What are clinical considerations for giving LAIs during the COVID-19 public health emergency?

Since LAI antipsychotics need to be administered in person, some planning can help assure continuity of treatment with LAIs even in situations where a person is unable or uncomfortable coming to clinic for their injection. In addition, patients who are older or who have pre-existing conditions should minimize their exposure to the community, including coming to a clinic. A particular area of concern are people in self-quarantine or isolation at their home, group home, or facility in which they live due to COVID-19.

Ideally, patients should be seen as infrequently as medically prudent during this public health emergency, to limit the possibility of exposure (both patients and healthcare staff). LAIs have pharmacokinetics that can be used to achieve this goal. Creative solutions may be needed to actually give the injection. All solutions are going to be local.

• Start by making a spreadsheet for all your patients on LAIs to make sure nobody falls through the cracks during this public health emergency.
• For patients who usually travel to a clinic, arrange for more local injection. This may be the patient’s primary care clinic in their home town or, temporarily, a mental health center that is closer.
• Pharmacies may be able to administer injections (pharmacists may provide patient injections in more than 30 states at present).
• Set up and coordinate outreach with services such as visiting nurses. However, they may have policies that limit who they can serve based on COVID-19 status.
• It may not be ideal to make medication changes during a pandemic. However, some changes within the same medications may be low risk while increasing the time until a patient needs to be seen again. Examples include moving Invega Sustenna patients to Trinza, moving from monthly Aristada injections to dosing Aristada every six weeks or every two months, or switching to oral medications in settings where medication administration can be supervised.
• Risperdal Consta patients pose particular problems due to an injection every two weeks and a move to Invega Sustenna, Invega Trinza, or Perseris may be reasonable since their dosing intervals are monthly or longer.
• The atypical antipsychotic LAIs all have missed dose guidelines detailed in their package insert. This provides information on how long one can wait before the next injection is due, and what additional measures must be taken when beyond that date. Delaying an injection until a person is finished with quarantine may be prudent, and using the missed dose guidelines will indicate when one must consider supplementing with oral medications.
• For individual patients for whom it is appropriate, giving a higher dose than the usual maintenance dose would provide a buffer were the next injection delayed.
• The administration of LAIs is complex enough that they need to be given by healthcare professionals. During a public health emergency, however, family members with some medical background could be trained to give an injection, as a last resort. Details of LAI storage,  administration, and post-injection monitoring would be essential. This approach would not be consistent with FDA labeling.
• Do not forget: if giving a LAI is not possible, temporarily prescribe oral medications again