Alternative to Vraylar (Cariprazine) in Pregnancy
For pregnant women requiring antipsychotic treatment, switch from Vraylar to either quetiapine or aripiprazole, as these have the most safety data and clinical experience during pregnancy, with quetiapine being preferred if metabolic concerns are minimal.
Recommended Alternatives
First-Line Options
Quetiapine is among the most frequently used antipsychotics in pregnancy and does not appear to cause consistent congenital harm to the fetus 1. No specific patterns of fetal limb or organ malformation have been reported with quetiapine 1. However, be aware that plasma concentrations decline dramatically during pregnancy if doses remain fixed, with steady-state levels decreasing by 8.7% in the first trimester, 35.0% in the second trimester, and 49.1% in the third trimester 2. Women during late pregnancy should take at least 2.5 times their baseline dose of quetiapine to maintain therapeutic levels 2.
Aripiprazole is another well-studied option with substantial pregnancy data 2. The active moiety (aripiprazole plus its active metabolite dehydroaripiprazole) shows decreased exposure during pregnancy by 12.6% in the first trimester, 38.8% in the second trimester, and 60.9% in the third trimester 2. Women during late pregnancy should take at least 2 times their baseline dose of aripiprazole to maintain effective concentrations 2.
Second-Line Option
Olanzapine is also frequently used in pregnancy and does not appear to cause consistent congenital harm 1. It shares similar safety profiles with quetiapine and aripiprazole regarding major malformations 1.
Critical Considerations
Why Not Continue Vraylar?
There is extremely limited data on cariprazine use during pregnancy. Only one case report exists documenting cariprazine maintenance during pregnancy, which showed no adverse effects 3. However, this single case is insufficient to establish safety, and cariprazine is not considered a first-line agent for pregnancy 4.
Metabolic Monitoring
All atypical antipsychotics may be associated with gestational diabetes 1. Screen for gestational diabetes with particular vigilance when using any atypical antipsychotic during pregnancy 1.
Neonatal Considerations
Antipsychotic medication use in pregnancy is associated with increased neonatal respiratory distress and withdrawal symptoms 1. Prepare neonatal teams for potential monitoring needs at delivery 1.
Avoid Risperidone
Risperidone is not considered a first-line agent for use during pregnancy due to possible associations with malformations that require further study 5. The majority of studies do not show associations with major malformations for most antipsychotics, with the possible exception of risperidone 5.
Implementation Strategy
Continue effective medication principle: Women who need antipsychotics during pregnancy should generally continue the antipsychotic that has been most effective for symptom remission 5. However, given the lack of data on cariprazine, switching is warranted 4, 3.
Dose adjustment protocol: Monitor clinical response closely and increase doses in the second and third trimesters as pharmacokinetic changes occur 2. Metabolic changes during pregnancy may necessitate dose adjustments 5.
Shared decision-making: Engage in comprehensive counseling to enable informed decisions, balancing the potential harm of untreated severe psychiatric illness against medication risks 3, 1.
Therapeutic drug monitoring: Consider checking drug levels during pregnancy to guide dose adjustments, particularly in the third trimester when exposure drops most significantly 2.
Common Pitfalls
- Maintaining fixed doses throughout pregnancy will result in subtherapeutic levels and potential relapse 2
- Abrupt discontinuation of antipsychotics risks severe psychiatric decompensation, which poses greater harm than continued treatment 1
- Failing to screen for gestational diabetes when using atypical antipsychotics 1
- Inadequate neonatal monitoring for respiratory distress and withdrawal symptoms at delivery 1