Aripiprazole

Pharmacologic Category

Second Generation (Atypical) Antipsychotic

Dosing: Adult

Note: Formulations: Available formulations include oral tablets and oral solution supplied as aripiprazole (base) and 2 ER IM injections: aripiprazole monohydrate and aripiprazole lauroxil (see Aripiprazole Lauroxil monograph). All doses are expressed as the equivalent amounts of aripiprazole (base). Aripiprazole tablets are also available with an embedded device that tracks drug ingestion using a smartphone app (Abilify Mycite).

Agitation/aggression (acute, severe) associated with psychiatric disorders (eg, schizophrenia, bipolar disorder), substance intoxication, or other organic causes (alternative agent) (off-label use):

Note: Antipsychotics are appropriate when psychosis is suspected to be the primary cause of agitation/aggression. Other agents are used preferentially in some intoxications (eg, stimulants) or alcohol withdrawal. Depending on presentation, may combine with a benzodiazepine (Moore 2020; WFSBP [Hasan 2012]; Wilson 2012).

Oral: Initial: 10 to 15 mg; may repeat based on response and tolerability every 2 hours up to 30 mg/day (Moore 2020).

Agitation/aggression and psychosis associated with dementia, severe or refractory (alternative agent) (off-label use):

Note: For short-term adjunctive use while addressing underlying causes of severe symptoms (APA [Reus 2016]).

Oral: Initial: 2 to 5 mg once daily; may increase dose based on response and tolerability in 5 mg increments at intervals ≥1 week up to 15 mg once daily. In patients without a clinically significant response after an adequate trial (eg, up to 4 weeks), taper and withdraw therapy. Only continue in patients with a demonstrated benefit and attempt to taper and withdraw at regular intervals; first taper attempt should occur ≤4 months of initiation (APA [Reus 2016]; De Deyn 2005; Mintzer 2007; Streim 2008).

Note: In severe agitation associated with dementia with Lewy bodies, antipsychotics are generally avoided; if use is required, titrating above 2 to 5 mg/day is not recommended (Farlow 2019).

Bipolar disorder:

Oral: Acute manic or mixed episodes (labeled use), acute hypomania (off-label use), and maintenance treatment (labeled use, formulation specific) as monotherapy or adjunctive therapy: Initial: 10 to 15 mg once daily; may increase dose based on response and tolerability in 5 to 10 mg/day increments at intervals of ≥1 week up to a maximum of 30 mg/day (CANMAT [Yatham 2013]; Stovall 2019). Note: Some experts suggest higher initial doses of up to 30 mg/day (Stovall 2019). For maintenance treatment, continue dose and combination regimen that was used to achieve control of the acute episode (CANMAT [Yatham 2013]).

IM, ER injectable suspension (aripiprazole monohydrate) (alternative agent): Maintenance: 400 mg once monthly (doses should be separated by ≥26 days). Note: Establish tolerability with oral aripiprazole prior to initiation of ER injection; due to the prolonged half-life of oral aripiprazole, it may take up to 2 weeks to fully assess tolerability. Continue (overlap) oral aripiprazole or other oral antipsychotic for 14 days during initiation of the ER injection.

Dosage adjustment of ER injection for adverse effects: Consider reducing dose to 300 mg once monthly.

Missed doses of ER injection:

Second or third doses missed:

>4 weeks but <5 weeks since last dose: Administer next dose as soon as possible.

>5 weeks since last dose: Administer oral aripiprazole for 14 days with next injection; adjust oral dose as needed based on response and tolerability.

Fourth or subsequent doses missed:

>4 weeks but <6 weeks since last dose: Administer next dose as soon as possible.

>6 weeks since last dose: Administer oral aripiprazole for 14 days with next injection; adjust oral dose as needed based on response and tolerability.

Delusional disorder (off-label use):

Note: Dosing based on expert opinion:

Oral: Initial: 2 to 5 mg once daily; gradually increase to 10 mg/day; if needed, may further increase dose at intervals of ≥1 to 2 weeks based upon response and tolerability up to 30 mg/day (Manschreck 2019; Miyamoto 2008; Stroup 2019).

Delusional infestation (delusional parasitosis) (off-label use):

Note: Dosing based on expert opinion:

Oral: Initial: 2 mg once daily; may increase dose gradually based on response and tolerability in 2 mg increments at intervals ≥2 weeks up to 12 mg/day (Campbell 2019; Heller 2013; Suh 2019). Some patients may require doses up to 30 mg/day for optimal response. After achieving adequate response, maintain for ≥1 to 3 months before attempting to taper and discontinue (Stroup 2019; Suh 2019).

Huntington disease-associated chorea (alternative agent) (off-label use):

Oral: Initial: 2 mg once daily; may increase dose gradually based on response and tolerability up to a usual range of 7.5 to 15 mg/day (Brusa 2009; Ciammola 2009; Suchowersky 2019).

Major depressive disorder (unipolar), treatment resistant (adjunctive therapy with antidepressant):

Oral: Initial: 2 to 5 mg/day; may increase dose based on response and tolerability in 5 mg increments at intervals ≥1 week up to a manufacturer's maximum of 15 mg/day. A further increase up to 20 mg/day may be necessary in some patients for optimal response (Berman 2009).

Obsessive-compulsive disorder, treatment resistant (adjunctive therapy to antidepressants) (off-label use):

Oral: Initial: 5 mg once daily; may increase dose gradually based on response and tolerability in 5 mg increments at intervals ≥1 week up to 15 mg/day (Ak 2011; APA 2007; Muscatello 2011; Pessina 2009; Sayyah 2012).

Schizophrenia:

Oral: Initial: 10 or 15 mg once daily; may increase dose based on response and tolerability in 5 mg increments at intervals ≥1 week up to a maximum of 30 mg/day (Kane 2009; Khanna 2014; Stroup 2019).

