What to do if a patient reports Extrapyramidal Symptoms (EPS) after using Vraylar (cariprazine)?

Management of Extrapyramidal Symptoms (EPS) After Vraylar (Cariprazine) Use

When a patient reports extrapyramidal symptoms (EPS) after using Vraylar (cariprazine), promptly assess the severity and type of symptoms, then consider dose reduction, anticholinergic medication administration, or medication switch depending on symptom severity.

Understanding EPS with Cariprazine

Cariprazine (Vraylar) is an atypical antipsychotic that works as a dopamine D3 and D2 receptor partial agonist with preferential binding to D3 receptors 1. Despite being an atypical antipsychotic with generally lower EPS risk than typical antipsychotics, cariprazine can still cause EPS, particularly akathisia.

Key facts about cariprazine-related EPS:

• Akathisia occurs more frequently than other EPS (7.6% overall incidence in bipolar depression studies) 2
• Higher doses are associated with higher EPS risk (1.5mg/day = 5.5% vs 3mg/day = 9.6% akathisia incidence) 2
• Most EPS symptoms are mild to moderate in severity (>95%) 2
• Symptoms typically occur during the first 3 weeks of treatment 2
• EPS is listed as a late-occurring adverse reaction in the FDA label 3

Assessment of EPS

When a patient reports EPS symptoms after using Vraylar:

1. Identify the specific type of EPS:

   • Akathisia (motor restlessness, inability to sit still)
   • Dystonia (sustained muscle contractions, abnormal postures)
   • Parkinsonism (tremor, rigidity, bradykinesia)
   • Tardive dyskinesia (involuntary, repetitive movements)

2. Assess severity:

   • Mild: Symptoms present but minimal impact on functioning
   • Moderate: Noticeable impact on daily activities
   • Severe: Significant distress or functional impairment

3. Determine timing:

   • Early-onset (within first few weeks) vs. late-onset
   • Relationship to dosage changes

Management Algorithm

For Mild EPS:

1. Dose reduction:

   • Consider lowering the dose of cariprazine 4
   • Monitor for symptom improvement over 1-2 weeks

2. Watchful waiting:

   • Many mild EPS symptoms resolve spontaneously within 1 week after dose adjustment 2
   • Educate patient about expected timeline for improvement

For Moderate to Severe EPS:

1. Anticholinergic medication:

   • First-line treatment: Diphenhydramine 25-50mg IV/IM/PO for acute dystonia 4
   • Alternative: Benztropine 1-2mg daily (maximum 6mg daily) 4

2. Dose reduction or medication holiday:

   • Consider temporarily reducing or pausing cariprazine
   • Resume at lower dose when symptoms improve

3. Medication switch:

   • If symptoms persist despite interventions, consider switching to an antipsychotic with lower EPS risk
   • Options include quetiapine or olanzapine 4

For Tardive Dyskinesia:

If tardive dyskinesia is suspected:

• Immediately evaluate for discontinuation of cariprazine 3
• The FDA label warns that tardive dyskinesia may not fully remit even after discontinuation 3
• Consider specialized neurological consultation

Monitoring and Follow-up

1. Short-term follow-up:

   • Schedule follow-up within 1-2 weeks to assess response to interventions
   • Median time to resolution after last dose is approximately 1 week 2

2. Long-term monitoring:

   • Use standardized scales like AIMS (Abnormal Involuntary Movement Scale) for ongoing monitoring 4
   • Periodically reassess the need for continued treatment 3

Important Considerations

• Patient education: Inform patients about potential EPS symptoms and the importance of reporting them promptly 3
• Conservative dosing: Use the lowest effective dose of cariprazine to minimize EPS risk 2
• Gradual titration: Slow titration may reduce the risk of EPS 2
• Special populations: Elderly patients and those with previous EPS history have higher risk 4
• Documentation: Document the type, severity, and management of EPS for future reference

Pitfalls to Avoid

• Misattribution: Don't assume all movement disorders are medication-related; consider other neurological causes
• Delayed recognition: Remember that cariprazine has a long half-life, and adverse reactions may appear several weeks after initiation 3
• Polypharmacy: Avoid combining multiple antipsychotics as this increases EPS risk 4
• Abrupt discontinuation: Don't stop cariprazine suddenly unless medically necessary, as this may worsen symptoms

By following this structured approach to managing EPS in patients taking cariprazine, you can effectively address symptoms while maintaining therapeutic benefits when possible.