Can a patient with elevated liver enzymes take Abilify (aripiprazole) and Lexapro (escitalopram)?

Managing Abilify and Lexapro in a Patient with Elevated Liver Enzymes

Patients with elevated liver enzymes should use Abilify (aripiprazole) with caution and consider alternatives to Lexapro (escitalopram) due to the higher risk of hepatotoxicity with escitalopram. 1, 2, 3

Risk Assessment for Each Medication

Aripiprazole (Abilify)

• Aripiprazole has a relatively favorable hepatic safety profile compared to other antipsychotics 4
• No specific contraindications for use in patients with elevated liver enzymes in available guidelines
• Generally well-tolerated with fewer metabolic side effects than other antipsychotics 4

Escitalopram (Lexapro)

• Associated with increased risk of hepatitis [odds ratio = 1.938] and cholestasis [odds ratio = 1.866] based on pharmacovigilance data 2
• Can cause drug-induced liver injury (DILI), which typically occurs within 10 days (±7 days) of initiation 2
• Among SSRIs, escitalopram has relatively lower hepatotoxicity potential compared to other antidepressants, but still poses risk 3

Recommended Approach

1. Assess severity of liver enzyme elevation:

   • Mild (<5× ULN): Closer monitoring may be sufficient
   • Moderate (5-10× ULN): Consider medication adjustments
   • Severe (>10× ULN): Immediate medication changes required 1

2. For Abilify (aripiprazole):

   • May continue with regular liver enzyme monitoring if elevation is mild
   • No specific dose adjustment recommendations for hepatic impairment
   • Monitor for signs of worsening liver function

3. For Lexapro (escitalopram):

   • Consider switching to an alternative SSRI with better hepatic safety profile (e.g., citalopram, paroxetine, or fluvoxamine) 3
   • If continuing Lexapro is clinically necessary, implement more frequent liver enzyme monitoring (every 2-4 weeks initially)
   • Discontinue immediately if liver enzymes worsen or if symptoms of liver injury develop

4. Monitoring recommendations:

   • Baseline liver function tests before starting/continuing treatment
   • Follow-up testing at 2-4 weeks, then monthly for 3 months
   • If stable, can extend to every 3 months 1
   • Monitor for clinical signs of hepatotoxicity (jaundice, right upper quadrant pain, fatigue, nausea)

Special Considerations

• Cross-toxicity: If the patient has previously experienced hepatotoxicity with one antidepressant, they may be at higher risk with others, particularly within the same class 3

• Combination risk: The combined use of both medications may potentially increase hepatotoxicity risk, though specific data on this combination is limited

• Underlying cause: Investigate and address the underlying cause of elevated liver enzymes (NAFLD, alcohol use, viral hepatitis, etc.) 1, 5

• Referral threshold: Consider hepatology referral if:

  • Liver enzymes >5× ULN
  • Any elevation of bilirubin with elevated transaminases
  • Evidence of impaired synthetic function
  • Persistent elevation despite medication adjustment 1

Warning Signs for Immediate Discontinuation

• Development of jaundice
• ALT/AST >3× baseline or continuing to rise despite medication adjustment
• Development of symptoms (fatigue, nausea, abdominal pain, dark urine)
• Any elevation of bilirubin with elevated transaminases 1, 2

If the patient requires both medications and has only mildly elevated liver enzymes, the benefits may outweigh the risks, but close monitoring is essential and alternative medications should be considered, particularly for escitalopram.