Is Vraylar (cariprazine) and lithium okay to use together in treating bipolar disorder?

Vraylar (Cariprazine) and Lithium Combination for Bipolar Disorder

Yes, Vraylar (cariprazine) and lithium can be used together safely and effectively in the treatment of bipolar disorder, with the combination potentially offering better symptom control than monotherapy. 1

Rationale for Combination Therapy

• Lithium is a well-established first-line mood stabilizer for bipolar disorder with proven efficacy in reducing suicide risk and preventing relapse 2
• Cariprazine (Vraylar), an atypical antipsychotic with unique D3/D2 receptor partial agonist properties, has demonstrated efficacy in treating manic, depressive, and mixed episodes in bipolar disorder 3
• Combination therapy is often necessary in bipolar disorder as monotherapy frequently provides insufficient symptom control, with studies showing that the regimen needed to stabilize acute symptoms should be maintained for 12-24 months 4

Benefits of This Specific Combination

• Lithium provides excellent long-term mood stabilization and significantly reduces suicide risk (8.6-fold reduction in suicide attempts) 2
• Cariprazine effectively treats both poles of bipolar disorder and may offer advantages in:
  • Addressing cognitive dysfunction common in bipolar disorder 3
  • Potentially reducing substance use in patients with comorbid substance use disorders 3
• The combination may provide more comprehensive symptom control than either medication alone, as withdrawal from combination therapy to monotherapy has been associated with high relapse rates 4

Monitoring Requirements

• Baseline laboratory monitoring for lithium should include:
  • Complete blood count
  • Thyroid function
  • Renal function (BUN, creatinine)
  • Electrolytes including serum calcium
  • Urinalysis 2
• Follow-up monitoring should occur every 3-6 months for lithium 2
• Both medications require monitoring for weight changes and metabolic parameters 1

Potential Interactions and Precautions

• No significant pharmacokinetic interactions between lithium and cariprazine have been reported in the literature
• The main concern with lithium combinations is the potential for neurotoxicity, which has been reported with some antipsychotics, although the risk appears low 5
• Careful monitoring for signs of neurotoxicity is recommended, especially during initiation and dose adjustments 5
• Medications that affect renal function (such as NSAIDs, ACE inhibitors, and diuretics) should be used with caution as they may increase lithium levels 5

Duration of Treatment

• The medication regimen that stabilizes acute symptoms should be maintained for at least 12-24 months 4, 2
• Many patients with bipolar disorder will require lifelong treatment to prevent relapse 4
• Poor medication adherence significantly increases relapse risk, with studies showing >90% of non-adherent patients relapsed compared to 37.5% of adherent patients 4, 2

Alternatives to Consider

• If the combination is not effective or poorly tolerated, other evidence-based options include:
  • Lamotrigine (particularly effective for preventing depressive episodes) 6
  • Valproate (effective for acute mania) 4
  • Other atypical antipsychotics such as quetiapine, aripiprazole, or olanzapine 4, 1

This combination represents a rational approach to bipolar disorder treatment, combining lithium's proven long-term efficacy with cariprazine's beneficial effects on both poles of the illness and potential cognitive benefits.