IM, ER injectable suspension (aripiprazole monohydrate): 400 mg once monthly (doses should be separated by ≥26 days). Note: Establish tolerability with oral aripiprazole prior to initiation of the ER injection; due to the prolonged half-life of oral aripiprazole, it may take up to 2 weeks to fully assess tolerability. Continue (overlap) oral aripiprazole or other oral antipsychotic for 14 days during initiation of the ER injection.

Dosage adjustment of ER injection for adverse effects: Consider reducing dose to 300 mg once monthly.

Missed doses of ER injection:

Second or third doses missed:

>4 weeks but <5 weeks since last dose: Administer next dose as soon as possible.

>5 weeks since last dose: Administer oral aripiprazole for 14 days with next injection; adjust oral dose as needed based on response and tolerability.

Fourth or subsequent doses missed:

>4 weeks but <6 weeks since last dose: Administer next dose as soon as possible.

>6 weeks since last dose: Administer oral aripiprazole for 14 days with next injection; adjust oral dose as needed based on response and tolerability.

Dosing conversions:

Orally disintegrating tablets to oral tablet: Orally disintegrating tablets may be substituted for the oral tablet on a mg-per-mg basis.

Oral solution to oral tablet: Oral solution may be substituted for the oral tablet on a mg-per-mg basis, up to 25 mg. Patients receiving 30 mg tablets should be given 25 mg oral solution.

Dosage adjustment based on CYP2D6 metabolizer status:

Oral: Aripiprazole dose should be reduced to 50% of the usual dose in known CYP2D6 poor metabolizers and to 25% of the usual dose in poor metabolizers receiving a concurrent strong CYP3A4 inhibitor (eg, itraconazole, clarithromycin); subsequently adjust dose for favorable response and tolerability.

IM, ER injectable suspension (aripiprazole monohydrate): Reduce aripiprazole dose to 300 mg once monthly in known CYP2D6 poor metabolizers; reduce dose to 200 mg once monthly in CYP2D6 poor metabolizers receiving a concurrent CYP3A4 inhibitor for >14 days. Subsequently adjust dose according to response and tolerability.

Discontinuation of therapy: Gradual dose reduction is advised to avoid withdrawal symptoms (ie, insomnia, headache, GI symptoms) unless discontinuation is due to significant adverse effects. In general, when discontinuing antipsychotic therapy for a chronic psychiatric disorder (eg, bipolar disorder, schizophrenia), decreasing the dose very gradually over weeks to months (eg, reducing the dose by 10% per month) with close monitoring is suggested to allow for detection of prodromal symptoms of disease recurrence (APA [Lehman 2004]; CPA 2005).

Switching antipsychotics: An optimal universal strategy for switching antipsychotic drugs has not been established. Strategies include: Cross-titration (gradually discontinuing the first antipsychotic while gradually increasing the new antipsychotic) and abrupt change (abruptly discontinuing the first antipsychotic and either increasing the new antipsychotic gradually or starting it at a treatment dose). In patients with schizophrenia at high risk of relapse, the current medication may be maintained at full dose as the new medication is increased (ie, overlap); once the new medication is at therapeutic dose, the first medication is gradually decreased and discontinued over 1 to 2 weeks (Cerovecki 2013; Remington 2005; Takeuchi 2017). Based upon clinical experience, some experts generally prefer cross-titration and overlap approaches rather than abrupt change (Post 2019; Stroup 2019).

* See Dosage and Administration in AHFS Essentials for additional information.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment: Adult

No dosage adjustment necessary.

Dosing: Hepatic Impairment: Adult

No dosage adjustment necessary.

Dosing: Pediatric

Note: Oral solution may be substituted for the oral tablet on a mg-per-mg basis, up to 25 mg. Patients receiving 30 mg tablets should be given 25 mg oral solution. Orally disintegrating tablets (Abilify Discmelt) are bioequivalent to the immediate release tablets (Abilify). Immediate release and extended release parenteral products are not interchangeable.

Attention-deficit/hyperactivity disorder (ADHD): Limited data available: Children ≥8 years and Adolescents: Oral: Initial: 2.5 mg/day; may increase on a weekly basis by 2.5 mg/day increments as tolerated; maximum daily dose: 10 mg/day; dosing based on an open-label, pilot study (n=23, age: 8 to 12 years) which reported significant improvement in ADHD outcome scores without an impact on cognitive measures (positive or negative); mean final dose: 6.7 ± 2.4 mg/day (Findling 2008). Other aripiprazole published reports in pediatric and adolescent patients in which ADHD is a comorbid diagnosis within the study population exist; however, effectiveness in ADHD was not a reported primary outcome measure (Bastiaens 2009; Budman 2008; Findling 2009; Murphy 2009; Valicenti-McDermott 2006).

Autism; treatment of associated irritiability (including aggression, deliberate self-injurious behavior, temper tantrums, and quickly changing moods): Children and Adolescents 6 to 17 years: Oral: Initial: 2 mg daily for 7 days, followed by 5 mg daily; subsequent dose increases may be made in 5 mg increments every ≥7 days, up to a maximum daily dose of 15 mg/day

Bipolar I disorder (acute manic or mixed episodes): Children and Adolescents 10 to 17 years: Oral: Initial: 2 mg daily for 2 days, followed by 5 mg daily for 2 days with a further increase to target dose of 10 mg daily; subsequent dose increases may be made in 5 mg increments, up to a maximum daily dose of 30 mg/day. Note: The safety of doses >30 mg/day has not been evaluated.

Conduct disorder (CD); aggression: Limited data available: Children ≥6 years and Adolescents: Oral: Initial: Patient weight <25 kg: 1 mg/day; 25 to 50 kg: 2 mg/day; 51 to 70 kg: 5 mg/day; >70 kg: 10 mg/day; may titrate after 2 weeks to clinical effectiveness; maximum daily dose: 15 mg/day. Dosing based on an open-label, prospective study (n=23; age: 6 to 17 years) which evaluated pharmacokinetics and effectiveness in patients with a primary diagnosis of CD (with or without comorbid ADHD); results showed improvement in CD symptom scores with only minor improvements in cognition (Findling 2009).

Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) or Asperger Disorder; treatment of associated irritability (aggression, self-injury, tantrums): Limited data available: Children ≥4 years and Adolescents: Oral:

Preschool age: Initial dose: 1.25 mg/day with titration every ≥5 days in 1.25 mg/day increments as tolerated or clinically indicated (Masi 2009)

Prepubertal children: Initial dose: 1.25 to 2.5 mg/day with titration every 3 to 5 days in 1.25 to 2.5 mg/day increments as tolerated or clinically indicated; maximum daily dose: 15 mg/day (Masi 2009; Stigler 2009)

Adolescents: Initial dose: 2.5 to 5 mg/day with titration every 5 days in 2.5 to 5 mg/day increments as tolerated or clinically indicated; doses >5 mg/day were divided twice daily; if sleep disorder was reported, the dose was given in morning and/or at lunchtime (Masi 2009); maximum daily dose: 15 mg/day (Stigler 2009)

An open-labeled, pilot study (n=25; mean age: 8.6 years; range: 5 to 17 years) reported an 88% response with a mean final dose of 7.8 mg/day (range: 2.5 to 15 mg/day) (Stigler 2009). A retrospective, noncontrolled, open-label study of 34 PDD patients (mean age: 10.2 years; range: 4 to 15 years) included 10 patients with autistic disorder and 24 patients with PDD-NOS reported a mean final dose: 8.1 ± 4.9 mg/day and an overall response rate of 32.4% (29.2% in patients with PDD-NOS) (Masi 2009). In a retrospective chart review of children and adolescents with developmental disability and a wide range of psychiatric disorders (n=32; age: 5 to 19 years), a mean starting dose of aripiprazole of 7.1 ± 0.32 mg/day and a mean maintenance dose of 10.55 ± 6.9 mg/day was used; a response rate of 56% was reported for the overall population. However, a study population subset analysis in patients with mental retardation (n=18) showed a lower response rate in patients with mental retardation with PDD-NOS (38%) than in patients with mental retardation without PDD-NOS (100%) (Valicenti-McDermott 2006).

Schizophrenia: Adolescents 13 to 17 years: Oral: Initial: 2 mg daily for 2 days, followed by 5 mg daily for 2 days with a further increase to target dose of 10 mg daily; subsequent dose increases may be made in 5 mg increments up to a maximum daily dose of 30 mg/day. Note: 30 mg/day was not found to be more effective than the 10 mg/day dose.

Tourette syndrome, tic disorders: Children ≥6 years and Adolescents: Oral:

Patient weight <50 kg: Initial: 2 mg daily for 2 days, then increase to target dose of 5 mg/day; in patients not achieving optimal control, dose may be further titrated at weekly intervals up to 10 mg/day

Patient weight ≥50 kg: Initial: 2 mg daily for 2 days, then increase to 5 mg/day for 5 days, then increase to target dose of 10 mg/day on day 8 of therapy; in patients not achieving optimal control, dose may be further titrated at weekly intervals in 5 mg/day increments up to 20 mg/day

Discontinuation of therapy: Children and Adolescents: American Academy of Child and Adolescent Psychiatry (AACAP), American Psychiatric Association (APA), Canadian Psychiatric Association (CPA), National Institute for Health and Care Excellence (NICE), and World Federation of Societies of Biological Psychiatry (WFSBP) guidelines recommend gradually tapering antipsychotics to avoid withdrawal symptoms and minimize the risk of relapse (AACAP [McClellan 2007]; APA [Lehman 2004]; Cerovecki 2013; CPA 2005; NICE 2013; WFSBP [Hasan 2012]); risk for withdrawal symptoms may be highest with highly anticholinergic or dopaminergic antipsychotics (Cerovecki 2013). When stopping antipsychotic therapy in patients with schizophrenia, the CPA guidelines recommend a gradual taper over 6 to 24 months and the APA guidelines recommend reducing the dose by 10% each month (APA [Lehman 2004]; CPA 2005). Continuing antiparkinsonism agents for a brief period after discontinuation may prevent withdrawal symptoms (Cerovecki 2013). When switching antipsychotics, three strategies have been suggested: Cross titration (gradually discontinuing the first antipsychotic while gradually increasing the new antipsychotic), overlap and taper (maintaining the dose of the first antipsychotic while gradually increasing the new antipsychotic, then tapering the first antipsychotic), and abrupt change (abruptly discontinuing the first antipsychotic and either increasing the new antipsychotic gradually or starting it at a treatment dose). Evidence supporting ideal switch strategies and taper rates is limited and results are conflicting (Cerovecki 2013; Remington 2005).

Dosage adjustment with concurrent CYP450 inducer or inhibitor therapy:

Oral: Children and Adolescents:

CYP3A4 inducers (eg, carbamazepine, rifampin): Aripiprazole dose should be doubled over 1 to 2 weeks; dose should be subsequently reduced if concurrent inducer agent discontinued.

Strong CYP3A4 inhibitors (eg, ketoconazole): Aripiprazole dose should be reduced to 50% of the usual dose, and proportionally increased upon discontinuation of the inhibitor agent.

CYP2D6 inhibitors (eg, fluoxetine, paroxetine): Aripiprazole dose should be reduced to 50% of the usual dose, and proportionally increased upon discontinuation of the inhibitor agent. Note: When aripiprazole is administered as adjunctive therapy to patients with MDD, the dose should not be adjusted, follow usual dosing recommendations.

CYP3A4 and CYP2D6 inhibitors: Aripiprazole dose should be reduced to 25% of the usual dose. In patients receiving inhibitors of differing (eg, moderate 3A4/strong 2D6) or same (eg, moderate 3A4/moderate 2D6) potencies (excluding concurrent strong inhibitors), further dosage adjustments can be made to achieve the desired clinical response. In patients receiving strong CYP3A4 and 2D6 inhibitors, aripiprazole dose is proportionally increased upon discontinuation of one or both inhibitor agents.

