Yes, you can start Abilify (aripiprazole) in a patient with both multiple sclerosis and bipolar disorder.
Aripiprazole is FDA-approved for bipolar disorder and has been specifically used successfully in patients with both MS and bipolar disorder, making it an appropriate treatment choice for this dual diagnosis. 1
Evidence Supporting Use
FDA Approval and Indications
Aripiprazole is FDA-approved for acute mania in adults with bipolar disorder 2. The medication selection for bipolar disorder should prioritize agents with proven efficacy, considering the phase of illness, side effect profile, and patient-specific factors 2.
Direct Evidence in MS + Bipolar Patients
Most compellingly, there is a published case report of a 51-year-old woman with both bipolar disorder (depressive episode) and multiple sclerosis in remission who was successfully treated with aripiprazole augmentation at 20-30 mg daily, achieving remission of her treatment-resistant bipolar depression 3. This directly addresses your clinical scenario.
Additionally, aripiprazole has been used successfully to treat psychotic symptoms in MS patients, demonstrating safety in this neurological population 4.
Practical Prescribing Approach
Starting Strategy
- Begin with a very low dose (1-5 mg daily) rather than standard doses, as evidence suggests lower doses may be more effective and better tolerated in bipolar depression 5
- Titrate slowly based on response and tolerability
- Standard doses of 15-30 mg used in acute mania trials may cause higher dropout rates 5
Monitoring Requirements
Critical safety monitoring includes:
- Metabolic parameters (weight, glucose, lipids) as aripiprazole can cause metabolic changes 1
- Movement disorders (akathisia is common, occurring in 13% vs 4% placebo) 1
- Compulsive behaviors - FDA warns about pathological gambling and other impulse control disorders 1
- Suicidality - particularly important given bipolar disorder carries inherent suicide risk 1
- Orthostatic hypotension and falls risk 1
Important Caveats
Watch for these specific concerns:
Akathisia is the most common side effect (8-13% incidence) and may be dose-related 1. Lower doses reduce this risk.
Drug interactions: Verify all current medications, as aripiprazole metabolism can be affected by CYP2D6 and CYP3A4 inhibitors/inducers 1
MS-specific considerations: While the case report showed safety in MS patients on interferon therapy 3, monitor for any worsening of neurological symptoms, though no specific contraindication exists
Temperature regulation: Both MS and antipsychotics can affect thermoregulation - counsel patient to avoid overheating and stay hydrated 1
Clinical Reasoning
The combination of MS and bipolar disorder is not uncommon - recent meta-analysis shows 3.2% prevalence of bipolar disorder in MS patients, with 2.5-fold increased risk compared to general population 6. This makes psychiatric treatment in MS patients a relevant clinical scenario requiring evidence-based approaches.
Aripiprazole's unique dopamine partial agonist mechanism may offer advantages in this population, and the direct case evidence of successful use in exactly this patient population 3 provides reassurance beyond theoretical safety considerations.
The key is starting low (1-5 mg), going slow with titration, and maintaining vigilant monitoring for both psychiatric response and medication side effects.