What antiemetic medication can be given to an adult or adolescent patient with a psychiatric condition, taking Abilify (aripiprazole), who is experiencing nausea?

Antiemetic Options for Patients Taking Abilify (Aripiprazole)

Ondansetron (a 5-HT3 receptor antagonist) is the preferred first-line antiemetic for patients taking Abilify, as it is safe, effective, and does not interact with aripiprazole or cause sedation or movement disorders. 1, 2

First-Line Recommendation

• Ondansetron should be the initial choice for nausea in patients on aripiprazole because it has no significant drug interactions with antipsychotics, causes minimal sedation, and does not increase the risk of extrapyramidal symptoms (EPS) 1
• Ondansetron can be administered intravenously, intramuscularly, or as an oral dissolving tablet, with IV administration providing the most rapid relief (mean nausea score reduction of 4.4 on a 10-point scale) 2
• This agent is particularly advantageous since aripiprazole itself can cause nausea as a common adverse effect 3, 4

Second-Line Options

If ondansetron is ineffective or unavailable, consider these alternatives based on clinical context:

Metoclopramide

• Metoclopramide (10-20 mg PO every 6 hours) offers both antiemetic and prokinetic effects, making it useful when gastric motility issues contribute to nausea 5, 6
• Critical caveat: Monitor closely for akathisia, which can develop any time within 48 hours post-administration 5
• Decreasing the infusion rate reduces akathisia incidence, and diphenhydramine can treat this adverse effect if it occurs 5
• Do not use if bowel obstruction is suspected 6

Olanzapine

• Olanzapine (2.5-5 mg PO/sublingual every 6-8 hours) has superior efficacy for breakthrough nausea compared to metoclopramide 5, 6
• However, combining two antipsychotics (aripiprazole + olanzapine) requires careful consideration of additive side effects, including sedation and metabolic effects
• This option is best reserved for refractory cases where other agents have failed 5

Promethazine

• Promethazine (12.5-25 mg every 4-6 hours) is an option when sedation is desirable 5, 7
• Important warning: Promethazine causes more sedation than other agents and has potential for vascular damage with IV administration 7, 1
• The average effective dose for active nausea is 25 mg, which may be repeated at 4-6 hour intervals as necessary 7

Prochlorperazine

• Prochlorperazine is a dopamine receptor antagonist that can be effective for nonspecific nausea 5
• Like metoclopramide, monitor for akathisia development within 48 hours 5

Agents to Avoid or Use with Extreme Caution

• Haloperidol: While effective as an antiemetic, combining it with aripiprazole means using two antipsychotics simultaneously, which increases risk of EPS and other dopaminergic side effects 5
• Droperidol: Limited to refractory cases due to FDA black box warning regarding QT prolongation 1

Additional Considerations

For Anxiety-Related Nausea

• Lorazepam or alprazolam may be beneficial when anxiety contributes to nausea 5, 6

For Refractory Cases

• Consider adding agents from different classes rather than replacing one antiemetic with another, as this provides synergistic effects through different mechanisms of action 5
• Dronabinol or nabilone (cannabinoid agents) may be offered for refractory nausea 5

Rule Out Reversible Causes

• Always assess for constipation, gastric outlet obstruction, hypercalcemia, or other medications causing nausea before escalating antiemetic therapy 5
• Check blood levels of potential culprits like digoxin, phenytoin, or carbamazepine if applicable 5