Aripiprazole Titration
Start aripiprazole at 10-15 mg once daily without titration, as the drug does not require dose escalation from a lower starting dose. 1
Starting Dose
- Adults with schizophrenia: Begin at 10 or 15 mg once daily, which serves as both the starting and target dose 1
- Adolescents (13-17 years) with schizophrenia: Start at 2 mg daily, increase to 5 mg after 2 days, then to the target dose of 10 mg after 2 additional days 1
- Adolescents with bipolar mania: Use 10 mg once daily 2
- Aripiprazole can be taken without regard to meals 1
Dose Adjustments
- Wait at least 2 weeks before increasing the dose, as this is the time required to reach steady-state plasma concentrations 1, 3
- The full therapeutic effect may take 1-2 weeks, and sometimes up to 4 weeks to manifest 3, 4
- If dose increases are needed, use 5 mg increments for adolescents 1
- The effective dose range is 10-30 mg/day, though doses above 10-15 mg/day have not demonstrated superior efficacy 1, 5
- Maximum recommended dose is 30 mg/day 1
Special Dosing Considerations
For patients taking CYP2D6 or CYP3A4 inhibitors:
- Reduce dose to half the usual dose when taking strong CYP2D6 inhibitors (quinidine, fluoxetine, paroxetine) or strong CYP3A4 inhibitors (itraconazole, clarithromycin) 1
- Reduce dose to one-quarter of the usual dose when taking both strong CYP2D6 and CYP3A4 inhibitors simultaneously 1
For patients taking CYP3A4 inducers:
- Double the usual dose over 1-2 weeks when taking strong CYP3A4 inducers (carbamazepine, rifampin) 1
- When the inducer is discontinued, reduce aripiprazole back to the original dose over 1-2 weeks 1
For known CYP2D6 poor metabolizers:
- Administer half of the usual dose 1
Oral Solution Formulation
- The oral solution can substitute for tablets on a mg-per-mg basis up to 25 mg 1
- Patients receiving 30 mg tablets should receive 25 mg of the oral solution 1
- The oral solution may be more appropriate for precise dose reductions in patients with difficulty swallowing 6
Monitoring
- Reassess patients periodically to determine the continued need for maintenance treatment 1
- During dose reduction, assess for withdrawal symptoms (anxiety, insomnia, irritability, mood changes) 6
- Patients should be reassessed at least every 3 months during any dose reduction process 6
Key Pharmacokinetic Points
- Mean elimination half-life is approximately 75 hours for aripiprazole and 94 hours for its active metabolite dehydro-aripiprazole 3
- Steady-state concentrations are attained within 14 days 3, 7
- The drug accumulates significantly over the first 2 weeks, with 4-fold higher plasma concentrations on day 14 compared to day 1 7