What are the considerations before starting Abilify (aripiprazole)?

Key Considerations Before Starting Aripiprazole (Abilify)

Before initiating aripiprazole, healthcare providers should conduct a thorough evaluation for risk factors including dementia in elderly patients, suicidal ideation in younger patients, metabolic disorders, and pre-existing movement disorders, as these conditions significantly impact morbidity and mortality outcomes. 1

Initial Patient Assessment

• Age considerations:

  • Elderly patients (≥65 years): Increased risk of death in those with dementia-related psychosis 1
  • Children/adolescents: Higher risk of suicidal thoughts, especially in first few months 1
  • Adolescents (≥13 years): Different dosing considerations than adults 2

• Medical history screening for:

  • Diabetes or high blood sugar (personal or family history)
  • Seizure disorders
  • Cardiovascular conditions (low/high blood pressure, heart problems, stroke)
  • Renal impairment
  • Hepatic impairment
  • Low white blood cell count
  • History of movement disorders 1

Medication Review and Drug Interactions

• Current medications review is essential as aripiprazole:

  • Is metabolized by CYP450 (CYP3A4 and CYP2D6) enzymes
  • May interact with strong CYP450 inducers (rifampin, phenobarbital, carbamazepine, phenytoin) reducing efficacy
  • May require dose adjustments when used with CYP3A4 and CYP2D6 inhibitors 1

• Document all current medications including:

  • Prescription medications
  • Over-the-counter medicines
  • Vitamins and herbal supplements 1

Dosing Considerations

• Initial dosing:

  • Adults with schizophrenia: 10-15 mg once daily 3, 4
  • Effective dose range: 10-25 mg/day for schizophrenia 4
  • No need for dosage titration in most patients 3

• Special populations:

  • Severe renal impairment: Consider dose reduction 1
  • Hepatic impairment: May require dose adjustment 1

Monitoring Requirements

Baseline Testing

• Blood glucose/HbA1c
• Lipid profile
• Blood pressure
• Weight
• Extrapyramidal symptoms assessment
• Mental status evaluation (especially for suicidal thoughts)

Ongoing Monitoring

• Weight: Regular monitoring for weight changes
• Metabolic parameters: Blood glucose, lipid profile
• Mental status: Mood changes, suicidal ideation, new or worsening depression
• Movement disorders: Tardive dyskinesia, akathisia, extrapyramidal symptoms 1

Patient Education

• Medication administration:

  • Can be taken with or without food
  • Take exactly as prescribed
  • If a dose is missed, take as soon as remembered unless close to next dose 1

• Key warnings to discuss:

  1. Risk of suicidal thoughts (especially in younger patients)
  2. Neuroleptic malignant syndrome symptoms (high fever, muscle stiffness, confusion)
  3. Tardive dyskinesia risk (involuntary movements)
  4. Metabolic effects (weight gain, blood sugar changes)
  5. Unusual urges (gambling, compulsive eating, sexual urges)
  6. Orthostatic hypotension (dizziness when standing)
  7. Risk of falls and injuries 1

• Lifestyle precautions:

  • Avoid driving or operating machinery until effects are known
  • Avoid overheating and dehydration
  • Avoid excessive exercise in hot weather
  • Stay hydrated 1

Common Side Effects to Anticipate

• Most common side effects:

  • Nausea
  • Dizziness
  • Insomnia
  • Anxiety
  • Headache
  • Restlessness (akathisia)
  • Blurred vision 1, 3

• Advantages compared to other antipsychotics:

  • Lower risk of weight gain
  • Lower risk of metabolic syndrome
  • Lower risk of hyperprolactinemia
  • Lower risk of QTc prolongation 3, 5

Special Considerations

• Pregnancy and breastfeeding:

  • Discuss risks/benefits for pregnant patients
  • Aripiprazole passes into breast milk 1

• Monitoring for serious adverse events:

  • Neuroleptic malignant syndrome
  • Tardive dyskinesia
  • Hyperglycemia and diabetes
  • Falls due to sedation or dizziness 1

Clinical Pitfalls to Avoid

1. Failing to screen for dementia in elderly patients - aripiprazole increases mortality risk in elderly patients with dementia-related psychosis 1

2. Not monitoring for metabolic changes - though lower risk than other antipsychotics, still requires monitoring 5

3. Missing early signs of tardive dyskinesia - may become irreversible even after discontinuation 1

4. Overlooking drug interactions - especially with CYP3A4 and CYP2D6 inhibitors or inducers 1

5. Inadequate patient education about potential side effects and warning signs requiring immediate medical attention 1