Dosage adjustment based on CYP2D6 metabolizer status:

Oral: Children and Adolescents: Aripiprazole dose should be reduced to 50% of the usual dose in CYP2D6 poor metabolizers and to 25% of the usual dose in poor metabolizers receiving a concurrent strong CYP3A4 inhibitor; subsequently adjust dose for favorable clinical response.

Dosing: Renal Impairment: Pediatric

No dosage adjustment required.

Dosing: Hepatic Impairment: Pediatric

No dosage adjustment required.

Use: Labeled Indications

Oral:

Bipolar disorder: As monotherapy or as an adjunct to lithium or valproate for acute treatment of manic or mixed episodes associated with bipolar disorder and maintenance treatment (tablet with sensor only) of bipolar disorder.

Irritability associated with autistic disorder: Treatment of irritability associated with autistic disorder (tablet, orally disintegrating tablet, and oral solution only) in children and adolescents.

Major depressive disorder (unipolar), treatment resistant: Adjunctive treatment of unipolar major depressive disorder in patients with an inadequate response to prior antidepressant therapy.

Schizophrenia: Treatment of schizophrenia.

Tourette disorder: Treatment of Tourette disorder (tablet, orally disintegrating tablet, and oral solution only) in children and adolescents.

Injection: Extended release:

Bipolar disorder: Maintenance monotherapy treatment of bipolar disorder.

Schizophrenia: Treatment of schizophrenia.

* See Uses in AHFS Essentials for additional information.

Use: Off-Label: Adult

Agitation/aggression (acute, severe) associated with psychiatric disorders (eg, schizophrenia, bipolar disorder), substance intoxication, or other organic causesLevel of Evidence [B, G]

Data from a randomized, double-blind, comparator trial and post hoc pooled analysis support the use of aripiprazole in the treatment of agitation associated with schizophrenia and schizoaffective disorders Ref.

Based on the World Federation of Societies of Biological Psychiatry (WFSBP) expert consensus for the assessment and management of agitation in psychiatry, oral aripiprazole is effective and recommended in the management of psychomotor agitation associated with psychiatric conditions (eg, schizophrenia, bipolar disorder), substance intoxication, or other organic causes.

Agitation/aggression and psychosis associated with dementia, severe or refractoryLevel of Evidence [B, G]

Data from randomized, double-blind, placebo-controlled trials support the use of aripiprazole in the treatment psychosis and agitation related to Alzheimer dementia Ref.

Based on the American Psychiatric Association (APA) practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia, antipsychotics, such as aripiprazole, may be considered for the treatment of agitation and psychosis in certain patients; however, evidence for efficacy is modest and use should be limited to patients whose symptoms are dangerous, severe, or cause significant patient distress due to safety risks associated with antipsychotics. Based on the WFSBP guidelines for the treatment of Alzheimer disease and other dementias, drug treatment with aripiprazole for behavioral and psychological aspects (including hyperactivity and psychosis) is recommended, at low doses and for short durations, as a last option after addressing causative factors and using psychosocial interventions.

Delusional disorderLevel of Evidence [C]

Data from a limited number of patients studied in case reports suggest that aripiprazole may be beneficial for the treatment of delusional disorder Ref. A systematic review suggests antipsychotics as an effective treatment option Ref.

Delusional infestation (delusional parasitosis)Level of Evidence [C]

Data from a limited number of patients studied in case reports suggest that aripiprazole may be beneficial for the treatment of delusional infestation Ref. Some experts suggest antipsychotics as an effective treatment option Ref.

Huntington disease-associated choreaLevel of Evidence [C]

Data from a limited number of patients studied in a noncontrolled trial and case reports suggest that aripiprazole may be beneficial for the treatment of chorea associated with Huntington disease Ref. Access Full Off-Label Monograph

Obsessive-compulsive disorder, treatment resistantLevel of Evidence [C, G]

Data from a limited number of patients studied suggest that aripiprazole augmentation of an antidepressant may be beneficial for the treatment of treatment-resistant obsessive-compulsive disorder (OCD) Ref.

Based on the APA practice guideline for the treatment of patients with OCD, antipsychotics given as augmentation are recommended in the management of treatment-resistant OCD in patients who have a partial response to initial treatment; however, evidence supporting aripiprazole is limited Ref.

Level of Evidence Definitions

Level of Evidence Scale

Comparative Efficacy

• ARIPIPRAZOLE EXTENDED-RELEASE INJECTION

Clinical Practice Guidelines

Agitation:

WFSBP, “Assessment and Management of Agitation in Psychiatry: Expert Consensus,” 2016

Alzheimer Disease and Other Dementias:

American Psychiatric Association, “Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia,” May 2016

WFSBP, “Guidelines for the Biological Treatment of Alzheimer’s Disease and Other Dementias,” 2011

Bipolar Disorder:

American Psychiatric Association. “Practice Guideline for the Treatment of Patients with Bipolar Disorder (Revision),” 2002

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD), ”2019 Guidelines for the Management of Patients with Bipolar Disorder,” 2018

National Institute for Health and Clinical Excellence (NICE), National Collaborating Centre for Mental Health, “Bipolar Disorder: The Assessment and Management of Bipolar Disorder in Adults, Children and Young People in Primary and Secondary Care,” 2014

WFSBP, “Guidelines for the Biological Treatment of Bipolar Disorders: Acute and Long-Term Treatment of Mixed States in Bipolar Disorder,” 2017

WFSBP, “Guidelines for the Biological Treatment of Bipolar Disorders: Update 2009 on the Treatment of Acute Mania,” 2009

WFSBP, “Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the Treatment of Acute Bipolar Depression,” 2010

WFSBP, “Guidelines for the Biological Treatment of Bipolar Disorders: Update 2012 on the Long-term Treatment of Bipolar Disorder,” 2013

Depression:

American Psychiatric Association, Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, May 2010

National Collaborating Centre for Mental Health (NCCMH), “Depression: The NICE Guideline on the Treatment and Management of Depression in Adults (Updated Edition).” 2010.

