What is the preferred treatment for refractory Obsessive-Compulsive Disorder (OCD) symptoms in pregnancy, Latuda (lurasidone) or Abilify (aripiprazole)?

Aripiprazole (Abilify) is Preferred Over Lurasidone (Latuda) for Refractory OCD During Pregnancy

For refractory OCD symptoms during pregnancy, aripiprazole (Abilify) is the preferred treatment option over lurasidone (Latuda) due to its more established safety profile and better evidence for use in OCD.

Evidence-Based Rationale for Aripiprazole

Safety in Pregnancy

• Aripiprazole has relatively reassuring safety data during pregnancy with larger prospective studies available 1
• While no medication is completely risk-free during pregnancy, newer safety data for aripiprazole are relatively reassuring compared to alternatives 1
• Although aripiprazole has been associated with pregnancy hypertension and lower birth weight in some studies, these findings need replication as they may reflect confounding factors 2

Efficacy for OCD

• For refractory OCD cases (where first-line treatments have failed), atypical antipsychotics are recommended as augmentation agents 3
• The treatment algorithm for OCD specifically mentions atypical antipsychotics (AAPs) as an augmentation strategy for inadequate response to first-line treatments 3

Considerations for OCD During Pregnancy

Disease Course During Pregnancy

• Pregnancy can exacerbate OCD symptoms in some women, with approximately 17% experiencing worsening symptoms during pregnancy 4
• Postpartum period carries even higher risk, with 29% of women with pre-existing OCD reporting exacerbation after delivery 4
• OCD symptoms during pregnancy and postpartum often involve intrusive thoughts about harming the infant, which can be particularly distressing 5

Treatment Algorithm for Refractory OCD in Pregnancy

1. First attempt CBT with exposure and response prevention if available and patient can engage
2. If symptoms remain severe or CBT is not feasible:
   • Consider medication augmentation with aripiprazole
   • Start with low dose (2.5-5mg) and titrate slowly
   • Monitor for pregnancy hypertension and other side effects

Why Not Lurasidone (Latuda)?

• Limited data exists on lurasidone use specifically for OCD
• Less established evidence for lurasidone in treating refractory OCD symptoms compared to aripiprazole
• While both medications require risk-benefit assessment during pregnancy, aripiprazole has more published pregnancy exposure data 1

Important Monitoring Considerations

• Regular blood pressure monitoring due to potential risk of pregnancy hypertension with aripiprazole 2
• Monitor for metabolic parameters, though aripiprazole has a more favorable metabolic profile than many other antipsychotics
• Assess fetal growth regularly due to potential association with lower birth weight 2
• Plan for careful postpartum monitoring as OCD symptoms may worsen during this period 4

Common Pitfalls to Avoid

• Discontinuing all psychiatric medications during pregnancy without considering the risk of untreated illness
• Failing to recognize that untreated severe OCD can lead to significant maternal distress and functional impairment
• Not providing adequate psychoeducation about the nature of intrusive thoughts in perinatal OCD
• Overlooking the increased risk of postpartum depression in women with OCD (37% comorbidity rate) 4

Remember that the risk-benefit assessment is crucial when considering medication during pregnancy, as discontinuing treatment can lead to worse mental health outcomes and functional impairments that may negatively impact both maternal and fetal wellbeing.