Indications for Aripiprazole, Buspirone, Olanzapine, and Divalproex Sodium
Aripiprazole, olanzapine, buspirone, and divalproex sodium are indicated for specific psychiatric conditions with aripiprazole and olanzapine primarily used for schizophrenia and bipolar disorder, buspirone for anxiety disorders, and divalproex sodium for bipolar disorder, epilepsy, and migraine prophylaxis.
Aripiprazole (Abilify)
Aripiprazole is FDA-approved for:
- Schizophrenia in adults and adolescents (13-17 years) 1
- Bipolar I disorder (acute manic/mixed episodes) in adults and adolescents (10-17 years) 2
- Adjunctive treatment with mood stabilizers (lithium or valproate) for bipolar I disorder 3
- Treatment of agitation associated with schizophrenia and bipolar mania 2
Aripiprazole is a third-generation antipsychotic with a unique mechanism as a partial dopamine D2 receptor agonist, which contributes to its efficacy in treating positive and negative symptoms of schizophrenia with lower risk of extrapyramidal symptoms 4.
Dosing considerations:
- Starting dose: 5 mg PO or IM (immediate-release) once daily 2
- Maintenance: Give q24h if scheduled dosing required 2
- Lower doses recommended for older patients and poor metabolizers of CYP450 2D6 2
Side effect profile:
- Less likely to cause extrapyramidal symptoms compared to typical antipsychotics 2
- May cause headache, agitation, anxiety, insomnia, dizziness, drowsiness 2
- Lower risk of metabolic side effects compared to olanzapine 5
Olanzapine (Zyprexa)
Olanzapine is FDA-approved for:
- Treatment of schizophrenia in adults and adolescents (13-17 years) 6
- Acute treatment of manic or mixed episodes associated with bipolar I disorder 6
- Maintenance treatment of bipolar I disorder 6
- Adjunct to valproate or lithium in the treatment of manic or mixed episodes associated with bipolar I disorder 6
- Treatment of acute agitation associated with schizophrenia and bipolar I mania (IM formulation) 6
- Treatment of depressive episodes associated with bipolar I disorder (in combination with fluoxetine) 6
- Treatment-resistant depression (in combination with fluoxetine) 6
Dosing considerations:
- Schizophrenia in adults: Start at 5-10 mg once daily; target 10 mg/day 6
- Bipolar disorder in adults: Start at 10 or 15 mg once daily 6
- Delirium management: 2.5-5 mg PO or SC stat; if scheduled dosing required, start with 2.5-5 mg daily (usually at bedtime) 2
Side effect profile:
- May cause drowsiness and orthostatic hypotension 2
- Metabolic effects with long-term use (weight gain, hyperglycemia, dyslipidemia) 2, 5
- Caution when combining with benzodiazepines due to risk of oversedation and respiratory depression 2
Buspirone (BuSpar)
Buspirone is indicated for:
Dosing considerations:
- Initial dosage: 5 mg twice daily 2
- Maximum dosage: 20 mg three times daily 2
- Useful only in patients with mild to moderate agitation 2
- May take 2-4 weeks to become effective 2
Divalproex Sodium (Depakote)
Divalproex sodium is indicated for:
- Bipolar disorder (acute manic episodes) 2
- Mood stabilization in bipolar disorder 2
- Epilepsy (seizure control) 2
- Migraine prophylaxis 2
Dosing considerations:
- Initial dosage: 125 mg twice daily 2
- Titrate to therapeutic blood level (40-90 mcg/mL) 2
- Generally better tolerated than other mood stabilizers 2
Side effect profile:
- Monitor liver enzyme levels 2
- Monitor platelets, prothrombin time, and partial thromboplastin time as indicated 2
Combination Therapy Considerations
- Aripiprazole + divalproex sodium: Effective combination for bipolar disorder with potentially improved compliance as a fixed-dose combination 7
- Aripiprazole + mood stabilizers: Effective for acute mania and maintenance treatment of bipolar I disorder with lower risk of metabolic side effects compared to other combination therapies 3
- Olanzapine + valproate/lithium: Approved for acute manic or mixed episodes associated with bipolar I disorder 6, 8
Clinical Pearls and Cautions
- For delirium management in cancer patients, aripiprazole and olanzapine may be used for perceptual disturbances or severe agitation, but should be used at the lowest effective dose for the shortest period possible 2
- In elderly patients with dementia-related psychosis, antipsychotics including olanzapine carry a boxed warning for increased mortality risk 6
- When treating bipolar disorder in children and adolescents, lithium is the only agent with FDA approval for patients age 12 years and older, though aripiprazole, olanzapine, and divalproex sodium are commonly used clinically 2
- Combination therapy with atypical antipsychotics and mood stabilizers is often more effective than monotherapy for treatment-resistant bipolar mania 8
Always consider patient-specific factors including age, comorbidities, potential drug interactions, and previous treatment response when selecting these medications.