Is aripiprazole (Abilify) appropriate for patients with bipolar disorder?

Aripiprazole for Bipolar Disorder

Aripiprazole is an appropriate and effective medication for patients with bipolar disorder, particularly as a first-line option for manic episodes and as maintenance therapy to prevent relapse. 1

Efficacy in Different Phases of Bipolar Disorder

Acute Mania/Mixed Episodes

• Aripiprazole is FDA-approved for the treatment of manic and mixed episodes in bipolar I disorder 2
• Effective at doses of 15-30 mg/day for manic or mixed states 3
• Response typically begins as early as day 3 of treatment 4
• Number needed to treat (NNT) for response is 6, and for remission is 14 at week 3 4

Maintenance Treatment

• Aripiprazole is superior to placebo in preventing relapse in bipolar I disorder 2
• Particularly effective in preventing manic episodes (6 manic episodes with aripiprazole vs. 19 with placebo in clinical trials) 2
• Can be used as monotherapy or as adjunctive therapy with lithium or valproate 2
• Median survival time without relapse is significantly longer with aripiprazole compared to placebo (118-203 days) 4

Bipolar Depression

• Less robust evidence for bipolar depression with a weak effect size of 0.17 at week 8 4
• May be beneficial as an adjunctive treatment for bipolar depression 5

Advantages of Aripiprazole in Bipolar Disorder

• Weight neutral or associated with weight loss, unlike some other antipsychotics 1
• Favorable metabolic profile with minimal impact on glucose and lipids 3
• No association with hyperprolactinemia 3
• Good tolerability profile that may promote treatment adherence 6

Dosing and Administration

• For acute mania: 15-30 mg/day (starting dose typically 15 mg/day) 6
• For maintenance therapy: 15-30 mg/day 2
• Lower starting doses may be appropriate when adding to or switching from another antipsychotic to improve tolerability 3

Potential Side Effects and Management

• Extrapyramidal symptoms (EPS) occur more frequently than with placebo but less than with haloperidol 6
• Akathisia may emerge at the start of treatment in some patients 3
• Gastrointestinal complaints can occur initially but are often time-limited 3
• Regular monitoring should include weight, BMI, blood pressure, fasting glucose, and lipid panel 1

Special Considerations

• Can be used as adjunctive therapy with mood stabilizers like lithium or valproate 2
• Particularly useful for patients with metabolic concerns or those who have experienced weight gain with other antipsychotics 1
• May be especially beneficial for patients with a predominant manic presentation 4

Clinical Algorithm for Use

1. For acute mania/mixed episodes:

   • Start with 15 mg/day
   • Can increase to 30 mg/day if needed for efficacy
   • Monitor for early response (typically within first week)

2. For maintenance therapy:

   • Continue effective acute treatment dose (15-30 mg/day)
   • Consider as monotherapy or adjunctive to mood stabilizers
   • Regular monitoring for side effects and symptom recurrence

3. For bipolar depression:

   • Consider as adjunctive therapy to mood stabilizers
   • Lower expectations for robust antidepressant effect
   • Monitor closely for emergence of manic symptoms

Aripiprazole's unique receptor-binding profile makes it a valuable option in the treatment arsenal for bipolar disorder, with particular strengths in treating and preventing manic episodes while offering a favorable side effect profile compared to many alternatives.