Can I increase Vraylar (cariprazine) from 1.5 to 3 milligrams (mg) every night at bedtime (qhs)?

Increasing Vraylar (Cariprazine) from 1.5 mg to 3 mg at Bedtime

Yes, increasing Vraylar from 1.5 mg to 3 mg at bedtime is appropriate and consistent with FDA-approved dosing guidelines for this medication. 1

Dosing Guidelines for Vraylar (Cariprazine)

• The FDA-approved dosing for Vraylar indicates that 3 mg daily is within the recommended therapeutic range for bipolar disorder and as adjunctive therapy for major depressive disorder 1
• For bipolar mania, the recommended dose range is 3-6 mg daily, making 3 mg an appropriate target dose 1
• For bipolar depression and as adjunctive therapy for major depressive disorder, the maximum recommended daily dosage is 3 mg 1
• The medication should be administered once daily and can be taken with or without food 1

Pharmacokinetic Considerations

• Cariprazine has a long half-life of 2-5 days for the parent compound 2, 3
• The active metabolite didesmethyl-cariprazine has an even longer half-life of 2-3 weeks 2
• Due to these long half-lives, steady state is not reached until 4-8 weeks of consistent dosing 4
• This means that dose adjustments should be made with the understanding that full effects may not be evident for several weeks 3

Titration Approach

• When increasing from 1.5 mg to 3 mg, no intermediate titration step is typically needed as both are standard dosing options 1
• The increase can be made directly from 1.5 mg to 3 mg daily 1
• Taking the medication at bedtime (qhs) is reasonable, especially if daytime sedation is a concern 4

Monitoring Considerations

• Monitor for common side effects which may become more pronounced at the higher dose, including: 2, 3

  • Akathisia (most common side effect)
  • Extrapyramidal symptoms
  • Insomnia
  • Constipation
  • Nausea
  • Dizziness

• Unlike many other antipsychotics, cariprazine has minimal impact on: 5, 4

  • Weight gain
  • Metabolic parameters
  • Prolactin levels
  • QTc prolongation

Clinical Pearls

• Cariprazine is a dopamine D3/D2 receptor partial agonist with higher affinity for D3 receptors, distinguishing it from other atypical antipsychotics 2
• The medication may have advantages for treating negative symptoms in schizophrenia and depressive symptoms in bipolar disorder 4
• Due to the long half-life, missed doses for a day or two may not significantly impact therapeutic levels once steady state is reached 3
• If side effects emerge after increasing to 3 mg, they may take several days to resolve even if the dose is reduced back to 1.5 mg 3

Caution

• If you experience significant akathisia or extrapyramidal symptoms after increasing to 3 mg, consult your healthcare provider promptly 5
• The long half-life means that side effects may persist longer than with other medications, even after dose reduction 2