Ross and Fabian.11 An African American man, age 44, was receiving haloperidol decanoate, 400 mg every 2 weeks, and oral haloperidol, 20 mg/d.11 Because of residual symptoms, a history of nonadherence, and concerns about increasing the haloperidol decanoate dose or frequency, oral haloperidol was discontinued and paliperidone palmitate, 156 mg every 4 weeks, was started. The patient was able to transition into a step-down unit, and no adverse effects were reported.
What to consider before initiating dual LAIA treatment
Evaluate the frequency of administration, flexibility of dosing, administration site, adverse effects, and monitoring requirements of each LAIA (Table 212-19) to ensure the patient’s optimal tolerability of the regimen. Previous tolerability of each medication must be confirmed by evaluating the patient’s medication history or oral or IM administration of each agent prior to initiating the LAIA.
When choosing 2 agents that are each administered once every 4 weeks, consider administering the medications together every 4 weeks or alternating administration so that the patient receives an injection every 2 weeks. Receiving an injection once every 2 weeks might be beneficial for patients who need close follow-up or are more sensitive to injection site reactions, whereas a regimen of once every 4 weeks might be beneficial for patients who are more resistant to receiving the injections, so there is potentially less time spent agitated or anxious leading up to the date of the injection.
Use the lowest effective dose of each LAIA to limit adverse effects and improve tolerability of the regimen. Monitor patients closely for adverse reactions and discontinue the regimen as soon as possible if a severe adverse reaction occurs.
Cost may influence the decision to use 2 LAIAs. The majority of LAIAs in the United States are available only as branded formulations. Insurance companies may require prior authorization for the use of 2 LAIAs.
Although there are no treatment guidelines for combining 2 LAIAs, this practice has been used. A few case reports have described successful use of dual LAIA treatment, but one should consider the risk of the publication’s bias. Overall, the decision to use 2 LAIAs is difficult because there is lack of a large evidence base supporting the practice or direction from treatment guidelines. Because of this, dual LAIA treatment should not be used for most patients. In cases of treatment-resistant schizophrenia where clozapine is not an option and adherence is a concern, it is reasonable to consider this strategy on a case-by-case basis.