From the Guidelines
For an 81-year-old patient with CKD and advanced dementia showing worsening behaviors on aripiprazole depot, the most appropriate option is to reconsider paliperidone palmitate (Invega Sustenna) with dose adjustment for renal impairment (25-50mg monthly), as it was previously effective for the patient before being discontinued due to renal function concerns 1. Given the patient's history of responsiveness to Invega and the current worsening of behaviors on aripiprazole, it is crucial to weigh the benefits and risks of antipsychotic medications in the context of dementia, as emphasized by the American Psychiatric Association practice guideline 1. The guideline suggests that antipsychotic medication should only be used for severe, dangerous, or distressing symptoms of agitation or psychosis in patients with dementia, and the decision should balance potential benefits and harms 1. Considering the patient's advanced age, CKD, and dementia, it is essential to prioritize minimizing side effects while controlling behaviors. Other options, such as increasing the aripiprazole dose if renal function permits, or considering other depot antipsychotics like risperidone (Risperdal Consta) or olanzapine pamoate (Zyprexa Relprevv) with appropriate renal dose adjustments, should be explored if paliperidone palmitate is not feasible 1. Additionally, optimizing oral medications like quetiapine and trazodone, and maintaining non-pharmacological approaches, are crucial components of the treatment plan. Close monitoring of renal function, sedation, and extrapyramidal symptoms is necessary, especially given the patient's age and kidney disease, to ensure the minimum effective dose is used while minimizing adverse effects 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Monthly Depot Shot Injections
- Aripiprazole is currently being used as a monthly intramuscular injection, but its effectiveness seems to be waning compared to Invega, which was previously used 2.
- Haloperidol decanoate is another option for monthly depot shot injections, which has been compared to fluphenazine decanoate in several studies 3, 4, 5.
- These studies suggest that haloperidol decanoate can be an effective alternative to fluphenazine decanoate, with some studies showing improved efficacy and reduced side effects 3, 5.
Dose Improvements
- The current dose of aripiprazole may not be optimal, and adjusting the dose could potentially improve its effectiveness 2.
- Adding a low dose of haloperidol to aripiprazole has been shown to improve antipsychotic efficacy in some cases, although this combination requires careful titration to avoid adverse side effects 6.
- The studies on haloperidol decanoate suggest that it can be effective at a dose range of 122-127 mg, given every 4 weeks 4, 5.
Alternative Options
- Other atypical antipsychotics, such as risperidone or paliperidone, may be considered as alternative options for monthly depot shot injections, although their effectiveness and safety in patients with CKD and advanced dementia would need to be carefully evaluated 2.
- The use of a combination of medications, such as aripiprazole and haloperidol, may also be considered, although this would require careful monitoring and adjustment to minimize adverse side effects 6.