Is switching from Risperidone (risperidone) to Latuda (lurasidone) a good choice for a patient with bipolar 2 disorder with psychotic symptoms who has shown no improvement on 6mg daily of Risperidone (risperidone) for over a month?

Switching from Risperidone to Lurasidone for Bipolar 2 with Psychotic Symptoms

Switching from risperidone to lurasidone is an appropriate choice for a patient with bipolar 2 disorder with psychotic symptoms who has shown no improvement after a month on risperidone 6mg daily. 1

Rationale for Medication Switch

• When a patient has been on an adequate dose of an antipsychotic for at least 4 weeks without significant improvement in symptoms, guidelines recommend switching to an alternative antipsychotic with a different pharmacodynamic profile 1
• The lack of response to risperidone after a month of treatment at a therapeutic dose (6mg daily) indicates the need for a medication change 1
• Switching strategies should involve gradual cross-titration informed by the half-life and receptor profiles of each medication 1

Benefits of Lurasidone for Bipolar 2 Depression with Psychotic Features

• Lurasidone has demonstrated efficacy as both monotherapy and adjunctive therapy for bipolar depression, with statistically and clinically significant reduction of depressive symptoms 2, 3
• Lurasidone has been FDA-approved for the treatment of depressive episodes associated with bipolar I disorder at doses of 20-120mg/day 2
• Lurasidone has shown meaningful treatment effect sizes for improvement in depression compared to placebo (0.51 as monotherapy, 0.34 as adjunctive therapy) 4

Dosing and Administration Considerations

• Lurasidone should be initiated at a lower dose (typically 20-40mg/day) and titrated based on response and tolerability 2
• Lurasidone must be taken with food (at least 350 calories) for optimal absorption 2
• Most patients in clinical trials received 20-40mg/day, though doses up to 80mg/day may be used 2

Side Effect Profile Comparison

• Lurasidone has a favorable metabolic profile with minimal weight gain and minimal effects on glucose and lipid levels, which is an advantage over many other antipsychotics 3
• Common side effects of lurasidone include somnolence, akathisia, nausea, and gastrointestinal upset 3
• Dopamine-related side effects such as parkinsonism and elevated prolactin are rare and mild with lurasidone 3
• Risperidone is associated with significant prolactin elevation and potential for weight gain, which may be problematic for long-term treatment 5

Implementation of the Switch

• Consider a gradual cross-titration approach, slowly decreasing risperidone while introducing lurasidone 1
• Begin lurasidone at 20mg daily with food while gradually tapering risperidone 2
• Monitor closely during the transition period for any worsening of symptoms or emergence of side effects 1
• Assess response to lurasidone after 4-6 weeks at an adequate dose before determining efficacy 1, 2

Important Considerations and Caveats

• If psychotic symptoms remain significant after an adequate trial of lurasidone, reassessment of diagnosis and potential contributing factors should be undertaken 1
• If bipolar depression with psychosis is confirmed and two antipsychotic trials have failed, consider clozapine as the next step, particularly if psychotic symptoms are prominent 1
• Be aware that lurasidone has been primarily studied for bipolar depression rather than for psychotic symptoms specifically 4
• Ensure that the patient takes lurasidone with food, as administration without food can result in significantly decreased absorption 2

Monitoring Recommendations

• Assess treatment effectiveness early and regularly during the switch process 1
• Monitor for both improvement in depressive and psychotic symptoms 2
• Watch for common side effects of lurasidone, particularly akathisia and nausea 3
• Evaluate response by week 2, as early response may predict later improvement 5