Restarting Abilify Maintena (Aripiprazole IM) After Discontinuation
Restart with Abilify Maintena 400 mg IM monthly with a 14-day overlap of oral aripiprazole 10-20 mg daily to ensure therapeutic levels are achieved while the long-acting formulation reaches steady state. 1
Initiation Protocol
Standard Dosing Approach
- Start with 400 mg IM as both the initiation and maintenance dose 1
- Pharmacokinetic data demonstrate that 400 mg is the appropriate starting dose regardless of prior oral aripiprazole dose (whether previously on 10 mg or 30 mg daily) 1
- The 400 mg dose achieves plasma concentrations consistent with therapeutic levels (94.0-534.0 ng/mL) observed with oral aripiprazole 10-30 mg daily 1
Critical Oral Overlap Period
- Provide concomitant oral aripiprazole 10-20 mg daily for 14 days after the first IM injection 1
- Pharmacokinetic simulations show median aripiprazole plasma concentrations reach therapeutic levels within 7 days, but the 14-day overlap accounts for interpatient variability and ensures adequate coverage 1
- Mean aripiprazole plasma concentration after 4 weeks with this approach ranges from 93-112 ng/mL, well within the therapeutic window 1
Transitioning from Invega
Since this patient has been off Abilify for an extended period and was recently on Invega 3 mg:
- Do not continue Invega after starting Abilify Maintena, as the patient has already decompensated on this regimen
- Begin oral aripiprazole 10-20 mg daily immediately while scheduling the first IM injection 1
- The oral aripiprazole serves dual purposes: provides immediate symptom control and ensures therapeutic levels during the first 2 weeks of IM treatment 1
Clinical Efficacy Data Supporting This Approach
- In clinical studies, 90.1% (1296/1439) of patients initiated on AOM 400 mg required no dose adjustment 1
- Discontinuation rates due to lack of efficacy were low across studies (2.3%-10.0%) 1
- Efficacy and safety in the first month after initiation were comparable regardless of whether patients were previously on oral aripiprazole 10 mg or 30 mg daily 1
Monitoring Considerations
- Assess clinical response within the first 4 weeks to determine if the 400 mg dose is adequate 1
- The patient previously responded to Abilify Maintena 400 mg, making this the logical restart dose rather than attempting dose escalation 2, 1
- Watch for extrapyramidal symptoms, though aripiprazole has a favorable tolerability profile compared to typical antipsychotics 3, 4
Common Pitfall to Avoid
Do not attempt a gradual cross-titration from Invega to oral aripiprazole before starting the IM formulation - the patient has already decompensated and needs rapid stabilization. The evidence shows that when patients are unstable, direct initiation with appropriate oral overlap is the preferred strategy 1. The post-hoc analysis showing better tolerability with >1-4 week cross-titration periods applies to stable patients switching medications, not to patients who have already decompensated 1.