Does Vraylar (cariprazine) cause orthostatic hypotension?

Does Vraylar (Cariprazine) Cause Orthostatic Hypotension?

Yes, Vraylar (cariprazine) can cause orthostatic hypotension, though it occurs infrequently compared to other atypical antipsychotics. According to the FDA drug label, symptomatic orthostatic hypotension is listed as a potential adverse effect, though it was infrequent in clinical trials and not more frequent than placebo 1.

Mechanism and Risk

Vraylar, as an atypical antipsychotic, has the potential to cause orthostatic hypotension through its effects on:

• Alpha-adrenergic receptors (though less potently than some other antipsychotics)
• Autonomic nervous system regulation
• Cardiovascular reflexes

Risk Factors for Orthostatic Hypotension with Vraylar

The FDA label specifically identifies patients who are vulnerable to hypotension when taking Vraylar 1:

• Elderly patients
• Patients with dehydration or hypovolemia
• Patients receiving concomitant antihypertensive medications
• Patients with known cardiovascular disease (history of myocardial infarction, ischemic heart disease, heart failure, or conduction abnormalities)
• Patients with cerebrovascular disease

Monitoring Recommendations

For patients taking Vraylar, orthostatic vital signs should be monitored, particularly in vulnerable populations 1. This includes:

• Measuring blood pressure and heart rate while lying down
• Repeating measurements after standing for 1-3 minutes
• Looking for a drop of ≥20 mmHg in systolic or ≥10 mmHg in diastolic BP within 3 minutes of standing 2

Precautions and Management

If orthostatic hypotension develops while taking Vraylar:

1. Non-pharmacological interventions 2:

   • Increase fluid intake to 2-3 liters daily
   • Increase salt intake to 6-9g daily (if not contraindicated)
   • Use compression garments
   • Implement positional changes gradually
   • Avoid hot environments and alcohol

2. Medication adjustments:

   • Consider dose reduction
   • Evaluate timing of administration
   • Review other medications that may contribute to orthostatic hypotension

Comparison to Other Antipsychotics

Orthostatic hypotension is a known adverse effect of many antipsychotics, but the incidence varies:

• First-generation antipsychotics like chlorpromazine have higher rates of orthostatic hypotension 3
• Second-generation antipsychotics like olanzapine, quetiapine, and risperidone are also associated with orthostatic hypotension 3
• Third-generation antipsychotics like aripiprazole and cariprazine (Vraylar) appear to have lower incidence 3

Special Considerations

The FDA label for Vraylar specifically notes that it has not been evaluated in patients with recent history of myocardial infarction or unstable cardiovascular disease, as such patients were excluded from pre-marketing clinical trials 1.

Falls Risk

The FDA label also warns that Vraylar may cause somnolence, postural hypotension, motor and sensory instability, which may lead to falls and consequent injuries 1. Complete fall risk assessments are recommended when:

• Initiating Vraylar treatment
• Periodically for patients on long-term therapy
• When patients have conditions that could exacerbate these effects

In conclusion, while orthostatic hypotension is a recognized potential side effect of Vraylar, it appears to occur less frequently than with many other antipsychotics. Nevertheless, appropriate monitoring and precautions should be taken, particularly in vulnerable populations.