Switching to Injectable Aripiprazole for Noncompliance
Yes, switching a noncompliant patient from oral to long-acting injectable (LAI) aripiprazole at discharge is not only acceptable but specifically indicated, as any patient requiring long-term treatment who demonstrates irregular medication-taking should be considered an appropriate candidate for LAI formulations. 1
Primary Indication: Documented Noncompliance
- Patients who are irregular in taking medications are particularly appropriate candidates for LAI given the well-established relationship between non-adherence and risk of relapse. 1
- Adherence has been demonstrated to be superior with long-acting injectables compared with oral medications, directly addressing patient noncompliance issues. 2
- Real-world data confirms significantly better adherence with aripiprazole LAI (0.89) compared to oral aripiprazole (0.78), a statistically significant difference. 3
Clinical Outcomes Supporting This Decision
The evidence strongly supports LAI use for reducing morbidity and mortality in noncompliant patients:
- LAI formulations are associated with reduced psychiatric hospitalization risk (7-13% lower risk compared to oral monotherapy in large cohort studies). 1
- Aripiprazole LAI significantly delayed time to impending relapse when compared with placebo (p < 0.0001) in controlled trials. 4
- Long-acting formulations reduce both unintentional and intentional nonadherence, which is critical for preventing the relapse-rehospitalization cycle. 5
Initiation Protocol
For aripiprazole LAI (Abilify Maintena), you have two evidence-based options:
One-Injection Start (OIS):
- Administer first LAI injection with 14 days of oral aripiprazole supplementation. 5, 6
- This is the traditional FDA-approved method. 5
Two-Injection Start (TIS) - Potentially Safer:
- Administer two 400 mg injections with only a single 20 mg oral supplementation. 7
- This newer regimen maintains serum levels within the therapeutic window, while OIS may produce peaks above the therapeutic window, potentially exposing patients to toxicity. 7
- Both regimens showed equivalent psychopathology improvement with good tolerability. 7
Key Advantages of Aripiprazole LAI
- Weight neutral and lacking metabolic side effects, conferring an advantage over other second-generation LAIs like risperidone or paliperidone. 5
- Monthly injection interval is attractive as patients prefer fewer injections. 5
- Simple constitution with sterile water and no refrigeration requirement make storage and administration easier. 5
- Well-tolerated during both short-term and long-term studies. 4
Important Caveats
Watch for akathisia and extrapyramidal symptoms, which are well-documented with all aripiprazole preparations and may affect some patients. 5, 6
Review concomitant medications carefully for metabolic inducers and inhibitors that could affect aripiprazole levels. 5
The oral supplementation period is a vulnerability: Ensure the patient understands the need for oral coverage during the first 14 days (OIS) or receives the TIS protocol to minimize this risk. 5, 6
Guideline Support
The British Journal of Psychiatry guidelines explicitly state that any patient for whom long-term treatment is indicated should be considered a candidate for LAI, and even if patients initially refuse this option, clinicians should work with them through the therapeutic alliance to help them understand the potential advantages. 1
Treatment should start as soon as possible after improvement of acute symptoms, making discharge an appropriate time for this transition. 1