WFSBP, “Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Update 2013 on the Acute and Continuation Treatment of Unipolar Depressive Disorders,” 2013

WFSBP, “Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance Treatment of Major Depressive Disorder - Update,” 2015

Obsessive-Compulsive Disorder:

American Psychiatric Association, “Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder,” 2007

American Psychiatric Association, “Guideline Watch (March 2013): Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder,” 2013

Schizophrenia:

American Psychiatric Association,” Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition,” 2004

National Institute for Health and Clinical Excellence (NICE), National Collaborating Center for Mental Health, "Psychosis and Schizophrenia in Adults: Treatment and Management " March 2014

National Institute for Health and Clinical Excellence (NICE), National Collaborating Center for Mental Health, "Psychosis and Schizophrenia in Children and Young People: Recognition and Management" 2013

WFSBP, “Guidelines for the Biological Treatment of Schizophrenia, Part 1: Update 2012 on the Acute Treatment of Schizophrenia and the Management of Treatment Resistance,” 2012

WFSBP, “Guidelines for the Biological Treatment of Schizophrenia, Part 2: Update 2012 on the Long-Term Treatment of Schizophrenia and Management of Antipsychotic-Induced Side Effects,” 2013

Administration: IM

Extended release: For IM use only; do not administer SubQ or IV. Inject slowly into deltoid or gluteal muscle using the appropriate provided needle; for nonobese patients, use the 1-inch (25 mm) needle with deltoid administration or the 1.5-inch (38 mm) needle with gluteal administration; for obese patients, use the 1.5-inch (38 mm) needle with deltoid administration or the 2-inch (51 mm) needle with gluteal administration. Do not massage muscle after administration. Rotate injection sites between the 2 deltoid or gluteal muscles. Administer monthly (doses should be separated by ≥26 days).

Administration: Oral

Administer with or without food. Tablet and oral solution may be interchanged on a mg-per-mg basis, up to 25 mg. Doses using 30 mg tablets should be exchanged for 25 mg oral solution. Orally-disintegrating tablets (Abilify Discmelt) are bioequivalent to the immediate-release tablets (Abilify).

Orally-disintegrating tablet: Remove from foil blister by peeling back (do not push tablet through the foil). Place tablet in mouth immediately upon removal. Tablet dissolves rapidly in saliva and may be swallowed without liquid. If needed, can be taken with liquid. Do not split tablet.

Tablet with sensor: Swallow tablets whole; do not divide, crush, or chew. Each tablet is embedded with an ingestible event marker (IEM). The patch that accompanies the tablets is a wearable sensor that detects a signal from the IEM sensor after the tablet is ingested and transmits data to a smartphone within 30 minutes to 2 hours of ingestion. If the detection system fails (ie, tablet is not detected after ingestion), do not repeat the dose. Before use, ensure that the patient is capable and willing to use smartphones and apps, and that the app is compatible with the patient's specific smartphone. Apply patch only when instructed by the app to the left side of the body just above the lower edge of the rib cage. Do not place the patch in areas where the skin is scraped, cracked, inflamed, or irritated, or in a location that overlaps the area of the most recently removed patch. Instruct patients to keep the patch on when showering, swimming, or exercising. The patch should be changed weekly or sooner as needed. The app will prompt patient to change the patch and will direct patient to apply and remove the patch correctly. Patients undergoing an MRI need to remove their patch and replace with a new one as soon as possible. If there is skin irritation, instruct patients to remove the patch. Refer to the information provided in the product packaging and electronic instructions for use with the Mycite app.

Administration: Pediatric

Oral (all dosage forms): May be administered with or without food.

Orally-disintegrating tablet: Do not remove tablet from blister pack until ready to administer; do not push tablet through foil (tablet may become damaged); peel back foil to expose tablet; use dry hands to remove tablet and place immediately on tongue. Tablet dissolves rapidly in saliva and may be swallowed without liquid; if needed, tablet can be taken with liquid. Do not split tablet.

Dietary Considerations

Some products may contain phenylalanine.

Storage/Stability

Injection, powder (extended release):

Prefilled syringe: Store below 30°C (86°F). Do not freeze. Protect from light and store in original package.

Vial for reconstitution: Store unused vials at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). If the suspension is not administered immediately after reconstitution, store at room temperature in the vial (do not store in a syringe).

Oral solution and tablets: Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Use oral solution within 6 months after opening. Do not store in conditions where tablets are exposed to humid conditions.

Mycite Patch: Store at 15°C to 30°C (59°F to 86°F); 15% to 93% relative humidity.

Preparation for Administration: Adult

Injection, powder (extended release):

Prefilled syringe: Reconstitute at room temperature. Rotate the syringe plunger rod to release diluent. Shake vigorously for 20 seconds or until the suspension is uniform; the resulting suspension will be milky white and opaque. (Refer to manufacturer’s labeling for full preparation technique.) Inject full syringe contents immediately following reconstitution.

Vial for reconstitution: Reconstitute using 1.5 mL sterile water for injection (SWFI) (provided) for the 300 mg vial or 1.9 mL SWFI (provided) for the 400 mg vial to a final concentration of 200 mg/mL; residual SWFI should be discarded after reconstitution. Shake vigorously for 30 seconds or until the suspension is uniform; the resulting suspension will be milky white and opaque. If the suspension is not administered immediately after reconstitution, shake vigorously for 60 seconds prior to administration.

Medication Patient Education with HCAHPS Considerations

What is this drug used for?

• It is used to treat schizophrenia.

• It is used to treat bipolar problems.

• It is used to treat low mood (depression).

• It is used to treat certain behavior problems in patients with autism.

• It is used to treat Tourette's syndrome.

