Cross-Tapering from Aripiprazole to Quetiapine
The recommended protocol for cross-tapering from aripiprazole to quetiapine involves gradually reducing aripiprazole while simultaneously titrating up quetiapine over a period of 2-4 weeks to minimize withdrawal symptoms and maintain symptom control.
Initial Steps
- Begin quetiapine at 25 mg on day 1, then follow this titration schedule: day 2 (100 mg), day 3 (200 mg), day 4 (300 mg), and day 5 (400 mg), administered in divided doses twice daily 1
- Maintain the current aripiprazole dose for the first week while initiating quetiapine to ensure adequate antipsychotic coverage 2
- After the first week, begin reducing aripiprazole by approximately 25% of the most recent dose every 1-2 weeks 3
Tapering Schedule
Weeks 1-2:
- Start quetiapine at 25 mg and titrate to target dose of 400 mg by day 5 1
- Maintain full aripiprazole dose for the first week 2
- Begin reducing aripiprazole by 25% of the most recent dose at the end of week 1 3
Weeks 2-4:
- Continue quetiapine at the target dose (typically 400 mg/day, range 150-750 mg/day based on response) 1
- Continue reducing aripiprazole by 25% of the most recent dose every 1-2 weeks until discontinued 3
- Monitor for withdrawal symptoms and adjust the tapering schedule as needed 4
Monitoring During Cross-Tapering
- Follow up frequently (at least monthly) during the cross-tapering process 4
- Monitor for signs of withdrawal (anxiety, insomnia, agitation) or psychotic symptom exacerbation 4
- Assess for medication side effects, particularly sedation, orthostatic hypotension, and extrapyramidal symptoms 4
- If withdrawal symptoms emerge, slow the taper rate of aripiprazole 4
Special Considerations
- For patients who have been on aripiprazole long-term (≥1 year), consider a slower taper over several months 4
- Quetiapine is more sedating than aripiprazole, so consider administering a larger portion of the quetiapine dose at bedtime 4
- Quetiapine has less risk of extrapyramidal symptoms than other atypical antipsychotics 4
- Patients with hepatic impairment require reduced quetiapine dosing 4
Evidence Quality and Clinical Implications
- Research shows that both immediate switching and gradual cross-tapering strategies are effective when transitioning between antipsychotics, but gradual cross-tapering is generally better tolerated 2, 5
- A cross-titration period of >1 to 4 weeks is associated with lower rates of discontinuation due to adverse events compared to more rapid switching (≤1 week) 6
- The hyperbolic tapering method (reducing by smaller and smaller amounts as the total dose decreases) may reduce the risk of withdrawal symptoms and relapse 3
Common Pitfalls to Avoid
- Avoid abrupt discontinuation of aripiprazole, as this may lead to withdrawal symptoms or symptom exacerbation 4
- Do not increase quetiapine too rapidly, as this may cause excessive sedation or orthostatic hypotension 4
- Be aware that quetiapine and aripiprazole have different side effect profiles - quetiapine is more sedating while aripiprazole may cause more akathisia 4
- If the patient is also taking benzodiazepines and these need to be discontinued as well, prioritize tapering the benzodiazepines first due to higher risks associated with benzodiazepine withdrawal 7