Initiation of aripiprazole once-monthly in patients with schizophrenia

This article provides rationale for recommendations on how to initiate aripiprazole once-monthly 400 mg (AOM 400), an injectable suspension, in patients with schizophrenia, supported by pharmacokinetic (PK) data and based on clinical studies.

An overview of data from a PK study, PK simulations, controlled clinical trials, and a naturalistic study is presented.

Pharmacokinetic data support 400 mg as the starting and maintenance dose of AOM; the plasma concentration profile of aripiprazole after initiating AOM 400 was consistent with therapeutic concentrations observed with oral aripiprazole 10 to 30 mg/d. PK simulations and observed data from a single-dose clinical trial indicate that median aripiprazole plasma concentrations reach therapeutic levels within 7 days of initiating AOM 400. Because of interpatient variability, a 14-day overlap with oral aripiprazole or another antipsychotic medication is considered sufficient to ensure therapeutic concentrations. In clinical studies, when patients initiated AOM 400 with concomitant oral aripiprazole (10-15 mg/d based on stabilized dose) or continued their previous antipsychotic for ≤14 days, mean aripiprazole plasma concentration after 4 weeks (93 to 112 ng/mL) was in range of the therapeutic window established for aripiprazole (94.0-534.0 ng/mL). In clinical studies, the 400-mg starting dose of AOM was efficacious and well tolerated. Across studies of variable duration and design, 1296/1439 (90.1%) patients initiated AOM 400 and required no dose change. Overall rates of discontinuation due to lack of efficacy across clinical studies were low in patients treated with AOM 400 (range, 2.3%-10.0%). In a post hoc analysis from a naturalistic study, cross-titration from other oral antipsychotic therapies to oral aripiprazole before initiating AOM 400 was better tolerated with a >1- to 4-week cross-titration period versus a ≤1-week period, as evidenced by lower rates of discontinuation due to adverse events during cross-titration (2.7% [7/239] vs 10.4% [5/48]). The efficacy and safety of AOM 400 in the month after initiation in the pivotal maintenance studies were comparable between subpopulations of patients previously stabilized on 10- or 30-mg doses of oral aripiprazole.

Findings from PK data, PK simulations, and clinical studies all support that 400 mg is the appropriate initiation dose of AOM for patients with schizophrenia. When switching to oral aripiprazole before initiating AOM 400, tapering the prior oral antipsychotic while titrating up the oral aripiprazole dose (target dose 10-30 mg/d) over >1 to 4 weeks may be an effective strategy. The efficacy, safety, and tolerability of AOM 400 were comparable regardless of whether patients were previously stabilized on oral aripiprazole 10 or 30 mg/d or other antipsychotic therapy and continued to receive the same oral antipsychotic for the first 14 days after initiating AOM 400.