• It may be given to you for other reasons. Talk with the doctor.

Frequently reported side effects of this drug

• Fatigue

• Agitation

• Anxiety

• Headache

• Nausea

• Vomiting

• Weight gain

• Constipation

• Trouble sleeping

• Change in appetite

• Lack of appetite

• Stuffy nose

• Sore throat

• Dry mouth

• Tremors

• Drooling

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Infection

• Depression like thoughts of suicide, anxiety, emotional instability, or confusion.

• High blood sugar like confusion, fatigue, increased thirst, increased hunger, passing a lot of urine, flushing, fast breathing, or breath that smells like fruit.

• Abnormal movements

• Twitching

• Change in balance

• Difficulty swallowing

• Vision changes

• Eye pain

• Eye irritation

• Difficulty speaking

• Severe dizziness

• Passing out

• Loss of strength and energy

• Blurred vision

• Uncontrollable urges

• Neuroleptic malignant syndrome like fever, muscle cramps or stiffness, dizziness, severe headache, confusion, change in thinking, fast heartbeat, abnormal heartbeat, or sweating a lot.

• Tardive dyskinesia like unable to control body movements; tongue, face, mouth, or jaw sticking out; mouth puckering; or puffing cheeks.

• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

Medication Safety Issues

Sound-alike/look-alike issues:

Geriatric Patients: High-Risk Medication:

Other safety issues:

Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and as follows, must be dispensed with this medication:

Abilify: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021436s044s045,021713s035s036,021729s027s028,021866s029s030lbl.pdf#page=77

Abilify Maintena: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/202971s013lbl.pdf#page=52

Abilify MyCite: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/207202s002s004lbl.pdf#page=48

Contraindications

Hypersensitivity (eg, anaphylaxis, pruritus, urticaria) to aripiprazole or any component of the formulation.

Warnings/Precautions

Major psychiatric warnings:

• Suicidal thinking/behavior: [US Boxed Warning]: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 to 24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk prior to prescribing. Short-term studies did not show an increased risk in patients >24 years of age and showed a decreased risk in patients ≥65 years. Closely monitor patients for clinical worsening, suicidality, or unusual changes in behavior, particularly during the initial 1 to 2 months of therapy or during periods of dosage adjustments (increases or decreases); the patient's family or caregiver should be instructed to closely observe the patient and communicate condition with health care provider. A medication guide concerning the use of antidepressants should be dispensed with each prescription. Aripiprazole is not FDA approved for adjunctive treatment of depression in children.

-The possibility of a suicide attempt is inherent in major depression and may persist until remission occurs. Worsening depression and severe abrupt suicidality that are not part of the presenting symptoms may require discontinuation or modification of drug therapy. Use caution in high-risk patients during initiation of therapy. Patients should be screened for bipolar disorder prior to initiation of treatment of major depression.

- Prescriptions should be written for the smallest quantity consistent with good patient care. The patient's family or caregiver should be alerted to monitor patients for the emergence of suicidality and associated behaviors such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, and mania; patients should be instructed to notify their health care provider if any of these symptoms or worsening depression or psychosis occur.

Concerns related to adverse reactions:

• Altered cardiac conduction: May alter cardiac conduction; life-threatening arrhythmias have occurred with therapeutic doses of antipsychotics.

• Blood dyscrasias: Leukopenia, neutropenia, and agranulocytosis (sometimes fatal) have been reported in clinical trials and postmarketing reports with antipsychotic use; presence of risk factors (eg, preexisting low WBC/ANC or history of drug-induced leuko-/neutropenia) should prompt periodic blood count assessment. Discontinue therapy at first signs of blood dyscrasias or if absolute neutrophil count <1,000/mm3.

• Cerebrovascular effects: An increased incidence of cerebrovascular effects (eg, transient ischemic attack, stroke), including fatalities, has been reported in placebo-controlled trials of aripiprazole for the unapproved use in elderly patients with dementia-related psychosis.

• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks that require mental alertness (eg, operating machinery, driving).

• Dyslipidemia: Has been reported with atypical antipsychotics; risk profile may differ between agents. In clinical trials, lipid changes observed with aripiprazole monotherapy were similar to those observed with placebo.

• Esophageal dysmotility/aspiration: Antipsychotic use has been associated with esophageal dysmotility and aspiration; risk increases with age. Use with caution in patients at risk for aspiration pneumonia (eg, Alzheimer dementia), particularly in patients >75 years (Herzig 2017; Maddalena 2004).

• Extrapyramidal symptoms: May cause extrapyramidal symptoms (EPS), including pseudoparkinsonism, acute dystonic reactions, akathisia, and tardive dyskinesia (risk of these reactions is generally much lower relative to typical/conventional antipsychotics; frequencies reported are similar to placebo). Risk of dystonia (and probably other EPS) may be greater with increased doses, use of conventional antipsychotics, males, and younger patients. Factors associated with greater vulnerability to tardive dyskinesia include older in age, female gender combined with postmenopausal status, Parkinson disease, pseudoparkinsonism symptoms, affective disorders (particularly major depressive disorder), concurrent medical diseases such as diabetes, previous brain damage, alcoholism, poor treatment response, and use of high doses of antipsychotics (APA [Lehman 2004]; Soares-Weiser 2007). Consider therapy discontinuation with signs/symptoms of tardive dyskinesia.

• Falls: May increase the risk for falls due to somnolence, orthostatic hypotension and motor or sensory instability. Complete fall risk assessments at baseline and periodically during treatment in patients with diseases or on medications that may also increase fall risk.

• Hyperglycemia: Atypical antipsychotics have been associated with development of hyperglycemia; in some cases, may be extreme and associated with ketoacidosis, hyperosmolar coma, or death. Use with caution in patients with diabetes or other disorders of glucose regulation; monitor for worsening of glucose control. Patients with risk factors for diabetes (eg, obesity or family history) should have a baseline fasting blood sugar and periodic assessment of glucose regulation. Reports of hyperglycemia with aripiprazole therapy have been few and specific risk associated with this agent is not known.

