Recommendation for Brixadi Dosing After Suboxone Stabilization
For a patient stabilized on Suboxone 8/2mg TID (24mg total daily), start with weekly Brixadi injections rather than monthly formulations to allow for more responsive dose adjustments and minimize the risk of inadequate coverage during the initial transition period. 1
Rationale for Weekly Dosing
The total daily Suboxone dose of 24mg (8mg TID) is relatively high, and weekly Brixadi formulations provide more flexibility for titration and adjustment during the critical transition period from sublingual to long-acting injectable therapy. 1
Weekly dosing allows for more rapid response to any issues with withdrawal symptoms or cravings that may emerge during the first month of transition, as adjustments can be made on a 7-day cycle rather than waiting 28 days between monthly doses. 1, 2
Extended-release buprenorphine formulations have demonstrated safety and efficacy in maintaining patients with opioid use disorder, with weekly formulations showing good tolerability and patient satisfaction, particularly regarding improved privacy and elimination of daily medication requirements. 2
Transition Protocol
The initial weekly Brixadi dose should correspond to the total daily sublingual buprenorphine dose, with 24mg daily Suboxone typically converting to the 24mg weekly Brixadi injection, administered subcutaneously. 1, 2
Patients should be monitored closely during the first 4 hours after the initial injection for any signs of precipitated withdrawal, though this risk is minimal when transitioning from adequate sublingual buprenorphine doses rather than initiating treatment. 2
After 4-8 weeks of stable weekly dosing with good symptom control, consideration can be given to transitioning to monthly Brixadi formulations for improved convenience, though this is not mandatory if weekly dosing is working well. 1
Key Clinical Considerations
Injection site pain is typically minimal (median pain score of 2/10 immediately post-injection, decreasing to 0/10 after 4 hours), and should not be a barrier to treatment. 2
Patient satisfaction with long-acting injectable formulations is high, with 67% of patients rating the elimination of daily medication as extremely important and 62% valuing improved privacy. 2
The combination of buprenorphine with naloxone in the prior Suboxone regimen does not affect the transition, as the naloxone component is poorly absorbed sublingually and serves primarily to deter intravenous misuse. 3, 4
Monitoring During Transition
Assess withdrawal symptoms using the Clinical Opiate Withdrawal Scale (COWS) at baseline and 4 hours post-injection for the first dose, with ongoing monitoring for cravings and illicit opioid use throughout the first month. 2
Daily telephone contact for the first 7 days is recommended to assess for any adverse events, withdrawal symptoms, or medication concerns, with in-person follow-up at day 7. 2
Treatment engagement should be evaluated at each weekly visit, with approximately 73% of patients remaining engaged in opioid use disorder treatment at 7 days in clinical studies. 2
Common Pitfalls to Avoid
Do not start with monthly formulations in patients on high sublingual doses (>16mg daily), as this eliminates the ability to make timely dose adjustments if the patient experiences breakthrough withdrawal or cravings during the first month. 1
Do not reduce the buprenorphine dose during the transition unless there are specific clinical indications, as maintaining equivalent dosing prevents withdrawal and maintains treatment stability. 4, 5
Do not discontinue the long-acting injectable due to minor injection site reactions, as these are typically self-limited and resolve within hours; only 1-6% of patients discontinue due to adverse events in clinical studies. 4, 5