAI should be preparation an LAI. More than ever, close collaboration administered? and communication between inpatient and If continuing the LAI is determined to be outpatient teams is critical. clinically necessary, consider switching the patient to a longer-acting preparation to maximize intervals between administra- Should an LAI be continued? tions and minimize the potential for infec- An important first step to approaching tion. From a public health perspective, the this challenge is to create a spreadsheet longest clinically prudent interval between for all patients receiving LAIs. Focusing injections may be the most important con- on a population-based approach is help- sideration, provided the patient can receive ful to be systematic and ensure that no a dose necessary to retain stability, and the patients fall through the cracks during LAI should be chosen accordingly. Deltoid this public health emergency.9 Once all injections may be able to be administered patients have been identified, the treat- with reduced contact, or on a “drive-up” ment team should review each patient to basis.10 Consider transitioning a patient determine if continuing to administer the who is receiving olanzapine pamoate antipsychotic as an LAI formulation is to an alternate LAI or oral formulation, essential, taking into account the patient’s because the 3-hour observation period current psychiatric status, historical medi- that is required after olanzapine pamoate cation adherence, potential severity and administration is particularly problematic. Discuss this article at dangerousness of decompensation if While it may not be ideal to make medica- www.facebook.com/ nonadherent, and structures to support tion changes during a pandemic, it is worth MDedgePsychiatry stability. For example, can a patient move carefully weighing the patient’s stability in with family who can monitor medica- and historical experience with other LAIs to tion adherence during the pandemic? Is determine if a safer/longer-spaced option it possible for the group home to assume is worth trying.11 medication administration? Additional We recommend only switching among Current Psychiatry 10 February 2021 consideration should be given to the living similar antipsychotics (ie, risperidone to Table 2 Long-acting injectable antipsychotics and equivalent oral dosing Medication Dosing schedule MDedge.com/psychiatry Abilify Aristada 882 mg 1,064 mg 882 mg 662 mg 441 mg q4wks q8wks q6wks q4wks q4wks Abilify Maintena 400 mg 300 mg 300 mg 300 mg 200 mg q4wks q4wks q4wks q4wks q4wks Abilify (PO) 20 mg 15 mg 15 mg 15 mg 10 mg Fluphenazine decanoate 25 mg 12.5 mg q3wks q2wks Fluphenazine (PO) 20 mg 10 mg Haldol decanoate 200 mg 100 mg q4wks q4wks Haldol (PO) 20 mg 10 mg Invega Trinza 819 mg 546 mg 410 mg 273 mg q12wks q12wks q12wks q12wks Invega Sustenna 234 mg 156 mg 117 mg 78 mg 39 mg Clinical Point q4wks q4wks q4wks q4wks q4wks If an LAI is necessary, Invega (PO) 12 mg 9 mg 6 mg 3 mg 1.5 mg consider switching Risperdal Consta 50 mg 37.5 mg 25 mg 12.5 mg q2wks q2wks q2wks q2wks to a longer-acting Perseris (subcutaneous) 120 mg 90 mg preparation q4wks q4wks to maximize Risperidone (PO) 4 mg 3 mg 2 mg 1 mg Zyprexa Relprevv 300 mg 405 mg 210 mg 300 mg 150 mg intervals between q2wks q4wks q2wks q4wks q2wks administrations Zyprexa (PO) 20 mg 15 mg 15 mg 10 mg 10 mg Source: Adapted from reference 1 PO: by mouth; q2wks: once every 2 weeks; q3wks: once every 3 weeks; q4wks: once every 4 weeks; q8wks: once every 8 weeks; q12wks: once every 12 weeks paliperidone), or between different prepara- with oral medications. For patients who tions of the same drug (ie, Abilify Maintena are in quarantine, it may be better to delay to Aristada), if possible, as these are the low- an injection until the patient ends their est risk transitions with regards to relapse. quarantine than to deliver the dose dur- Table 3 (page 12) provides examples. ing quarantine. Administering an injec- tion earlier also is usually safe; off-cycle visits may help minimize patient contact When should the LAI be (ie, if the patient happens to be coming administered? into the vicinity of the clinic, or requires The pharmacokinetics of LAIs allow for phlebotomy for therapeutic drug monitor- some flexibility in terms of when an LAI ing), and assist in planning for possible needs to be administered. The package resurgences. When appropriate, and after inserts of all second-generation LAIs considering the risk of worsening adverse include missed-dose guidelines. These effects, administering a higher dose than guidelines provide information on how the usual maintenance dose would pro- long one can wait before the next injec- vide a buffer if the next injection was to tion is due, and what additional measures be delayed. Therapeutic drug monitoring must be taken when beyond that date. can help to optimize dosing and avoid low Delaying an injection may be prudent, and plasma drug levels,