Switching from Oral Aripiprazole 25 mg to Long-Acting Injectable (LAI)
For a patient stable on oral aripiprazole 25 mg daily, initiate aripiprazole LAI 400 mg intramuscularly and continue oral aripiprazole 25 mg daily for 14 days after the first injection, then discontinue the oral formulation. 1, 2
Clinical Rationale for LAI Conversion
The decision to switch to LAI should be based on clinical indication rather than duration of oral treatment—specifically for patients with:
- Recurrent relapses related to non-adherence 1
- Documented history of adherence problems 1
- Patient preference for LAI formulation to avoid covert non-adherence 1
- Confirmed inadequate adherence at any treatment stage 1
Adherence with LAI formulations is superior to oral medications, making this switch particularly valuable for preventing relapse 3
Specific Initiation Protocol
Step 1: First LAI Injection
- Administer aripiprazole LAI 400 mg intramuscularly as the starting dose 2
- This 400 mg dose is appropriate regardless of whether the patient was on oral aripiprazole 10 mg or 30 mg daily 2
- Continue oral aripiprazole 25 mg daily for exactly 14 days after the first injection 2
Step 2: Oral Overlap Period
- The 14-day oral overlap ensures therapeutic aripiprazole plasma concentrations are maintained during the LAI loading phase 2
- Median aripiprazole plasma concentrations reach therapeutic levels within 7 days of initiating LAI, but the 14-day overlap accounts for interpatient variability 2
- After 4 weeks, mean aripiprazole plasma concentrations (93-112 ng/mL) fall within the established therapeutic window (94.0-534.0 ng/mL) 2
Step 3: Discontinue Oral Medication
- Stop oral aripiprazole completely after day 14 2
- Continue monthly LAI 400 mg injections (every 4 weeks) 2
Alternative Dosing Intervals
If monthly injections are not optimal for your patient, consider:
These extended intervals may improve adherence further and are unique to aripiprazole lauroxil LAI (Aristada), unlike aripiprazole monohydrate LAI (Abilify Maintena) which only offers monthly dosing 4
Monitoring During Transition
Week 1-4 (Critical Period)
- Assess for akathisia and tremor (occur in ≤10-11% of patients) 5
- Monitor for injection-site reactions (the primary difference from oral aripiprazole's side effect profile) 4
- Evaluate psychotic symptom control using standardized scales 6
- Check for orthostatic vital signs if switching from another antipsychotic 6
Ongoing Monitoring
- Metabolic parameters remain favorable with aripiprazole LAI compared to other antipsychotics 4, 5
- Aripiprazole uniquely reduces serum prolactin levels rather than elevating them 5
- QTc interval monitoring shows aripiprazole is associated with reduced QTc interval 5
Critical Pitfalls to Avoid
Do not skip the 14-day oral overlap—this is essential to prevent subtherapeutic levels and potential relapse during the transition period 2
Do not change the LAI dose based on the oral dose—400 mg LAI is the appropriate starting dose whether the patient was on oral aripiprazole 10 mg or 30 mg daily, as demonstrated by comparable efficacy and safety across these subpopulations 2
Do not assume treatment failure if switching from oral aripiprazole—the switch to LAI should be for adherence reasons, not inadequate efficacy 1. If the patient failed oral aripiprazole despite confirmed adherence at therapeutic doses for ≥4 weeks, consider switching to an antipsychotic with a different pharmacodynamic profile rather than continuing aripiprazole as LAI 6
Avoid premature discontinuation of oral overlap—while median concentrations reach therapeutic levels by day 7, interpatient variability necessitates the full 14-day overlap to ensure all patients maintain therapeutic levels 2