In a patient showing signs of relapse while on olanzapine (olanzapine) and aripiprazole (aripiprazole), should the doses be increased or should they be switched to a different medication?

Management of Relapse in a Patient on Olanzapine and Aripiprazole

When a patient shows signs of relapse while on olanzapine and aripiprazole, the most effective approach is to gradually increase the dose of olanzapine first, as it has demonstrated superior efficacy compared to aripiprazole in head-to-head trials. 1

Assessment of Relapse

Before making medication changes, confirm the nature of the relapse:

• Evaluate positive symptoms (delusions, hallucinations)
• Assess negative symptoms (apathy, social withdrawal)
• Rule out non-adherence to current regimen
• Consider substance use or other stressors as triggers

Medication Adjustment Algorithm

Step 1: Optimize Current Medications

• Increase olanzapine dose first

  • Current recommended target dose: 7.5-10 mg/day 2
  • Can be safely increased up to 20 mg/day 2, 1
  • Monitor for weight gain, metabolic effects, and sedation

• If olanzapine increase is insufficient after 2-4 weeks:

  • Consider increasing aripiprazole dose (up to 30 mg/day) 3

Step 2: If Inadequate Response After Dose Optimization

• Consider switching strategies only after trials of two first-line atypical antipsychotics at adequate doses (12 weeks total) 2
• Options for switching:
  1. Switch to quetiapine (shown to have high efficacy in relapse cases) 2
  2. Switch to risperidone (if weight gain is a concern) 4

Switching Strategies

If switching is necessary, use a gradual cross-titration approach:

• Gradual discontinuation strategy: Maintain the original antipsychotic at 100% dose for 1 week while starting the new medication, then reduce to 50% in the second week, then discontinue 4
• This approach has shown a 12% discontinuation rate compared to 25-28% with abrupt or rapid discontinuation 4

Monitoring and Side Effect Management

• Extrapyramidal symptoms (EPS):

  • Assess for akathisia, dystonia, or parkinsonism every 3-6 months 2
  • Use Abnormal Involuntary Movement Scale (AIMS) 2
  • Aripiprazole has lower EPS risk (10%) compared to other agents (18%) 3

• Metabolic effects:

  • Monitor weight, lipids, and glucose regularly
  • Olanzapine is associated with significant weight gain (+2.54 kg over 52 weeks) 3
  • Aripiprazole has minimal weight impact (+0.04 kg over 52 weeks) 3

Common Pitfalls to Avoid

1. Abrupt discontinuation: Leads to higher discontinuation rates and withdrawal symptoms 4

2. Inadequate dose trials: Ensure each medication is tried at an optimal dose for at least 4-6 weeks before concluding ineffectiveness

3. Overlooking adherence issues: Verify medication adherence before assuming treatment failure

4. Ignoring comorbidities: Address any comorbid conditions (substance use, mood disorders) that may contribute to apparent relapse

5. Polypharmacy without evidence: While combination therapy may be necessary, avoid using multiple antipsychotics without clear evidence of benefit

In summary, when managing relapse in patients on olanzapine and aripiprazole, a gradual dose increase of olanzapine should be the first approach, followed by optimizing aripiprazole if needed. Only after adequate trials of both medications should switching to another antipsychotic be considered, and this should be done using a gradual cross-titration strategy.