• Impulse control disorders: Has been associated with compulsive behaviors and/or loss of impulse control, which has manifested as pathological gambling, uncontrolled sexual urges, uncontrolled spending, binge or compulsive eating, and/or other intense urges. Patients with prior history of impulse control issues may be at increased risk. Dose reduction or discontinuation of therapy has been reported to reverse these behaviors in most, but not all, cases (Gaboriau 2014; Moore 2014; Smith 2011).

• Neuroleptic malignant syndrome: Use may be associated with neuroleptic malignant syndrome; monitor for mental status changes, fever, muscle rigidity and/or autonomic instability.

• Orthostatic hypotension: May cause orthostatic hypotension; use with caution in patients at risk of this effect or in those who would not tolerate transient hypotensive episodes (cerebrovascular disease, cardiovascular disease, hypovolemia, or concurrent medication use which may predispose to hypotension/bradycardia).

• Temperature regulation: Impaired core body temperature regulation may occur; caution with strenuous exercise, heat exposure, dehydration, and concomitant medication possessing anticholinergic effects.

• Weight gain: Significant weight gain (>7% of baseline weight) has been observed with antipsychotic therapy; incidence varies with product. Monitor waist circumference and BMI.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with cardiac disease, cerebrovascular disease, prior myocardial infarction, ischemic heart disease, or conditions which predispose to hypotension.

• Dementia: [US Boxed Warning]: Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death compared to placebo. Most deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Use with caution in patients with Lewy body dementia or Parkinson disease dementia due to greater risk of adverse effects, increased sensitivity to extrapyramidal effects, and association with irreversible cognitive decompensation or death (APA [Reus 2016]). Aripiprazole is not approved for the treatment of dementia-related psychosis.

• Parkinson disease: Use with caution in patients with Parkinson disease; antipsychotics may aggravate motor disturbances (APA [Lehman 2004; APA [Reus 2016]).

• Seizures: Use with caution in patients at risk of seizures, including those with a history of seizures, head trauma, brain damage, alcoholism, or concurrent therapy with medications which may lower seizure threshold. Elderly patients may be at increased risk of seizures due to an increased prevalence of predisposing factors.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Dosage form specific issues:

• Lactose: Tablets may contain lactose; avoid use in patients with galactose intolerance or glucose-galactose malabsorption.

• Phenylalanine: Orally-disintegrating tablets may contain phenylalanine.

• Product interchangeability: Injection There are 2 ER formulations available for IM administration: Aripiprazole monohydrate (Abilify Maintena) and aripiprazole lauroxil (Aristada and Aristada Initio).

• Tablet with sensor: The ability of aripiprazole tablets with sensor to improve patient compliance or modify aripiprazole dosage has not been established. The use of aripiprazole tablets with sensor to track drug ingestion in “real time” or during an emergency is not recommended because detection may be delayed or not occur.

Other warnings/precautions:

• Discontinuation of therapy: When discontinuing antipsychotic therapy, the American Psychiatric Association (APA), Canadian Psychiatric Association (CPA), and World Federation of Societies of Biological Psychiatry (WFSBP) guidelines recommend gradually tapering antipsychotics to avoid physical withdrawal symptoms, including anorexia, anxiety, diaphoresis, diarrhea, dizziness, dyskinesia, headache, myalgia, nausea, paresthesia, restlessness, tremulousness and vomiting (APA [Lehman 2004]; CPA [Addington 2005]; Lambert 2007; WFSBP [Hasan 2012]). The risk of withdrawal symptoms is highest following abrupt discontinuation of highly anticholinergic or dopaminergic antipsychotics (Cerovecki 2013). Additional factors such as duration of antipsychotic exposure, the indication for use, medication half-life and risk for relapse should be considered. In schizophrenia, there is no reliable indicator to differentiate the minority who will not from the majority who will relapse with drug discontinuation. However, studies in which the medication of well-stabilized patients were discontinued indicate that 75% of patients relapse within 6 to 24 months. Indefinite maintenance antipsychotic medication is generally recommended, and especially for patients who have had multiple prior episodes or two episodes within 5 years (APA [Lehman 2004]).

* See Cautions in AHFS Essentials for additional information.

Geriatric Considerations

Aripiprazole has been studied in elderly patients with psychosis associated with Alzheimer's disease. The package insert does not provide the outcomes of this study other than somnolence was more frequent with aripiprazole (8%) than placebo (1%). Aripiprazole's delayed onset of action and long half-life may limit its role in treating older persons with psychosis.

Elderly patients have an increased risk of adverse effects to antipsychotics. In light of this risk, and relative to their small beneficial effect in the treatment of dementia-related psychosis and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic.

Warnings: Additional Pediatric Considerations

Aripiprazole may cause a higher than normal weight gain in children and adolescents; monitor growth (including weight, height, BMI, and waist circumference) in pediatric patients receiving aripiprazole; compare weight gain to standard growth curves. Note: A prospective, nonrandomized cohort study followed 338 antipsychotic naive pediatric patients (age: 4 to 19 years) for a median of 10.8 weeks (range: 10.5 to 11.2 weeks) and reported the following significant mean increases in weight in kg (and % change from baseline): Olanzapine: 8.5 kg (15.2%), quetiapine: 6.1 kg (10.4%), risperidone: 5.3 kg (10.4%), and aripiprazole: 4.4 kg (8.1%) compared to the control cohort: 0.2 kg (0.65%).

