How should I initiate long‑acting aripiprazole (Abilify Maintena) in a patient, including oral overlap and loading dose considerations?

How to Start Abilify Maintena (Aripiprazole Long-Acting Injectable)

Initiate Abilify Maintena 400 mg intramuscularly with either a two-injection start regimen (two 400 mg injections plus one 20 mg oral dose on day 1) or the traditional single 400 mg injection plus 14 days of oral aripiprazole 10-20 mg daily. 1, 2

Two Initiation Options

Option 1: Two-Injection Start Regimen (Preferred for Simplicity)

• Administer two 400 mg intramuscular injections of Abilify Maintena on the same day (one in each deltoid or gluteal muscle) 1
• Give one 20 mg oral aripiprazole tablet on the same day as the injections 1
• No additional oral supplementation required after day 1 1
• This regimen achieves therapeutic plasma concentrations without the need for 14 days of oral overlap 1, 3
• Real-world data from 133 patients showed this approach was well-tolerated with no severe adverse effects and similar safety profile to the traditional regimen 1
• European healthcare professionals reported high satisfaction (84.0%) with patient outcomes using this method 3

Option 2: Traditional Single-Injection Start

• Administer one 400 mg intramuscular injection of Abilify Maintena 2
• Continue oral aripiprazole 10-20 mg daily for 14 consecutive days starting on the day of the first injection 2
• The oral dose should match the patient's previously stabilized oral aripiprazole dose (typically 10-15 mg daily) 2
• Median aripiprazole plasma concentrations reach therapeutic levels within 7 days, but 14-day overlap ensures adequate coverage given interpatient variability 2

Pre-Initiation Considerations

For Antipsychotic-Naive Patients

• Do not start Abilify Maintena directly in antipsychotic-naive patients 2
• First establish tolerability with oral aripiprazole 10-30 mg daily until the patient is clinically stable 2
• Cross-titration periods of >1 to 4 weeks are better tolerated than rapid switches (≤1 week), with lower discontinuation rates due to adverse events (2.7% vs 10.4%) 2

For Patients Switching from Other Antipsychotics

• Taper the previous oral antipsychotic while titrating up oral aripiprazole to a target dose of 10-30 mg daily over >1 to 4 weeks 2
• Once stable on oral aripiprazole, initiate Abilify Maintena using either regimen above 2
• Alternatively, continue the previous antipsychotic for the first 14 days after initiating the single-injection regimen 2

Maintenance Dosing

• Continue with 400 mg intramuscularly once monthly (every 4 weeks) 4, 2
• Across clinical studies, 90.1% of patients (1296/1439) required no dose change from the 400 mg starting dose 2
• Discontinuation rates due to lack of efficacy were low (2.3%-10.0%) across studies 2

Injection Technique

• Administer as a deep intramuscular injection into the deltoid or gluteal muscle 4
• For two-injection start: use separate injection sites (e.g., one deltoid and one gluteal, or both deltoids) 1
• Rotate injection sites with each monthly dose 4

Monitoring Parameters

• Assess for extrapyramidal symptoms, as aripiprazole has a favorable profile but monitoring remains important 4
• Monitor metabolic parameters (weight, glucose, lipids), though aripiprazole is associated with fewer metabolic disturbances compared to some other atypical antipsychotics 4
• Evaluate for cardiovascular tolerability, particularly orthostatic hypotension during initiation 4
• Watch for common adverse effects including headache, anxiety, insomnia, nausea, and lightheadedness 5

Common Pitfalls to Avoid

• Avoid starting Abilify Maintena without establishing oral tolerability first in antipsychotic-naive patients 2
• Do not rush cross-titration from other antipsychotics—allow >1 to 4 weeks for better tolerability 2
• Do not assume dose adjustments are needed—400 mg is appropriate for both initiation and maintenance in the vast majority of patients 2
• With the two-injection start, do not give additional oral supplementation beyond the single 20 mg dose on day 1, as this may lead to excessive plasma concentrations 1
• Address patient concerns about receiving two injections on the same day, as patient reluctance is a common barrier (66.0% of surveyed HCPs reported this) 3