Switching from Invega (Paliperidone) to Abilify (Aripiprazole)
For patients switching from Invega to Abilify, initiate aripiprazole at 10-15 mg/day while continuing the current antipsychotic for 14 days, then discontinue Invega; alternatively, cross-titrate over 1-4 weeks by gradually tapering Invega while titrating up aripiprazole to minimize discontinuation due to adverse events. 1
Recommended Switching Protocol
Option 1: Overlap Method (Preferred for Stability)
- Start aripiprazole 10-15 mg/day orally while maintaining current Invega dose 1
- Continue both medications for 14 days to ensure therapeutic aripiprazole concentrations are achieved, as median plasma levels reach therapeutic range within 7 days but interpatient variability necessitates the 14-day overlap 1
- Discontinue Invega after the 14-day overlap period 1
- This approach maintains therapeutic coverage throughout the transition and was well-tolerated in clinical studies with 90.1% of patients requiring no dose adjustment 1
Option 2: Cross-Titration Method (Better Tolerability)
- Gradually taper Invega while simultaneously titrating up aripiprazole over >1 to 4 weeks 1
- Target aripiprazole dose of 10-30 mg/day based on symptom severity and prior stabilization dose 1
- This method demonstrated superior tolerability with discontinuation rates due to adverse events of only 2.7% versus 10.4% with rapid switches (≤1 week) 1
- The longer cross-titration period (>1-4 weeks) significantly reduces adverse event-related discontinuations 1
Key Pharmacological Considerations
Mechanism Differences Requiring Careful Transition
- Paliperidone is a D2 antagonist, while aripiprazole is a D2 partial agonist 2
- This fundamental difference means switching from full D2 blockade to partial agonism may initially cause symptom fluctuation 2
- Aripiprazole also provides partial 5-HT1A agonism and 5-HT2A antagonism, creating a distinct receptor profile 2
Dosing Equivalence
- Aripiprazole 10-30 mg/day achieves therapeutic plasma concentrations (94.0-534.0 ng/mL) comparable to effective antipsychotic treatment 1
- Most patients stabilize on aripiprazole 10-15 mg/day, though some require up to 30 mg/day 1
- Efficacy and safety are comparable across this dose range 1
Critical Monitoring Parameters
First 1-2 Weeks
- Monitor for signs of agitation, irritability, or unusual behavioral changes that may indicate inadequate D2 receptor coverage during the transition 3
- Assess for extrapyramidal symptoms (EPS), though aripiprazole has lower EPS risk than traditional antipsychotics 4
- Evaluate for sedation and akathisia, which are common early side effects of aripiprazole 4
Weeks 2-6
- Maintain therapeutic dose for at least 4-6 weeks before assessing adequate response 3
- Monitor weight and metabolic parameters, as aripiprazole has lower metabolic risk than many antipsychotics but still causes weight gain 4
- Assess for hyperprolactinemia resolution, as aripiprazole has lower prolactin elevation risk compared to paliperidone 3
Common Pitfalls to Avoid
- Do not abruptly discontinue Invega without overlap or cross-titration, as this creates a treatment gap risking symptom exacerbation 1
- Avoid cross-titration periods ≤1 week, which increase adverse event-related discontinuation rates from 2.7% to 10.4% 1
- Do not combine multiple antipsychotics simultaneously beyond the recommended overlap period, as this increases side effect burden without additional benefit 3
- Do not assume immediate therapeutic effect—aripiprazole demonstrates rapid onset within one week, but full assessment requires 4-6 weeks 2, 3
Special Considerations for Long-Acting Injectable Invega
Switching from Invega Sustenna (Monthly)
- Begin aripiprazole oral at the time the next monthly injection would be due 5, 6
- The monthly formulation provides coverage for approximately 4 weeks, allowing seamless transition 6