What should a provider consider when administering long-acting injectable (LAI) antipsychotics?

LAIs must be administered by a healthcare provider. This may be a nurse (NP/RN/LVN/LPN), PA, physician, or pharmacist in a clinic (psychiatric or primary care), hospital, or pharmacy.

Injection preparations:

• Injections must be administered by a healthcare professional.
• All except one LAI (Perseris) are injected intramuscularly.
• Consider if advance preparation is needed.
  • Risperdal Consta should be out of the refrigerator and allow to sit at room temperature for at least 30 minutes prior to reconstitution; Perseris (kits) should be out of the refrigerator for 15 minutes prior to injection.

• Reconstitution:
  • Perseris preparation requires mixing of at least 60 cycles between liquid delivery system and risperidone powder syringes.
  • Abilify maintena, Risperdal Consta, and Zyprexa Relprevv require reconstitution of the powdered microspheres. Abilify Maintena (dual chamber syringe) contains aripiprazole powder and liquid that are mixed by twisting to integrate the two. Rispedal Consta, Zyprexa Relprevv, and Abilify Maintena (single dose vial) contain powdered drug and the liquid in a syringe (Consta) or a second vial respectively.
  • Aristada, Aristada Initio, Invega Sustenna, Invega Trinza, and the decanoates do not require reconstitution, though mixing of various degrees is required for the second generation LAIs.

• Supplies needed:
  • Alcohol swabs for cleansing the injection site and vials of decanoate.
  • gauze pads for blotting the injection site as needed.
  • Adhesive bandage to apply to the injection site, as preferred and needed.
  • Syringes – 3 ml syringes are sufficient size for any decanoate injection and have adequate markings for smaller volume injections (for decanoates only).
    • Those that come with an attached 21 g needle simplify preparation.
  • Needles – 21 g 1” and 1.5” needles for deltoid and gluteal injections respectively (for decanoates only).
    • All second generation antipsychotic LAIs come in kits with the necessary syringes and needles.
  • The injection room ideally has an exam table with paper such that a patient can sit or lay down to be as comfortable as possible. Note, some patients may prefer to stand.

Injection site selection:

Injection site selection should be based on:

• Patient preference. For example, people with trauma history may feel highly uncomfortable with a gluteal injection.
• Body habitus. Thinner patients with less muscle mass will likely have less discomfort with a gluteal injection. Obese patients require the use of a longer needle, 1.5″ – 2”.
• Specific stipulations or recommendation of manufacturer (see below).
• Always rotate injection sites. Rotating injection sites to avoids muscle hypertrophy, abscesses, and tissue damage by repeated, frequent injections at the same site.

Contrasting different LAIs regarding administration basics:

• Decanoates can be administered in either deltoid or gluteal muscles. Injection volume should not exceed than 3 ml in any location.
• Decanoates should be administered slowly, and given the high viscosity, require strong and steady pressure.
  • For more information on decanoates, see these tips on fluphenazine decanoate and haloperidol decanoate.
• The first loading dose of Invega Sustenna 234 mg is recommended to be given in the deltoid for faster distribution.
  • For more information, see this tip on Invega Sustenna.
• All Aristada injections above 441 mg must be given in the gluteal muscle.
  • Aristada Initio should be administered into a separate muscle.
• Due to the crystalline nature of Aristada the loosely associated particles must be injected quickly in order for sheer-thinning to occur. Sheer-thinning is the process in which viscosity decreases as the injection is administered rapidly.  If you do it too slowly, the medication clogs the needle as the crystals clump together.
  • For more information, see this tips on Aristada.
• Zyprexa Relprevv must be given in the gluteal muscle.
• Zyprexa Relprevv requires a three-hour observation in the clinic due to the risk of Post-Injection Delirium Sedation Syndrome.
• Perseris should be given subcutaneously. Choose abdominal injection site around umbilicus that has adequate subcutaneous tissue free of skin conditions, and pinch the skin at injection site before and during administration.
  • For more information, see this tip on Perseris.

REFERENCES

• RISPERDAL CONSTA USPI, Section 2.8: Instructions for Use