Can Abilify (aripiprazole) and Seroquel (quetiapine) be used together?

Combining Abilify (Aripiprazole) and Seroquel (Quetiapine)

While antipsychotic monotherapy is generally recommended as first-line treatment, combining Abilify (aripiprazole) and Seroquel (quetiapine) may be appropriate in specific clinical situations such as treatment-resistant schizophrenia or when managing complex symptom profiles. 1

Guidelines on Antipsychotic Polypharmacy

Current Guideline Recommendations

• Most treatment guidelines primarily recommend antipsychotic monotherapy, though they acknowledge specific situations where polypharmacy may be beneficial 1
• The National Institute for Health and Care Excellence (NICE) recommends against regular combined antipsychotic medication except for short periods (e.g., when changing medications) or when augmenting clozapine treatment 1
• The World Federation of Societies of Biological Psychiatry guidelines suggest antipsychotic polypharmacy should only be considered in certain individual cases such as treatment-resistant schizophrenia 1
• The Finnish Current Care Guideline acknowledges that some patients may benefit from concurrent use of two antipsychotics, specifically noting that combining aripiprazole with another antipsychotic may reduce negative symptoms 1

Clinical Considerations for Aripiprazole and Quetiapine Combination

Potential Benefits

• The combination may help address different symptom domains due to their complementary mechanisms of action - aripiprazole is a partial D2 agonist while quetiapine is primarily a D2 antagonist 2, 3
• Aripiprazole added to another antipsychotic (including quetiapine) may help reduce metabolic side effects, weight gain, hyperprolactinemia, and sexual dysfunction 1
• This combination may be useful when a patient has partial response to monotherapy but continues to experience residual symptoms 1

Potential Risks and Side Effects

• Increased global side-effect burden compared to monotherapy 1
• Potential for increased risk of:
  • Parkinsonian side effects 1
  • Anticholinergic burden 1
  • Cognitive impairment 1
  • Sedation (particularly from quetiapine) 4
  • Akathisia (particularly from aripiprazole) 4

Monitoring Recommendations

• Regular assessment of:
  • Extrapyramidal symptoms, particularly akathisia which is more common with aripiprazole 3, 4
  • Metabolic parameters (weight, blood glucose, lipids) 1, 4
  • Sedation levels 4
  • QTc interval 1
  • Overall symptom response 1

Decision Algorithm for Aripiprazole-Quetiapine Combination

1. First attempt monotherapy:

   • Try adequate trials of individual antipsychotics at optimal doses before considering combination 1
   • Consider clozapine if two monotherapy trials have failed 1

2. Rule out factors reducing treatment efficacy:

   • Confirm medication adherence (consider long-acting injectables if adherence is an issue) 1
   • Check blood levels to ensure adequate dosing 1

3. Consider combination therapy when:

   • Patient has inadequate response to clozapine or clozapine is contraindicated 1
   • Patient shows partial response to monotherapy but has residual symptoms 1
   • Patient experiences intolerable side effects at effective doses of a single agent 1

4. Implementation strategy:

   • Start with lower doses of each medication and titrate gradually 1
   • Monitor closely for side effects, particularly in the first few weeks 4
   • Reassess regularly to determine if combination remains necessary 1

Important Caveats

• Despite guideline recommendations for monotherapy, antipsychotic polypharmacy is widely used in clinical practice (10-20% of outpatients and up to 40% of inpatients with schizophrenia) 1
• The combination should be selected with complementary side effect profiles - aripiprazole may help counteract some metabolic and sedative effects of quetiapine 1
• Drug-drug interactions should be considered, especially regarding cytochrome P450 metabolism 1
• Regular reassessment is essential to determine if combination therapy remains necessary or if a return to monotherapy is possible 1

Remember that while this combination may be beneficial for some patients, the decision should be based on careful consideration of the patient's specific symptom profile, previous treatment responses, and side effect vulnerabilities.