Long-acting injectable antipsychotics (LAIs) use for older adults

Studies of LAI use for older adults are sparse, but those available show positive clinical outcomes (e.g., for risperidone microspheres LAI ^1,2,3 and olanzapine LAI³ [both studied in older adults with schizophrenia, risperidone microspheres also FDA-indicated for bipolar maintenance]).

• Older adults are at higher risk for psychosis due to factors such as deterioration of cortical areas, neurochemical changes, comorbid medical diagnoses, social isolation, sensory reductions, and often poly-pharmacy.²
• A trial examining risperdal microspheres LAI (Risperdal Consta) for older adults showed improvement in more than 50% of participants.¹

Non-adherence to antipsychotic medication often results in high morbidity, discomfort, and reduced quality of life.²

• LAIs provide a more steady state of the drug.²
• Administration of LAIs also establishes a routine of clinician interaction, which is beneficial to older adults who often have multiple chronic conditions. Long term care facilities may limit prescription of LAIs for older adults in attempting to curtail inappropriate prescription of antipsychotic medications for behavioral issues, yet LAIs are authorized when a resident has a corresponding, life-long disorder (e.g., schizophrenia).²

Dosing LAIs for older adults²

• Starting doses can often be 25% those of younger adults
• Maintenance doses typically require only 25-50% those of younger adults
• In trial, therapeutic drug levels of olanzapine LAI (Zyprexa Relprevv) were unaffected by age and hypothesized to be due to the bypass of exposure to age-related changes in the GI absorption and metabolism.³

LAIs should be considered for older adults in need of maintenance antipsychotic therapy.²

• LAIs are not shown to have more adverse outcomes or negative outcomes than their oral counterparts, nor are most side effects of LAIs usually dose-related, yet EPS and hyperprolactinemia likely remain dose-dependent side effects whether oral or LAI. This is important since older adults may be at higher risk of experiencing side effects of antipsychotic medications in general.² Older adults should be monitored particularly closely for development of tardive dyskinesia.
• An exception would be injection site pain or reaction, which should be monitored closely.² Body habitus and muscle volume should be considered with LAIs, as many older adults have reduced muscle mass.

The FDA’s black box warning applies to all antipsychotic medications, LAIs being no exception. It warns of “increased mortality in elderly patients with dementia-related psychosis.” It is essential that LAI use in older adults follows FDA indications specific to each drug.

REFERENCES

1. Catalán, R., & Penadés, R. (2011). Risperidone long-acting injection: Safety and efficacy inelderly patients with schizophrenia. Journal of Central Nervous System Disease, 3(2011), 95-105. https://doi.org/10.4137/JCNSD.S4125
2. Masand, P., Gupta, S., & Masand, P. (2003). Long-acting injectable antipsychotics in the elderly: guidelines for effective use. Drugs & Aging, 20(15), 1099-1110. https://doi.org/10.2165/00002512-200320150-00003
3. Tveito, M., Smith, R., Molden, E., Haslemo, T., Refsum, H., Hartberg, C., Correll, C., & Hoiseth, G. (2018). Age impacts olanzapine exposure differently during use of oral versus long-acting injectable formulations: An observational study including 8,288 patients. Journal Of Clinical Psychopharmacology, 38(6), 570-576. https://doi.org/10.1097/JCP.0000000000000961

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