Can I give risperidone (Risperdal) 2mg twice daily (bid) to a patient with catatonia who recently received Abilify (aripiprazole) long-acting?

Can You Give Risperidone 2mg BID to a Patient with Catatonia Who Recently Received Long-Acting Aripiprazole?

No, you should NOT give risperidone 2mg BID as initial treatment for acute catatonia in this patient—benzodiazepines (specifically lorazepam) are the first-line treatment, and risperidone carries risk of worsening catatonia or precipitating neuroleptic malignant syndrome.

First-Line Treatment: Benzodiazepines

• Lorazepam is the definitive first-line treatment for acute catatonia, with up to 80% of patients responding promptly to lorazepam challenge 1.
• The standard approach is lorazepam 1-2mg IV/IM initially, which can be repeated every 1-2 hours as needed, with doses up to 15mg per day reported in severe cases 2.
• Benzodiazepines work by enhancing GABA transmission, which directly addresses the proposed pathophysiology of catatonia (low GABA activity) 3, 4.

Critical Safety Concerns with Antipsychotics in Catatonia

Risk of Worsening Catatonia

• Conventional antipsychotics are known to induce or worsen catatonic states into malignant catatonia and should be avoided 2.
• Risperidone specifically has been reported to cause dose-dependent catatonia in at least one case report, where severe catatonia developed at 5mg daily and subsided only after switching to clozapine 5.
• The temporal relationship between risperidone administration and catatonia development represents a documented risk 5.

Interaction with Long-Acting Aripiprazole

• Your patient still has aripiprazole on board from the long-acting injection, which can remain active for weeks to months depending on the formulation 6.
• Adding risperidone creates antipsychotic polypharmacy, which guidelines generally recommend against except in specific circumstances like clozapine augmentation 6.
• The combination of two antipsychotics increases the risk of extrapyramidal symptoms, which can complicate or worsen the catatonic presentation 6.

When Antipsychotics Might Be Considered

After Benzodiazepine Trial

• If the patient fails to respond to adequate benzodiazepine treatment (lorazepam up to 15mg/day for 72 hours), electroconvulsive therapy (ECT) is the next definitive treatment 2, 4.
• Only after benzodiazepines and/or ECT have been considered should atypical antipsychotics be contemplated 2, 1.

Atypical Antipsychotic Selection

• If an atypical antipsychotic is deemed necessary (e.g., for underlying psychosis once catatonia resolves), aripiprazole may actually be preferable to risperidone for catatonia 3.
• Aripiprazole has been reported to rapidly resolve catatonic symptoms at doses ≥25mg/day, likely due to its unique partial D2 agonist/antagonist profile and GABA-enhancing properties 3.
• The patient already has aripiprazole on board, which may be beneficial rather than problematic 3.
• Risperidone's 5-HT2A antagonism may theoretically help catatonia, but case reports of risperidone-induced catatonia create significant concern 5, 1.

Recommended Clinical Algorithm

1. Immediate treatment: Start lorazepam 1-2mg IV/IM, repeat every 1-2 hours as needed 1, 4.
2. Monitor response: Assess for improvement in catatonic symptoms over 24-72 hours 2.
3. If inadequate response: Increase lorazepam up to 15mg/day in divided doses 2.
4. If still refractory: Arrange for ECT, which is definitive treatment 2, 4.
5. Avoid adding risperidone while catatonia is active—the existing aripiprazole may actually be helpful once catatonia resolves with benzodiazepines 3.
6. If antipsychotic adjustment needed: Consider increasing aripiprazole dose (if long-acting levels are subtherapeutic) or waiting for catatonia resolution before any changes 3.

Key Pitfalls to Avoid

• Do not assume antipsychotics are appropriate for acute catatonia—this is a medical emergency requiring specific treatment 2, 4.
• Do not add risperidone without first attempting adequate benzodiazepine treatment—this violates established treatment algorithms 1, 2.
• Do not overlook the risk of malignant catatonia, which carries high mortality without proper treatment 2, 4.
• Do not create unnecessary polypharmacy when the patient already has a long-acting antipsychotic on board 6.