Is it appropriate to taper Abilify (aripiprazole) to 2mg for 4 days then discontinue and start Latuda (lurasidone) 20mg daily in a patient with bipolar disorder and chronic depression?

Recommendation for Transitioning from Abilify to Latuda in Bipolar Depression

The proposed plan to taper Abilify to 2mg for 4 days then discontinue and start Latuda 20mg daily is not optimal—a more gradual cross-taper over 1-2 weeks is recommended to minimize withdrawal symptoms and maintain mood stability, while Latuda represents an appropriate evidence-based choice for bipolar I depression. 1, 2, 3

Rationale for Switching to Latuda

• Lurasidone (Latuda) is FDA-approved and guideline-supported for bipolar I depression, with clinically meaningful treatment effect sizes (0.51 for monotherapy) and a number needed to treat of 5 for response 4, 5
• The switch is justified given the patient's lack of improvement on current therapy and history of akathisia with Abilify at 5mg 6, 5
• Lurasidone has demonstrated efficacy in acute bipolar depression with relatively few side effects, particularly minimal metabolic effects and lower rates of akathisia compared to higher-potency dopamine antagonists 6, 7

Problems with the Proposed Taper Schedule

• A 4-day taper from 5mg to 2mg then discontinuation is too rapid and increases risk of withdrawal symptoms and mood destabilization 1, 2, 3
• Gradual tapering of antipsychotics over 2-4 weeks is recommended to avoid withdrawal symptoms including anxiety, insomnia, irritability, and rebound worsening of underlying conditions 1, 2
• Abrupt discontinuation can trigger severe withdrawal symptoms and should be avoided 1, 2

Recommended Cross-Taper Protocol

Week 1-2:

• Reduce Abilify from 5mg to 2.5mg daily 1, 2
• Start Latuda 20mg daily with food (must be taken with at least 350 calories for proper absorption) 6, 5
• Monitor closely for akathisia, which can occur with Latuda but at lower rates than with Abilify 6

Week 3:

• Reduce Abilify to 1-2mg daily (or discontinue if patient tolerating well) 1, 2
• Continue Latuda 20mg daily 6, 5

Week 4:

• Discontinue Abilify completely 1, 2
• Continue Latuda 20mg daily; may increase to 40-60mg if needed for optimal response (therapeutic range 20-120mg) 6, 5

Critical Monitoring During Transition

Daily monitoring in first week should assess: 1, 2

• Mood symptoms and suicidal ideation (particularly important given patient's SI on admission)
• Akathisia or other extrapyramidal symptoms
• Sleep patterns and anxiety levels
• Withdrawal symptoms (restlessness, agitation, insomnia, nausea)

Weekly assessments for first month should include: 1, 2

• Depression severity using standardized scales
• Distinguishing withdrawal symptoms (emerge within days, self-limiting) from true relapse (develops gradually over weeks)
• Side effects including somnolence, nausea, and gastrointestinal upset 6

Addressing the Effexor Component

• Antidepressants should always be combined with a mood stabilizer in bipolar disorder and are not recommended as monotherapy 8
• The patient is currently on Effexor 150mg with Abilify; continuing the antidepressant during the cross-taper is appropriate as long as a mood stabilizer (Latuda in this case) is maintained 8
• Consider whether Effexor at 150mg is optimally dosed or if adjustment is needed once Latuda is established 8

Common Pitfalls to Avoid

• Do not abruptly discontinue Abilify even at low doses, as this can trigger withdrawal and mood destabilization 1, 2
• Do not start Latuda without food—it requires at least 350 calories for adequate absorption and efficacy 6, 5
• Do not misinterpret early withdrawal symptoms as treatment failure—these typically emerge within days and resolve, whereas true relapse develops over weeks 2, 3
• If severe symptoms develop during tapering that pose safety concerns, return to the previous dose and extend each reduction phase by 1-2 weeks 2

Long-Term Considerations

• Lurasidone has demonstrated safety and effectiveness over 2 years of treatment with minimal effects on weight and metabolic parameters 7
• The probability of relapse during 18 months of continuation treatment with lurasidone monotherapy is estimated at 18.3% 7
• Mean weight change over extended treatment is approximately +0.8 kg, with minimal effects on cholesterol and triglycerides 7
• Maintenance treatment for bipolar disorder should continue for at least 2 years after the last episode 8