How to manage tremor associated with Abilify (aripiprazole)?

Managing Tremor Associated with Aripiprazole

Beta-blockers, particularly propranolol, are the first-line treatment for aripiprazole-induced tremor, with dose reduction or medication switch being alternative options if tremor is severe or persistent.

Understanding Aripiprazole-Induced Tremor

Aripiprazole (Abilify) is known to cause tremor as a side effect, with clinical trials showing:

• Tremor incidence of 8% with aripiprazole versus 2% with placebo in long-term studies 1
• Higher tremor rates at higher doses, particularly in pediatric populations (placebo: 2%; 10mg: 2%; 30mg: 11.8%) 1
• Most cases are mild to moderate in intensity, occur early in therapy (within 49 days), and are often limited in duration (≤10 days) 1

Assessment of Tremor

When a patient presents with tremor while taking aripiprazole:

1. Evaluate the tremor characteristics:

   • Timing in relation to medication initiation or dose changes
   • Severity and impact on daily functioning
   • Associated symptoms (akathisia, parkinsonism, other extrapyramidal symptoms)

2. Rule out other causes:

   • Other medications that may cause tremor
   • Underlying medical conditions (thyroid disease, anxiety)
   • Substance use or withdrawal

Management Algorithm

First-line approach:

• Initiate propranolol 20-40mg twice daily 2, 3
  • Propranolol is well-established for treating essential tremor and medication-induced tremors
  • Can be titrated up to 120mg daily if needed and tolerated

If beta-blockers are contraindicated or ineffective:

1. Reduce aripiprazole dose if clinically feasible 4

   • Lower doses are associated with lower tremor incidence 1

2. Consider switching to another antipsychotic with lower risk of tremor if:

   • Tremor is severe or persistent despite treatment
   • Tremor significantly impacts quality of life
   • Other extrapyramidal symptoms are present

3. Add anticholinergic medication (e.g., benztropine 0.5-2mg twice daily) if tremor is accompanied by other parkinsonian symptoms 5

Special Considerations

• Monitor for akathisia: Aripiprazole can cause akathisia (9% vs 6% placebo in pediatric patients), which may present alongside tremor 1

• Watch for development of parkinsonism: Case reports indicate aripiprazole may rarely lead to parkinsonism with cardinal features including asymmetric tremor, rigidity, and bradykinesia 5

• Consider timing: Most tremors occur early in treatment and may resolve spontaneously within 10 days 1

Pitfalls to Avoid

1. Don't confuse tremor with akathisia: Akathisia presents as motor restlessness and subjective distress, requiring different management

2. Don't overlook the possibility of drug interactions: Medications that inhibit CYP2D6 or CYP3A4 can increase aripiprazole levels and exacerbate tremor

3. Don't immediately discontinue aripiprazole: Abrupt discontinuation may lead to withdrawal symptoms or psychiatric decompensation

4. Don't ignore tremor that worsens or persists: This could indicate development of more serious movement disorders requiring prompt intervention

By following this approach, most cases of aripiprazole-induced tremor can be effectively managed while maintaining the therapeutic benefits of the medication.