Can Abilify (aripiprazole) cause hypotension?

Aripiprazole and Hypotension

Aripiprazole (Abilify) can cause orthostatic hypotension due to its α1-adrenergic receptor antagonism, with clinical trials showing an incidence of 1% compared to 0.3% with placebo in adults. 1

Mechanism and Risk

Aripiprazole's hypotensive effects are primarily related to:

• α1-adrenergic receptor antagonism
• Postural changes in blood pressure
• Autonomic nervous system effects

The FDA drug label specifically notes that in short-term placebo-controlled trials of adult patients on oral aripiprazole, the following hypotension-related events were observed 1:

• Orthostatic hypotension: 1% (vs 0.3% placebo)
• Postural dizziness: 0.5% (vs 0.3% placebo)
• Syncope: 0.5% (vs 0.4% placebo)

In pediatric patients 6-18 years of age, the incidence was lower but still present:

• Orthostatic hypotension: 0.5% (vs 0% placebo)
• Postural dizziness: 0.4% (vs 0% placebo)
• Syncope: 0.2% (vs 0% placebo)

Risk Factors

Aripiprazole should be used with caution in patients with:

• Known cardiovascular disease (history of myocardial infarction, ischemic heart disease, heart failure, or conduction abnormalities)
• Cerebrovascular disease
• Conditions predisposing to hypotension:
  • Dehydration
  • Hypovolemia
  • Concurrent treatment with antihypertensive medications 1

Monitoring and Management

For patients taking aripiprazole:

1. Monitor for symptoms of hypotension:

   • Dizziness
   • Lightheadedness
   • Blurred vision
   • Syncope

2. Management strategies if hypotension occurs:

   • Consider dose reduction
   • Administer aripiprazole and other blood pressure-affecting medications at different times of day
   • Evaluate volume status and adjust diuretics if needed
   • In cases of severe hypotension with evidence of hypoperfusion, consider decreasing the dose or discontinuing aripiprazole 2

3. Special considerations:

   • Elderly patients are at higher risk for hypotensive effects
   • Patients with cardiovascular disease require closer monitoring
   • Falls risk assessment should be completed, as antipsychotics including aripiprazole may cause somnolence, postural hypotension, and motor/sensory instability leading to falls 1

Comparison to Other Antipsychotics

While aripiprazole can cause hypotension, it generally has a more favorable cardiovascular profile compared to some other antipsychotics:

• Quetiapine and haloperidol are associated with hypotension in <10% of cases 2
• First-generation antipsychotics typically have more pronounced cardiovascular effects
• Aripiprazole has been noted for its favorable cardiovascular tolerability profile in some studies 3

Clinical Pearls

• Hypotensive effects are generally seen within 24-48 hours of the first dose or dose increases
• Symptoms often subside with repeated dosing without dose adjustment
• The risk of significant orthostatic change in blood pressure (defined as decrease in systolic BP ≥20 mmHg with heart rate increase ≥25 bpm) was not meaningfully different from placebo 1
• In rare cases, aripiprazole has been associated with worsened hypertension control when switching from other antipsychotics 4

For patients requiring an antipsychotic with minimal cardiovascular effects, careful consideration of alternatives and close monitoring during initiation and dose adjustments is essential to minimize the risk of hypotension-related adverse events.