Guidance for Missed Maintenance Doses for Long-acting Injectable Antipsychotics

Some information presented within this Center of Excellence was created in collaboration with the California Department of State Hospitals (DSH). This includes that the content has been specifically aligned to the DSH’s medication guidelines (DSH Psychotropic Medication Operational Procedures, appended to DSH Policy Directive 3400). These medication guidelines are applicable only to the DSH settings and inclusion within this resource does not indicate that they must be followed in any non-DSH settings. The medication guidelines included in this resource are those of DSH and do not necessarily represent the views, policy(ies), and/or position(s) of the American Psychiatric Association (APA).

This tip provides suggestions and guidance on the administration of Long Acting Injectable Antipsychotics (LAIs) for patients who miss their LAI on the specified administration date.

Guidance for specific LAIs

Abilify Maintena (aripiprazole monohydrate monthly LAI):

Abilify Maintena doses should be administered not earlier than 26 days after the last injection.
If a maintenance Abilify Maintena dose is missed, the next maintenance dose should be administered not later than 6 weeks after the last injection.
References: Lexicomp; Prescribers Digital Reference

Aristada (aripiprazole lauroxil monthly, every 6 week, or 2-month LAI):

The recommended ARISTADA dosing interval is monthly for the 441 mg, 662 mg and 882 mg doses, every 6 weeks for the 882 mg dose, or every 2 months for the 1064 mg dose and should be maintained.
In the event of early dosing, an Aristada injection should not be given earlier than 14 days after the previous injection
- Reference: Aristada Prescribing Information
In the event of missed dose, an Aristada injection should be administered not later than the following:
Monthly 441 mg not later than 6 weeks after the last injection;
Monthly 662mg or 882 mg not later than 8 weeks after the last injection;
882 mg every 6 weeks, not later than 8 weeks after the last injection;
1064 mg every 2 months, not later than 10 weeks after the last injection.
References: Aristada USPI; Lexicomp; Prescribers Digital Reference

Haloperidol Decanoate (haldol monthly LAI):

If a maintenance dose is missed, the next maintenance dose must be given within 6 weeks, if > 6 weeks, reload haloperidol decanoate using 2 or 3 loading doses depending on plasma concentration.
References:
- American Psychiatric Association. (2021). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. 3^rd edition.
- Lexicomp; Prescribers Digital Reference
- Meyer, Jonathan M., and Stephen M. Stahl. The clinical use of antipsychotic plasma levels: stahl’s handbooks. Cambridge University Press, 2021.

Invega Hafyera (paliperidone palmitate 6-month LAI):

Timing of Missed Maintenance Dose
Patients can be given up to 2 weeks before or 3 weeks after the scheduled 6-month dose.
Missed dose more than 6 months and 3 weeks, up to but Less than 8 months since last dose, do not administer the next dose of Invega Hafyera, instead use a re-initiation regimen.
If the last dose of Invega Hafyera was 1,092 mg, give Invega Sustenna 156 mg in the deltoid muscle on day 1 and than administer Invega Hafyera 1,092 mg into gluteal muscle one month after day 1.
If the last dose of Invega Hafyera was 1,560 mg, give Invega Sustenna 234 mg in the deltoid muscle on day 1 and then administer Invega Hafyera 1,560 mg into gluteal muscle one month after day 1.
Missed dose 8 months but up to and including 11 months since last dose, do not administer the next dose of Invega Hafyera, instead use a re- initiation regimen.
If the last dose of Invega Hafyera was 1,092 mg, give Invega Sustenna 156 mg in the deltoid muscle on day 1, Invega Sutenna 156 mg in the deltoid muscle on day 8, and then administer Invega Hafyera 1,092 mg into the gluteal muscle one month after day 8.
If the last dose of Invega Hafyera was 1,560 mg, give Invega Sustenna 156 mg in the deltoid muscle on day 1, Invega Sustenna 156 mg in the deltoid muscle on day 8, and then administer Invega Hafyera 1,560 mg into the gluteal muscle one month after day 8.
Missed dose more than 11 months since last dose
Re-initiate treatment with Invega Sustenna as described in the prescribing information for Invega Sustenna. Invega Hafyera can then be resumed after Invega Sustenna has been administered for at least 4 months
Reference: Invega Hafyera USPI

Invega Sustenna (paliperidone palmitate monthly LAI):

