What is the recommended tapering schedule when switching a patient from Latuda (lurasidone) to Abilify (aripiprazole)?

Switching from Latuda to Abilify: Cross-Taper Strategy

When switching from Latuda (lurasidone) to Abilify (aripiprazole), use a gradual cross-taper over 1-3 months with hyperbolic dose reductions, never abruptly discontinue Latuda, and initiate Abilify at a low dose while slowly tapering Latuda to minimize withdrawal symptoms and dopaminergic rebound. 1

Critical Safety Principles

• Never abruptly discontinue Latuda, as this constitutes unacceptable medical care and can precipitate severe withdrawal symptoms, rapid mood destabilization, and dopaminergic hypersensitivity leading to relapse 1, 2
• Abrupt antipsychotic discontinuation or major dose reduction can lead to significant withdrawal symptoms equivalent to suddenly stopping antihypertensives 1
• Patient agreement and collaboration are essential throughout the switching process 1

Recommended Cross-Taper Protocol

Initial Phase (Weeks 1-2)

• Start Abilify at 2-5 mg daily while maintaining full Latuda dose 3
• Monitor for tolerability and early side effects during this overlap period 3
• This allows the new medication to begin exerting therapeutic effects before reducing the original medication 4

Tapering Phase (Weeks 2-12)

Use hyperbolic (exponential) tapering for Latuda reduction:

• Reduce Latuda by 25% of the current dose (not original dose) every 2-4 weeks 1, 2
• Each reduction should be a percentage of the previous dose to maintain linear reduction in D2 receptor blockade 2
• Simultaneously titrate Abilify upward to therapeutic dose (10-15 mg for most indications) over 2-4 weeks 3

Example tapering schedule for patient on Latuda 80 mg:

• Weeks 1-2: Latuda 80 mg + Abilify 2-5 mg
• Weeks 3-4: Latuda 60 mg (25% reduction) + Abilify 10 mg
• Weeks 5-6: Latuda 45 mg (25% of 60 mg) + Abilify 10-15 mg
• Weeks 7-8: Latuda 30 mg (approximately 25% of 45 mg) + Abilify 10-15 mg
• Weeks 9-10: Latuda 20 mg + Abilify 10-15 mg
• Weeks 11-12: Latuda 10 mg + Abilify 10-15 mg
• Week 13+: Discontinue Latuda, continue Abilify

1, 2

Final Discontinuation Phase

• The final doses before complete cessation may need to be very small (as low as 1/40th therapeutic dose) to prevent large decreases in D2 blockade 2
• Consider extending intervals between doses before complete discontinuation if withdrawal symptoms emerge 1
• Final reductions should occur over 3-6 months for patients who have been on Latuda long-term 2

Important Considerations for Aripiprazole

Aripiprazole is a partial D2 agonist, which creates unique switching challenges:

• When switching to aripiprazole specifically, some evidence suggests immediate discontinuation may be viable, though gradual tapering remains safer 3
• The partial agonist properties may actually help mitigate dopaminergic hypersensitivity during the transition 3
• However, the conservative approach with gradual cross-taper is still recommended to minimize risk 1, 4

Monitoring During the Switch

Schedule follow-up every 2-4 weeks during active tapering: 1

• Assess for withdrawal symptoms: insomnia, anxiety, irritability, agitation, nausea, diaphoresis 1
• Monitor for return of original psychiatric symptoms (psychosis, mood instability, depression) 1
• Screen for extrapyramidal symptoms as Abilify has different EPS profile than Latuda 3
• Watch for akathisia, which is more common with aripiprazole 3

Managing Withdrawal Symptoms

If withdrawal symptoms occur during tapering: 1

• Temporarily return to the previous Latuda dose and stabilize for 2-4 weeks 1
• Attempt a smaller reduction (10-15% instead of 25%) after symptoms resolve 1, 2
• Consider extending time between dose reductions to 4-6 weeks 1
• Do not push forward with the taper if the patient is struggling 1

Adjunctive medications for specific withdrawal symptoms: 1

• Trazodone 25-50 mg for insomnia
• Benzodiazepines (short-term only) for severe anxiety
• Propranolol for autonomic symptoms (tachycardia, tremor)

Critical Pitfalls to Avoid

• Do not use fixed timelines - the taper must be adjusted based on individual response, not a predetermined schedule 1
• Do not abandon the patient if they struggle with the taper; consider pausing at a stable dose rather than discontinuing care 1
• Do not make "cold referrals" to other clinicians during the switch without ensuring they have agreed to accept the patient's care 1
• Do not reduce by fixed amounts (e.g., 20 mg every 2 weeks) - use percentage-based reductions to maintain proportional D2 blockade changes 2
• Avoid antipsychotic polypharmacy long-term - the cross-taper should be time-limited, not result in indefinite dual therapy 3

Alternative Approach: Immediate Discontinuation

While gradual cross-taper is the conservative recommendation, immediate discontinuation with simultaneous aripiprazole initiation may be considered in specific circumstances: 3

• Patient has been on Latuda for short duration (< 3 months)
• Patient is experiencing severe intolerable side effects requiring rapid switch
• Patient is clinically stable with good insight and close monitoring available
• Switching specifically to aripiprazole (partial agonist properties may mitigate withdrawal)

However, this approach carries higher risk and should only be used when benefits clearly outweigh risks 4, 3

When to Refer to Specialist

Immediate psychiatric specialist involvement is indicated for: 1

• History of severe relapse with previous antipsychotic switches
• Co-occurring substance use disorders
• Unstable psychiatric comorbidities (active suicidality, severe mood instability)
• Previous unsuccessful switching attempts
• Pregnancy or planning pregnancy during the switch

Duration and Expectations

• Minimum switching duration: 4-8 weeks for most patients 4, 3
• Extended switching duration: 3-6 months for patients on Latuda long-term (> 1 year) or at high doses 2
• Success is defined by maintaining psychiatric stability without significant withdrawal symptoms, not by speed of the switch 1
• Pauses in the taper are acceptable and often necessary 1