Vraylar (Cariprazine) as a Replacement for Abilify (Aripiprazole)
Switching from Abilify to Vraylar is generally not recommended if you are experiencing tardive dyskinesia (TD), as both medications carry similar risks for movement disorders, and Vraylar does not offer a protective advantage against TD. 1
Understanding the TD Risk with Both Medications
Both Abilify and Vraylar are atypical antipsychotics that can cause tardive dyskinesia, a potentially irreversible movement disorder characterized by involuntary, dyskinetic movements. 1
The risk of TD increases with duration of treatment and cumulative dose for all antipsychotics, including both aripiprazole and cariprazine. 1
Abilify has a lower risk of extrapyramidal symptoms (EPS) compared to first-generation antipsychotics, though this risk increases at higher doses. 2
If TD has already developed on Abilify, switching to another antipsychotic like Vraylar will not reverse the condition and may perpetuate or worsen the movement disorder. 1
Key Pharmacological Differences
Vraylar has a very long half-life with its major active metabolite (didesmethylcariprazine) taking 1-3 weeks to reach steady state, meaning adverse effects can emerge or persist for weeks after starting or stopping the medication. 1
After discontinuing Vraylar, the active metabolite remains detectable for up to 8 weeks, creating a prolonged washout period that complicates medication management. 1
Aripiprazole has not been associated with QTc prolongation or torsade de pointes, making it preferable in certain cardiac situations, though this is not relevant to TD management. 3, 2
Recommended Approach If TD Has Developed
When TD appears in a patient on any antipsychotic, drug discontinuation should be strongly considered. 1
Gradual withdrawal of the antipsychotic over a period greater than 1 month is recommended to minimize discontinuation effects including dyskinesias, parkinsonian symptoms, and dystonias. 3
Abrupt discontinuation can cause withdrawal dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome. 3
If continued antipsychotic treatment is absolutely necessary despite TD, use the lowest effective dose and shortest duration that produces a satisfactory clinical response. 1
Periodically reassess the need for continued antipsychotic treatment once TD has developed. 1
When Vraylar Might Be Considered (Not for TD)
Vraylar may offer advantages over Abilify in specific clinical scenarios unrelated to TD:
For negative symptoms of schizophrenia, cariprazine showed significantly greater improvement compared to aripiprazole in patients with moderate/severe negative symptoms. 4
Cariprazine demonstrated efficacy on negative symptoms even after adjusting for positive symptom changes (P = 0.0038 for 4.5-6 mg/d vs placebo). 4
In bipolar depression, cariprazine showed smaller treatment effects compared to lurasidone, olanzapine, and quetiapine, with aripiprazole being ineffective. 5
Critical Pitfalls to Avoid
Do not assume that switching from one atypical antipsychotic to another will reduce TD risk once the syndrome has developed. 1
Do not underestimate Vraylar's prolonged pharmacokinetic profile – adverse effects including EPS and akathisia can emerge weeks after initiation and persist weeks after discontinuation. 1
Do not switch medications without a clear therapeutic rationale beyond TD management, as both drugs carry similar movement disorder risks. 1
Monitor for adverse reactions including EPS for several weeks after starting Vraylar and after each dosage increase due to accumulation of active metabolites. 1
Bottom Line
If TD is developing on Abilify, the priority should be gradual discontinuation or dose reduction of the antipsychotic rather than switching to Vraylar. 1 Both medications share the same class-related risk for tardive dyskinesia, and Vraylar's extended half-life creates additional management challenges. 1 Consider non-pharmacological interventions and reserve chronic antipsychotic treatment only for patients with chronic illness known to respond to these medications when alternative treatments are not available. 1