Article Figures & Data
Figures
- Figure 1.
Treatment planning for competency restoration with antipsychotics.
Tables
- Table 1
Legal Elements for Involuntary Medication to Restore Trial Competency (from Sell v. U.S.6)
Element Criteria 1 Important government interests are at stake 2 Medication is substantially likely to render the defendant competent to stand trial and substantially unlikely to have side effects interfering with the fairness of the trial 3 Medication is necessary to further government interests and less intrusive treatments are unlikely to achieve the same results 4 Medications are “medically appropriate” Long-Acting Injectable Antipsychotic Antipsychotic Class Delivery Prerequisite to Delivery Dosing Interval Method Requires Oral Supplement after Initial Injection Requires Loading Dose Notable Side Effects Notable Properties Fluphenazine decanoate 1st generation IM or SQ Establish tolerability with any shorter-acting form of fluphenazine Up to 6 weeks (individualized for each patient) No No Weight gain, metabolic syndrome, EPS,c tardive dyskinesia, QT prolongation Low monetary cost; highest risk of EPS, tardive dyskinesia (irreversible; risk increases with increased treatment duration and dose; much less common in short treatment periods) Haloperidol decanoate 1st generation IM Establish tolerability with any shorter-acting form of haloperidol 4 weeks No No Weight gain, metabolic syndrome, EPS,c tardive dyskinesia, QT prolongation Low monetary cost; highest risk of EPS, tardive dyskinesia (irreversible; risk increases with increased treatment duration and dose; much less common in short treatment periods) Olanzapine pamoate (Zyprexa Relprevv®) 2nd generation IM Establish tolerability with oral olanzapine 2 or 4 weeks No No Post-injection syndrome,d weight gain, metabolic syndrome Risk of post-injection syndrome Risperidone microspheres (Risperdal Consta®) 2nd generation IM Establish tolerability with oral risperidone 2 weeks Yes, 3 weeks No Hyperprolactinemia, galactorrhea, weight gain, sometimes EPS Shortest-acting injectable antipsychotic on this list Paliperidoneb palmitate (Invega Sustenna®) 2nd generation IM Establish tolerability with oral risperidone, oral paliperidone, or injectable risperidone 4 weeks No Yes Hyperprolactinemia, galactorrhea, weight gain, sometimes EPS Requires loading dose, but can be administered monthly after second injection Paliperidoneb palmitate (Invega Trinza®) 2nd generation IM Establish tolerability with Invega Sustenna® paliperidone palmitate (at least 4-month trial) 3 months No No Hyperprolactinemia, galactorrhea, weight gain, sometimes EPS Requires 4-month trial of tolerability with Invega Sustenna® prior to initiation of this longer-acting injectable antipsychotic Risperidone RBP-7000 (Perseris®) 2nd generation SQ Establish tolerability with oral risperidone 4 weeks No No Hyperprolactinemia, galactorrhea, weight gain, sometimes EPS Does not require oral supplementation or loading dose Aripiprazole monohydrate (Abilify Maintena®) 2nd generation IM Establish tolerability with oral aripiprazole 4 weeks Yes, 2 weeks No Akathisia Requires 2 weeks of concomitant administration of oral medication after initial injection Aripiprazole lauroxil (Aristada®) 2nd generation IM Establish tolerability with oral aripiprazole 4, 6, or 8 weeks (depending on dose) Yes, 3 weeks No Akathisia Requires 3 weeks of concomitant administration of oral medication after initial injection All above information obtained from each medication’s respective prescribing information/package insert.
aIM = intramuscular; SQ = subcutaneous.
bpaliperidone is the active metabolite of risperidone.
↵cEPS (extrapyramidal side effects) include: dystonia, akathisia, parkinsonism, tardive akathisia, tardive dyskinesia; risk is higher with FGAs than with SGAs.
↵dPost-injection syndrome refers to the combination of symptoms consistent with olanzapine overdose and may include severe sedation or delirium. Patients who receive olanzapine pamoate must be monitored for 3 hours after injection by a healthcare professional.
