What are clinical situations where the use of an oral antipsychotic together with a long-acting injectable (LAI) antipsychotics may make sense?

The goal for a LAI is its use as antipsychotic monotherapy. However, there are a few clinical scenarios where combining a LAI with an oral antipsychotic may be considered. (The use of oral supplementation during the transition phase onto a LAI is not considered in the scenarios.)

Consider using oral antipsychotic medication with a LAI when:

• The highest available dose of the LAI is insufficient to achieve antipsychotic target blood levels. Therapeutic drug monitoring (TDM) can be used to clarify if ongoing symptoms are due to an insufficient antipsychotic blood level despite maximum dose of the LAI. Insufficient levels can usually be attributed to 1) drug interactions, 2) unusual pharmacokinetics (ultra-rapid metabolizers), or 3) commonly with Risperdal Consta where the highest dose of 50 mg every two weeks corresponds only to 4 mg oral dose.
  • See this tip for more information on TDM.
• A patient has residual symptoms despite optimal LAI monotherapy and antipsychotic combination therapy is used to achieve better symptom control.
• An oral antipsychotic not available as a LAI is used adjunctively for specific benefits (e.g., add-on therapy with quetiapine for its sedating properties).
• Clozapine, which is not available as a LAI, is supported by a LAI to prevent break-through symptoms and a full relapse if clozapine doses are missed.
  • Clozapine augmented with aripiprazole is used, as an evidence-based combination to manage the metabolic side effects of clozapine. Aripiprazole added to clozapine has also been shown to reduce psychotic relapse; giving aripiprazole as a LAI may provide additional safety (see bullet point above).
  • For more information on LAI formulations of aripiprazole, see these tips on Abilify Maintena and Aristada.