Is Aripiprazole Lower Risk for Tardive Dyskinesia Compared to Risperidone, and Will Switching Resolve TD?
Aripiprazole (Abilify) does carry a lower risk of causing tardive dyskinesia compared to risperidone, and switching to aripiprazole may improve existing TD symptoms, though complete resolution is not guaranteed and TD may persist even after medication changes. 1, 2
Comparative Risk Profile
Atypical antipsychotics have significantly lower TD risk than typical antipsychotics, but important differences exist between individual agents:
- Risperidone appears to be the most likely among atypical antipsychotics to produce extrapyramidal side effects and has documented cases of tardive dyskinesia in both adults and teenagers 3
- The weighted mean annual incidence of TD for second-generation antipsychotics is 0.8% (range 0.0%-1.5%) in adults, compared to 5.4% (range 4.1%-7.4%) in adults treated with haloperidol 2
- Both the FDA labels for aripiprazole and risperidone acknowledge that TD can occur with either medication, though the risk profile differs 4, 5
Critical caveat: Aripiprazole is not risk-free for TD. Case reports document de novo tardive dyskinesia developing in neuroleptic-naïve patients treated with aripiprazole alone, with symptoms appearing within 2 months and failing to resolve despite immediate discontinuation 6
Will Switching to Aripiprazole Resolve Existing TD?
Switching may improve but not necessarily resolve TD:
- In an open-label study, patients switched from other antipsychotics to aripiprazole showed significant improvement in TD symptoms, with mean AIMS scores decreasing from 15.8 to 5.0 over 16 weeks 7
- The American Academy of Child and Adolescent Psychiatry recommends considering switching to atypical antipsychotics with lower D2 receptor affinity if continued pharmacotherapy is necessary 1
- Evidence suggests that atypical antipsychotic therapy may ameliorate long-standing TD 8
However, TD is potentially irreversible:
- Up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia, and TD may persist even after medication discontinuation 1, 9
- Both FDA labels explicitly state that TD is "potentially irreversible" and may not remit even after antipsychotic withdrawal 4, 5
- Early detection is crucial as TD may persist despite intervention 1
Management Algorithm for Your Patient
If TD has already developed on risperidone:
Assess TD severity using standardized measures like the Abnormal Involuntary Movement Scale (AIMS) 1
For moderate to severe or disabling TD, treat with a VMAT2 inhibitor (valbenazine or deutetrabenazine) as first-line pharmacotherapy 1
If continued antipsychotic therapy is necessary:
- Consider switching to aripiprazole with gradual cross-titration based on half-life and receptor profiles 1
- Alternatively, clozapine has the lowest risk profile for movement disorders among all antipsychotics and may be the preferred switch option 1
- Perform gradual cross-titration to minimize withdrawal dyskinesia 1
If antipsychotic can be discontinued, gradually withdraw the offending medication 1, 9
Monitor closely every 3-6 months using AIMS even after switching 1
Important considerations:
- Do not use anticholinergic medications for TD—they are indicated for acute dystonia and parkinsonism, not tardive dyskinesia 1
- The smallest effective dose and shortest duration of treatment should be used 4, 5
- Aripiprazole's unique mechanism as a partial D2 receptor agonist may stabilize D2 up-regulation, potentially explaining its beneficial effects on existing TD 10
The concern over TD should not outweigh potential benefits of antipsychotics for patients who genuinely need these medications, but adequate informed consent regarding TD risk is necessary when prescribing antipsychotics. 1, 9