What are clinical indications for the use of long-acting injectable (LAI) antipsychotics?

LAIs are highly effective to prevent relapse for patients with schizophrenia. They should be a first-line treatment for the acute and maintenance phases of schizophrenia, not a treatment of last resort. Consider adopting an opt-out strategy: LAIs are the default option, and patients need to actively choose not to take a LAI. Patients may prefer a LAI – if offered.

LAIs should be offered to patients who are at high risk of relapse (e.g., young first-episode patient trying to complete school, criminal offending due to violence). LAIs provide an excellent opportunity to ensure uninterrupted care to patients who may experience barriers to care including ability to fill and safely store oral medications, stigma associated with daily oral medication use, risk of accidental or intentional misuse of oral medications (such as mistakenly skipping or doubling doses).

The ideal setting in which to initiate LAIs is often the inpatient setting; this provides coverage during the transition to outpatient, which can be bumpy. Use of LAIs should not be delayed or deferred to outpatient services.

LAIs are no panacea. They are not an effective strategy for patients unwilling to take antipsychotics unless treatment is court-ordered and can be enforced. They are ineffective for treatment-resistant patients who need clozapine (but may be used adjunctively in clozapine treated patients to provide some coverage if a dose of clozapine is missed).

Prior to initiating any LAIs, you must establish tolerability with the oral version of the antipsychotics.

Prioritize LAI for these special cases of schizophrenia:

• Patient preference of LAI over daily oral medication regimen
• First-episode schizophrenia
• Serious illness course
• Partial adherence due to co-morbid drug use
• Partial adherence due to chaotic life where adherence is difficult
• High-risk for forensic offending during relapse
• Rule-out treatment-resistant schizophrenia (i.e., determine responsiveness to LAI assists in determining whether adherence had been reason for previous non-response)
• Complex medication regimen that increases a likelihood of medication errors
• Treatment settings with suboptimal access to care (inconsistent insurance coverage, frequent changes in pharmacies and pharmacy benefits, living in shelter, frequent homelessness, lack of supportive family and services)

Consider for other indications:   

• Maintenance phase of bipolar disorder
• Harm reduction in non-adherent patients (i.e., a LAI given once at time of discharge will delay relapse)
• Court-ordered antipsychotic maintenance treatment
• Frequent relapse of symptoms (use of LAIs for relapse prevention and recovery – also most likely rationale for insurance coverage/medical necessity of LAIs)