When should aripiprazole (atypical antipsychotic) be administered?

When to Give Aripiprazole

Aripiprazole should be administered for schizophrenia, bipolar I disorder (manic or mixed episodes), and as an augmentation strategy for treatment-resistant cases or to address specific symptom domains like negative symptoms. 1

Primary Indications

Schizophrenia

• First-line treatment option for patients with schizophrenia at a dose of 10-15 mg/day 2
• Effective for both positive and negative symptoms
• Particularly beneficial when metabolic side effects are a concern
• Starting dose: 10-15 mg once daily, with efficacy typically seen within the first 1-2 weeks of treatment 2

Bipolar I Disorder

• Effective for acute manic or mixed episodes at doses of 15-30 mg/day 3, 4
• Can be used as monotherapy or in combination with mood stabilizers
• Particularly useful when weight gain and metabolic concerns are present

Specific Clinical Scenarios

Treatment-Resistant Schizophrenia

• As an augmentation strategy to clozapine when positive symptoms remain significant despite adequate clozapine treatment 1
• Can help reduce clozapine-induced metabolic side effects when used as an adjunct

Negative Symptoms of Schizophrenia

• Consider as a switch option or augmentation strategy when negative symptoms are predominant 1
• Low-dose aripiprazole (10 mg/day) may be optimal for negative symptoms 5

Combination Therapy Considerations

• May be combined with another antipsychotic to reduce negative symptoms 1
• Can be used with mood stabilizers (lithium or valproate) in bipolar disorder 4

Dosing Guidelines

• Schizophrenia: Start with 10-15 mg once daily; optimal dose appears to be 10 mg/day 5
• Bipolar disorder: 15-30 mg/day 3
• No need for dose titration in most cases 2
• Doses above 20 mg/day provide minimal additional benefit and may increase side effects 5

Monitoring Requirements

Before starting:

• Baseline BMI, waist circumference, blood pressure
• Laboratory tests: HbA1c, glucose, lipids, prolactin, liver function, electrolytes, complete blood count
• ECG (especially in patients with cardiovascular risk factors) 1, 6

During treatment:

• Monitor for orthostatic hypotension, particularly in patients with cardiovascular disease 6
• Watch for movement disorders, especially akathisia which is common with aripiprazole 4
• Regular metabolic monitoring (though aripiprazole has lower risk of metabolic issues than many other antipsychotics) 2

Cautions and Contraindications

• Use with caution in patients with:
  • Cardiovascular or cerebrovascular disease
  • History of seizures
  • Risk factors for hypotension 6
• Monitor closely for falls risk, especially in elderly patients 6
• Be aware of potential for cognitive and motor impairment 6

Common Adverse Effects to Monitor

• Akathisia (most distinctive side effect)
• Insomnia and anxiety
• Headache
• Nausea and gastrointestinal disturbances (often time-limited) 3, 4

Aripiprazole's unique mechanism as a dopamine partial agonist gives it advantages in terms of metabolic profile, with lower propensity for weight gain, hyperprolactinemia, and QT prolongation compared to many other antipsychotics 3, 2.