Is Abilify (aripiprazole) safe for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)?

Is Abilify Safe for PANDAS?

Abilify (aripiprazole) is not specifically recommended for PANDAS treatment, and there is no evidence supporting its safety or efficacy in this population. The first-line treatment for PANDAS is antibiotics to eradicate streptococcal infection, not antipsychotic medications 1, 2, 3.

Why Aripiprazole Is Not Indicated for PANDAS

PANDAS Is Considered an Unproven Hypothesis

• The American Heart Association explicitly states that PANDAS "should be considered only as a yet-unproven hypothesis" and emphasizes the need for careful consideration of this concept 1, 2, 3
• The diagnosis itself remains controversial with limited definitive evidence for its autoimmune pathophysiology 4, 5

First-Line Treatment Is Antibiotics, Not Antipsychotics

• The initial treatment for PANDAS should be antibiotics to eradicate the streptococcal infection, specifically penicillin V (500 mg four times daily for 10 days) or amoxicillin (500 mg three times daily for 10 days) 1, 2
• For penicillin-allergic patients, erythromycin, clindamycin, or azithromycin are suitable alternatives 1
• The American Heart Association recommends against immunoregulatory therapy (IVIG, plasma exchange) as first-line treatment 1, 2, 3

Considerations If Antipsychotic Use Is Being Contemplated

Limited Evidence in Pediatric Populations

While there is no specific evidence for aripiprazole in PANDAS, general guidance for psychiatric medications in children with neuropsychiatric disorders suggests:

• For psychotic disorders in children with intellectual/developmental disabilities, atypical antipsychotics like aripiprazole are generally preferred over first-generation antipsychotics due to lower risk of extrapyramidal symptoms 6
• However, this recommendation applies to diagnosed psychotic disorders, not to the acute neuropsychiatric symptoms of PANDAS 6

Treatment Should Target Confirmed Psychiatric Diagnoses

• Psychotropic medications should only be prescribed after diagnosis of a DSM-5 psychiatric disorder and should be part of a comprehensive treatment plan 6
• Prescribing medication for behavioral problems (such as aggression or compulsions) should be minimized if possible, as these behaviors may be due to various disorders or other factors 6
• Medication targeting behavioral problems is best limited to individuals who pose a risk of injury to self or others or if other treatments have failed 6

Clinical Approach to PANDAS

Diagnostic Workup

• Obtain anti-streptolysin O (ASO) titer and anti-DNase B titer to document recent strep exposure 3
• Throat culture is indicated if the patient has any throat symptoms 3
• Look for new motor or vocal tics, choreiform movements, and sudden onset of OCD symptoms as key distinguishing features 3

Treatment Algorithm

1. Treat active streptococcal infection with appropriate antibiotics 1, 2, 3
2. Consider cognitive-behavioral therapy (CBT) for OCD symptoms, which has shown benefit in PANDAS 7
3. Post-treatment throat cultures are indicated only in patients who remain symptomatic or experience symptom recurrence 1

Critical Caveat

There is no published evidence supporting the use of aripiprazole specifically for PANDAS. The limited research on PANDAS treatment focuses on antibiotics, immunomodulatory therapies, and CBT 8, 7, 9. If psychiatric symptoms persist after appropriate antibiotic treatment, referral to a psychiatrist specializing in pediatric neuropsychiatric disorders may be warranted 6, but antipsychotic use should be reserved for confirmed psychiatric diagnoses (such as psychosis or mania), not for the primary treatment of PANDAS-related OCD or tic symptoms.