Children and Adolescents

• Approved for use in schizophrenia (ages 13 and older), manic/mixed episodes (ages 10 and older), and irritability associated with autism (ages 6–17)

• Clinical experience and early data suggest aripiprazole may be safe and effective for behavioral disturbances in children and adolescents, especially at lower doses

• Children and adolescents using aripiprazole may need to be monitored more often than adults and may tolerate lower doses better

• May be more risk of weight gain in children than in adults

Pregnancy

• Risk Category C [some animal studies show adverse effects; no controlled studies in humans]

• There is a risk of abnormal muscle movements and withdrawal symptoms in newborns whose mothers took an antipsychotic during the third trimester; symptoms may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty feeding

• Psychotic symptoms may worsen during pregnancy and some form of treatment may be necessary

• Aripiprazole may be preferable to anticonvulsant mood stabilizers if treatment is required during pregnancy

Breast Feeding

• Unknown if aripiprazole is secreted in human breast milk, but all psychotropics assumed to be secreted in breast milk

✽ Recommended either to discontinue drug or bottle feed

• Infants of women who choose to breast feed while on aripiprazole should be monitored for possible adverse effects

ARIPIPRAZOLE: THE ART OF PSYCHOPHARMACOLOGY

Potential Advantages

• Some cases of psychosis and bipolar disorder refractory to treatment with other antipsychotics

✽ Patients concerned about gaining weight and patients who are already obese or overweight

✽ Patients with diabetes

✽ Patients with dyslipidemia (especially elevated triglycerides)

• Patients requiring rapid onset of antipsychotic action without dosage titration

✽ Patients who wish to avoid sedation

Potential Disadvantages

• Patients in whom sedation is desired

• May be more difficult to dose for children, elderly, or “off-label” uses

Primary Target Symptoms

• Positive symptoms of psychosis

• Negative symptoms of psychosis

• Cognitive symptoms

• Unstable mood and depression

• Aggressive symptoms

Pearls

✽ Approved as an adjunct treatment for depression (e.g., to SSRIs, SNRIs)

• May work better in 2–10 mg/day range than at higher doses for augmenting SSRIs/SNRIs in treatment-resistant unipolar depression

• Frequently used for bipolar depression as augmenting agent to lithium, valproate and/or lamotrigine

✽ Well accepted in clinical practice when wanting to avoid weight gain because less weight gain than most other antipsychotics

✽ Well accepted in clinical practice when wanting to avoid sedation because less sedation than most other antipsychotics at all doses

✽ Can even be activating, which can be reduced by lowering the dose or starting at a lower dose

• If sedation is desired, a benzodiazepine can be added short-term at the initiation of treatment until symptoms of agitation and insomnia are stabilized or intermittently as needed

✽ May not have diabetes or dyslipidemia risk, but monitoring is still indicated

• Anecdotal reports of utility in treatment-resistant cases of psychosis

• Has a very favorable tolerability profile in clinical practice

• Favorable tolerability profile leading to “off-label” uses for many indications other than schizophrenia (e.g., bipolar II disorder, including hypomanic, mixed, rapid cycling, and depressed phases; treatment-resistant depression; anxiety disorders)

• A short-acting intramuscular formulation is available as well as long acting depot

• Lacks D1 antagonist, anticholinergic, and antihistamine properties, which may explain relative lack of sedation or cognitive side effects in most patients

• High affinity of aripiprazole for D2 receptors means that combining with other D2 antagonist antipsychotics could reverse their actions and thus often makes sense not to combine with other antipsychotics

• An exception to this is in case of hyperprolactinemia or galactorrhea, when administration of even low dose (1–5 mg) can reverse the hyperprolactinemia/galactorrhea of other antipsychotics, also proving that aripiprazole interferes with the D2 actions of other antipsychotics

• Abilify Maintena (depot) may be particularly well suited to early-onset psychosis/first-episode psychosis to reduce rehospitalizations and to enhance adherence with relatively low side effect burden

THE ART OF SWITCHING