12 Clinical Cases for Long-Acting Antipsychotic Medications
Long-acting injectable antipsychotics (LAIs) are an underutilized treatment option that can significantly improve medication adherence and reduce relapse rates in patients with schizophrenia and other psychotic disorders. 1
Case 1: First Episode Psychosis with Poor Medication Adherence
A 22-year-old male university student presents with his first psychotic episode characterized by paranoid delusions and auditory hallucinations. After initial stabilization on oral risperidone 4mg daily, he shows good symptom response but frequently forgets to take his medication, leading to symptom fluctuations.
Management:
- Discuss LAI options early in treatment course
- Initiate oral risperidone for 4 weeks to establish tolerability
- Transition to risperidone LAI 25mg every 2 weeks with oral supplementation for first 3 weeks
- Monitor for effectiveness and side effects at 4 weeks
- Consider increasing to 37.5mg if response is suboptimal
Case 2: Chronic Schizophrenia with Multiple Relapses
A 35-year-old female with 10-year history of schizophrenia has experienced four hospitalizations in the past two years due to medication non-adherence. She reports disliking the daily reminder of her illness that oral medications represent.
Management:
- Transition from current oral antipsychotic to paliperidone LAI
- Start with 150mg in deltoid muscle on day 1, followed by 100mg one week later
- Continue with 100mg monthly thereafter
- Monitor plasma levels 7-11 days after injection if response is suboptimal 2
- Assess for symptom improvement using standardized measures 1
Case 3: Treatment-Resistant Schizophrenia
A 40-year-old male with schizophrenia has failed adequate trials of two different oral antipsychotics despite reported good adherence. Symptoms include persistent delusions and negative symptoms affecting functioning.
Management:
- Initiate clozapine trial as recommended for treatment-resistant schizophrenia 1
- If clozapine is effective but patient struggles with adherence to blood monitoring, consider adding LAI as augmentation strategy
- Monitor clozapine blood levels to ensure therapeutic range (≥350 ng/mL) 2
- Consider metformin to attenuate potential weight gain with clozapine 1
Case 4: Elderly Patient with Schizophrenia
A 72-year-old male with long-standing schizophrenia has developed mild cognitive impairment and frequently forgets to take his medications. He lives independently but family members are concerned about his self-care.
Management:
- Consider risperidone LAI at lower starting dose (25mg every 2 weeks)
- Monitor closely for extrapyramidal symptoms and orthostatic hypotension
- Assess cognitive function regularly
- LAIs have shown efficacy and safety in elderly patients with significant symptom improvements 3
Case 5: Comorbid Substance Use Disorder
A 29-year-old male with schizophrenia and comorbid cannabis use disorder has difficulty maintaining medication adherence. His psychotic symptoms worsen during periods of increased substance use.
Management:
- Initiate LAI to provide consistent antipsychotic coverage
- Consider paliperidone LAI monthly injection
- Integrate with substance use treatment program
- Monitor for drug interactions and adjust dosing as needed
- Implement coordinated specialty care program as recommended 1
Case 6: Transitioning from Acute Hospitalization
A 31-year-old female is being discharged after her third hospitalization for acute psychosis. Previous discharges resulted in medication discontinuation within weeks.
Management:
- Start LAI before discharge to ensure continuity of care
- Provide oral supplementation during initial period if needed
- Schedule first outpatient follow-up within one week of discharge
- Implement assertive community treatment for ongoing support 1
- Monitor for injection site reactions and extrapyramidal symptoms 4
Case 7: Patient with Metabolic Concerns
A 45-year-old male with schizophrenia and metabolic syndrome (obesity, hypertension, type 2 diabetes) requires antipsychotic treatment but is concerned about further metabolic deterioration.
Management:
- Select LAI with lower metabolic risk profile
- Consider aripiprazole LAI which has lower propensity for weight gain
- Monitor metabolic parameters regularly (weight, blood pressure, glucose, lipids)
- Implement lifestyle interventions concurrently
- Consider metformin as adjunctive therapy 1
Case 8: Pregnancy Planning
A 27-year-old female with stable schizophrenia on risperidone LAI is planning pregnancy in the next year. She has been stable on LAI for 18 months.
Management:
- Discuss risks/benefits of continuing LAI during pregnancy planning and pregnancy
- Consider transition to lowest effective dose or alternative treatment
- Ensure effective contraception until treatment plan is established 1
- Provide psychoeducation about importance of psychiatric stability during pregnancy
- Involve obstetric team early in planning
Case 9: Early Intervention in Schizophrenia
A 19-year-old male experiencing first episode psychosis has responded well to oral antipsychotic but expresses concern about stigma of daily medication and impact on his college studies.
Management:
- Discuss LAI as option to avoid daily medication reminders
- Emphasize benefits for academic success through consistent symptom control
- Start with lower dose LAI (e.g., risperidone 25mg every 2 weeks)
- Integrate with coordinated specialty care program 1
- Provide psychoeducation about illness course and treatment 1
Case 10: Post-Discharge Medication Continuity
A 38-year-old homeless male with schizophrenia is being discharged after stabilization. Previous discharges have resulted in immediate loss to follow-up and medication discontinuation.
Management:
- Initiate LAI before discharge
- Connect with assertive community treatment team 1
- Schedule injection appointments coordinated with other services
- Consider longer-acting formulations to reduce required frequency of visits
- Implement supported employment services 1
Case 11: Switching Between LAIs
A 42-year-old female with schizoaffective disorder has been on risperidone LAI for 2 years with partial response but troublesome hyperprolactinemia causing amenorrhea.
Management:
- Consider switching to aripiprazole LAI which has lower prolactin elevation risk
- Overlap with oral aripiprazole during transition period
- Monitor prolactin levels before and after switch
- Gradually cross-titrate based on half-life and receptor profiles 1
- Assess for withdrawal symptoms during transition
Case 12: LAI in Acute Exacerbation
A 33-year-old male presents with acute psychotic exacerbation after stopping oral medication 2 months ago. He has history of good response to risperidone but poor adherence.
Management:
- Stabilize acute symptoms with oral medication
- Initiate LAI once tolerability is established
- Consider higher initial loading dose strategies if available for selected LAI
- Provide oral supplementation during initial lag period
- Implement psychoeducation and CBT for psychosis 1
Key Considerations for LAI Use:
Initiation Protocols:
- Most LAIs require initial oral medication trial to establish tolerability
- Overlap with oral medication is needed during initial weeks for most LAIs
- Loading dose strategies vary by specific LAI
Monitoring Requirements:
Special Populations:
- Lower starting doses for elderly patients
- Caution in hepatic/renal impairment
- Consideration of metabolic risk factors
- Pregnancy and breastfeeding considerations
Practical Implementation:
- Coordinate with psychosocial interventions
- Integrate with assertive community treatment when indicated
- Provide psychoeducation about LAI benefits
- Consider patient preferences in shared decision-making
LAIs remain underutilized despite evidence supporting their role in preventing relapse and improving long-term outcomes in schizophrenia and other psychotic disorders 1. These cases illustrate the diverse clinical scenarios where LAIs may be particularly beneficial.