Can Abilify (aripiprazole) be added to the treatment plan?

Adding Aripiprazole (Abilify) to Treatment Plan

Aripiprazole (Abilify) can be added to the treatment plan for bipolar disorder as an effective adjunctive therapy with mood stabilizers, particularly when combined with valproate or lithium for acute mania and long-term maintenance treatment. 1

Indications for Adding Aripiprazole

Aripiprazole is FDA-approved for:

• Acute treatment of manic and mixed episodes associated with Bipolar I Disorder
• Maintenance treatment of Bipolar I Disorder
• Adjunctive treatment of Major Depressive Disorder
• Irritability associated with Autistic Disorder
• Treatment of Tourette's Disorder 1

Dosing Recommendations

For Bipolar I Disorder:

• Starting dose: 15 mg once daily as monotherapy or 10-15 mg once daily as adjunctive therapy with lithium or valproate
• Target dose: 15 mg/day (can be increased to 30 mg/day based on clinical response)
• No dosage adjustment needed for renal or hepatic impairment
• Can be taken with or without food 1

Efficacy Evidence

Aripiprazole has demonstrated efficacy in:

• Acute mania treatment (response seen within one week in short-term studies) 2
• Long-term maintenance treatment with continued efficacy and increased time-to-relapse 3
• Combination therapy with mood stabilizers, particularly with valproate for patients with comorbid anxiety, drug abuse, or mixed features 4

A Cochrane review found aripiprazole more effective than placebo in reducing manic symptoms at three and four weeks (YMRS mean difference -3.66,95% CI -5.82 to -2.05) 5

Advantages of Aripiprazole

1. Unique mechanism of action: Partial agonist at dopamine D2 and serotonin 5-HT1A receptors, antagonist at 5-HT2A receptors 2

2. Favorable metabolic profile:

   • Lower risk of weight gain compared to other atypical antipsychotics
   • Less likely to cause metabolic disturbances
   • Minimal sedation effects 3

3. Combination benefits:

   • Aripiprazole-valproate combination is particularly promising for patients with comorbid anxiety, drug abuse, or mixed features 4

Monitoring and Side Effect Management

Common Side Effects to Monitor:

• Extrapyramidal symptoms (EPS): More common than with placebo but less than with haloperidol 5
• Gastrointestinal disturbances: Nausea, constipation 5
• Akathisia: Monitor especially during initial treatment period 1

Required Monitoring:

• Weekly assessments for the first 4 weeks to watch for emergence of manic/hypomanic symptoms 6
• Regular monitoring of weight, BMI, blood pressure 6

Serious Adverse Effects (Rare but Important):

• Neuroleptic malignant syndrome
• Tardive dyskinesia
• Metabolic changes (though less common than with other atypical antipsychotics)
• Increased risk of suicidal thoughts in children, adolescents, and young adults 1

Special Considerations

1. Black Box Warnings:

   • Increased mortality in elderly patients with dementia-related psychosis (not approved for this use)
   • Increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults 1

2. Drug Interactions:

   • Aripiprazole is listed as a medication that may cause elevated blood pressure 7
   • Consider potential interactions with other CNS medications

3. Contraindications:

   • Known hypersensitivity to aripiprazole 1

Practical Implementation

1. When initiating aripiprazole:

   • Start with lower doses (10-15 mg) and titrate as needed
   • Consider lower starting doses in elderly patients
   • Inform patients about possible akathisia and EPS, especially in the first few weeks

2. For optimal outcomes:

   • Combine with mood stabilizers (lithium or valproate) for enhanced efficacy 4
   • Maintain regular follow-up to assess response and monitor for side effects
   • Educate patients about the importance of medication adherence

3. When switching from other antipsychotics:

   • Consider gradual cross-titration to minimize withdrawal effects
   • Period of overlapping antipsychotic administration should be minimized 1

Aripiprazole offers a valuable therapeutic option for bipolar disorder with its favorable metabolic profile and efficacy in both acute and maintenance treatment phases, particularly when used in combination with mood stabilizers.