What to do for a patient with intermittent explosive disorder on Abilify (aripiprazole) and Prozac (fluoxetine) who has had a high episode?

Management of Acute Agitation in a Patient with Intermittent Explosive Disorder on Aripiprazole and Fluoxetine

For a patient with intermittent explosive disorder experiencing an acute agitation episode while on Abilify (aripiprazole) and Prozac (fluoxetine), immediate administration of a benzodiazepine such as lorazepam 1-2 mg is recommended to rapidly control the agitation.

Assessment of Current Episode

When evaluating a patient with intermittent explosive disorder experiencing an acute agitation episode:

• Assess for severity of agitation and potential for harm to self or others
• Rule out medical causes of agitation (delirium, substance intoxication/withdrawal)
• Determine if this represents treatment failure or breakthrough symptoms despite current medication

Immediate Management

Pharmacological Intervention

• First-line for acute agitation:

  • Lorazepam 1-2 mg orally, sublingually, or intramuscularly for rapid control 1
  • May repeat dose after 1 hour if needed for persistent agitation
  • Lower doses (0.5-1 mg) should be used if the patient is elderly, frail, or has respiratory issues 1

• Alternative if benzodiazepines are contraindicated:

  • Consider additional dose of aripiprazole 5-10 mg (if not at maximum daily dose) 2
  • Monitor closely for sedation, orthostatic hypotension, and extrapyramidal symptoms 2

Non-pharmacological Approaches

• Provide a calm, quiet environment with minimal stimulation
• Use de-escalation techniques: speak calmly, avoid confrontation
• Ensure patient and staff safety with appropriate supervision

Post-Acute Management

After the acute episode is controlled, reassess the current medication regimen:

Medication Optimization

1. Evaluate current dosing of existing medications:

   • Ensure aripiprazole dose is optimized (typical range 10-30 mg daily) 3
   • Confirm fluoxetine dose is adequate (typically 20-80 mg daily for IED) 4

2. Consider medication adjustments:

   • Fluoxetine has demonstrated efficacy in IED with significant reduction in aggression scores, though complete remission occurs in less than 50% of patients 4
   • Aripiprazole as a partial D2 agonist may help with impulsivity control 1, 2

3. Potential augmentation strategies:

   • If current regimen is inadequate, consider adding a mood stabilizer 5
   • Avoid antipsychotic polypharmacy unless clearly indicated 1

Long-term Management Considerations

• Schedule follow-up within 1-2 weeks to assess response to any medication changes

• Monitor for side effects of current medications, including:

  • Metabolic changes with aripiprazole (weight gain, hyperglycemia) 3
  • Potential drug interactions between fluoxetine and aripiprazole (fluoxetine inhibits CYP2D6, potentially increasing aripiprazole levels) 2

• Consider cognitive-behavioral therapy focused on anger management 5

Important Caveats

• Benzodiazepines should be used cautiously and for the shortest duration possible to avoid dependence
• Monitor for paradoxical reactions to benzodiazepines, which can occasionally worsen agitation
• Be aware that inflammatory markers in IED may not change significantly with pharmacotherapy 6
• IED often has high comorbidity with mood disorders (93%), substance use disorders (48%), and anxiety disorders (48%) 7, which may complicate treatment

The goal of treatment is to achieve rapid control of the acute episode while optimizing the long-term medication regimen to prevent future episodes and improve overall functioning.