Timing of Missed Maintenance Dose
4-6 weeks since last injection – resume regular monthly dosing as soon as possible with the patient’s previously stabilized dose
More than 6 weeks to 6 months since last injection – resume the same dose the patient was stabilized on with a deltoid injection as soon as possible, then administer the same dose one week after at the same dose (deltoid injection). One month after the second injection, resume the previously stabilized dose via the deltoid or gluteal muscle. *Of note, if the patient was previously stabilized on 234 mg, the first two injections described above should be given at 156 mg.
More than 6 months – restart with recommended initiation of 234 mg on Day 1 (deltoid), then 156 mg one week later (deltoid). Then, continue maintenance doses in the deltoid or gluteal muscle one month after the second loading dose.
References:

Invega Trinza (paliperidone palmitate 3-month LAI):

Time of Missed Maintenance Doses
Patients can be given the injection 2 weeks before or after the 3-month time point.
Missed dose 5 to 4 months since the last injection – dose should be administered as soon as possible, then continue with the 3-month injections after this dose.
4 months to 9 months since last injection:
If last Trinza dose was 273 mg, give Invega Sustenna 78 mg on day 1, and 78 mg on day 8 (both deltoid), then administer Trinza 273 mg one month after day 8 (gluteal or deltoid).
If last Trinza dose was 410 mg, give Invega Sustenna 117 mg on day 1, and 117 mg on day 8 (both deltoid), then administer Trinza 410 mg one month after day 8 (gluteal or deltoid).
If last Trinza dose was 546 mg, give Invega Sustenna 156 mg on day 1, and 156 mg on day 8 (both deltoid), then administer Trinza 546 mg one month after day 8 (gluteal or deltoid).
If last Trinza dose was 819 mg, give Invega Sustenna 156 mg on day 1, and 156 mg on day 8 (both deltoid), then administer Trinza 819 mg one month after day 8 (gluteal or deltoid).
> 9 months since last injection – re-initiate treatment with 1-month paliperidone palmitate injection, then resume Trinza after the patient has been treated with 1-month paliperidone palmitate for at least four
References: Invega Trinza USPI; Invega Trinza Prescribing Information; Lexicomp; Prescribers Digital Reference

Fluphenazine Decanoate (proxlin LAI):

For those patients who are scheduled to receive fluphenazine decanoate injections every 2 or 3 weeks, if between 4-6 weeks from last dose, give maintenance dose. If > 6 weeks, return to prior loading schedule.
For those patients who are scheduled to receive fluphenazine decanoate injections every 4 weeks and who have received at least 2 previous injections as scheduled, the next dose should be administered not later than 8 weeks after the last injection.
References:
- American Psychiatric Association. (2021). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. 3^rd edition.
- Lexicomp; Prescribers Digital Reference
- Meyer, Jonathan M., and Stephen M. Stahl. The clinical use of antipsychotic plasma levels: stahl’s handbooks. Cambridge University Press, 2021.

Risperdal Consta (risperidone 2-week LAI):

Timing of missed maintenance doses depends on whether steady-state plasma concentrations have been reached. Steady state concentration is generally reached after 4 injections.
Steady state plasma concentration achieved
3-6 weeks since last injection – give next dose of Risperdal Consta as soon as possible. Monitor for symptom recurrence.
> 6 weeks since last injection – give next dose of Risperdal Consta as soon as possible with 3 weeks coverage with an oral antipsychotic (such as risperidone).
Steady-state plasma concentration not achieved – given next dose of Risperdal Consta as soon as possible and provide oral antipsychotic (risperidone) coverage for 3 weeks.
References:
- American Psychiatric Association. (2021). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. 3^rd edition.
- Risperdal Consta USPI; Risperdal Consta Prescribing Information; Lexicomp; Prescribers Digital Reference

Erzofri (palpiperidone palmitate monthly LAI):

To avoid a missed monthly dose, patients may be given the injection up to 7 days before or after the monthly time point.

Timing of Missed Maintenance Dose:

4 to 6 weeks since last injection- resume regular monthly dosing as soon as possible with the patient’s previously stabilized dose, followed by injections at monthly intervals
More than 6 weeks to 6 months since last injection- Resume the same dose the patient was previously stabilized on (unless the patient was stabilized on a dose of 234 mg, then the first 2 injections should be 156 mg) in the following manner: administer a deltoid injection as soon as possible, administer a second deltoid injection 1 week later at the same dose, thereafter resume administering the previously stabilized dose in the deltoid or gluteal muscle 1 month after the second injection
More than 6 months since last injection- restart dosing with recommended initiation. Administer a 351 mg deltoid injection on Day 1. Thereafter, resume administering the previously stabilized dose in the deltoid or gluteal muscle 1 month after the initial injection.

Patients who have missed doses of their LAI and present outside the window of administration as described in this policy will require consultation with Medical Staff. Please refer to the References section for additional resources.