Hyperglycemia has been reported with aripiprazole; in analysis of pediatric trials (patients 6 to 18 years, diagnosis including schizophrenia, autistic disorder, bipolar disorder, and Tourette's disorder), the mean change in fasting glucose was not observed to be significantly different than placebo-treated patients (median exposure range: 43 to 57 days). However, with longer exposure (mean: 17.2 months), an increased risk for the development of type 2 diabetes mellitus (DM) was observed in pediatric patients 10 to 18 years receiving second-generation antipsychotics (SGA); for patients initiated on SGA: 0.4% incidence with mean exposure at time type 2 DM diagnosed: 13.5 months; for SGA noniniators (patients receiving another agent prior to SGA initiation): 0.2% incidence with mean exposure at time of type 2 DM diagnosed: 14.6 months. Amongst specific SGA’s, the risk was highest for aripiprazole (p=0.001) followed by ziprasidone (p=0.06) compared to risperidone as the reference group but not quetiapine or olanzapine (Rubin 2015). Increases in metabolic indices (eg, serum cholesterol, triglycerides) were also reported; however, these changes were not significant in patients receiving aripiprazole (Correll 2009); additionally, in clinical trials, lipid changes observed with aripiprazole monotherapy in pediatric patients were similar to those observed with placebo. Biannual monitoring of cardiometabolic indices after the first 3 months of therapy is suggested (Correll 2009).

Children and adolescents may experience a higher frequency of some adverse effects than adults, including EPS (20% vs 5%), fatigue (17% vs 8%), and somnolence (23% vs 6%).

Pediatric psychiatric disorders are frequently serious mental disorders which present with variable symptoms that do not always match adult diagnostic criteria. Conduct a thorough diagnostic evaluation and carefully consider risks of psychotropic medication before initiation in pediatric patients with schizophrenia, bipolar disorder, or irritability associated with autistic disorder. Medication therapy for pediatric patients with these disorders is indicated as part of a total treatment program that frequently includes educational, psychological, and social interventions. Long-term usefulness of aripiprazole should be periodically re-evaluated in patients receiving the drug for extended periods of time.

Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP, 1997; Shehab, 2009).

Reproductive Considerations

If treatment is needed in a woman planning a pregnancy, use of an agent other than aripiprazole is preferred (Larsen 2015).

Pregnancy Considerations

Aripiprazole crosses the placenta; aripiprazole and dehydro-aripiprazole can be detected in the cord blood at delivery (Nguyen 2011; Watanabe 2011).

Antipsychotic use during the third trimester of pregnancy has a risk for abnormal muscle movements (extrapyramidal symptoms [EPS]) and/or withdrawal symptoms in newborns following delivery. Symptoms in the newborn may include agitation, feeding disorder, hypertonia, hypotonia, respiratory distress, somnolence, and tremor; these effects may be self-limiting or require hospitalization.

Treatment algorithms have been developed by the ACOG and the APA for the management of depression in women prior to conception and during pregnancy (Yonkers 2009). The ACOG recommends that therapy during pregnancy be individualized; treatment with psychiatric medications during pregnancy should incorporate the clinical expertise of the mental health clinician, obstetrician, primary health care provider, and pediatrician. Safety data related to atypical antipsychotics during pregnancy is limited, as such, routine use is not recommended. However, if a woman is inadvertently exposed to an atypical antipsychotic while pregnant, continuing therapy may be preferable to switching to an agent that the fetus has not yet been exposed to; consider risk:benefit (ACOG 2008). If treatment is initiated during pregnancy, use of an agent other than aripiprazole is preferred (Larsen 2015).

Health care providers are encouraged to enroll women exposed to aripiprazole during pregnancy in the National Pregnancy Registry for Atypical Antipsychotics (866-961-2388 or http://www.womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/).

Breast-Feeding Considerations

Aripiprazole and dehydro-aripiprazole are present in breast milk. (Nordeng 2014)

The relative infant dose (RID) of aripiprazole is 8.3% when calculated using the highest mean breast milk concentration located and compared to a weight-adjusted maternal dose of 10 mg/day.

In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000). However, some sources note breastfeeding should only be considered if the RID is <5% for psychotropic agents (Larsen 2015).

The RID of aripiprazole was calculated using a mean milk concentration of 56 ng/mL (aripiprazole) and 8.8 ng/mL (dehydro-aripiprazole), providing an estimated daily infant dose via breast milk of 47 mcg/day. This milk concentration was obtained following maternal administration of aripiprazole 10 mg/day during pregnancy and while breastfeeding. Milk samples were obtained at 8 and 10 weeks' postpartum. The RID was calculated by the authors of the study using the actual maternal weight. Peak milk concentrations appeared ~3 hours after the dose, but remained relatively constant throughout the dosing interval (Nordeng 2014).

Although reports of aripiprazole use in breastfeeding women are limited, lactation failure has been observed in some cases (Lutz 2010; Mendhekar 2006; Nordeng 2014). In general, infants exposed to second generation antipsychotics via breast milk should be monitored weekly for the first month of exposure for symptoms, such as appetite changes, insomnia, irritability, or lethargy (Uguz 2016).

According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother. Until additional information is available, use of agents other than aripiprazole in breastfeeding women is preferred (Pacchiarotti 2016; Uguz 2016).

Briggs' Drugs in Pregnancy & Lactation

• Aripiprazole

Adverse Reactions

Unless otherwise noted, frequency of adverse reactions is shown as reported for adult patients receiving aripiprazole monotherapy. Spectrum and incidence of adverse effects similar in children; exceptions noted when incidence is much higher in children.

IM:

>10%:

Endocrine & metabolic: Decreased HDL cholesterol (14%), increased LDL cholesterol (10% to 14%), increased serum cholesterol (4% to 22%), increased serum triglycerides (7% to 27%), weight gain (17% to 22%)

Nervous system: Akathisia (dose-related; 2% to 12%), headache (12%)

1% to 10%:

Cardiovascular: Orthostatic hypotension (3%), tachycardia (≤2%)

Endocrine & metabolic: Increased serum glucose (8%), weight loss (4%)

Gastrointestinal: Abdominal distress (2%), constipation (10%), diarrhea (3%), nausea (9%), vomiting (3%), xerostomia (4%)

Hematologic & oncologic: Neutropenia (6%)

Local: Injection site reaction (≤1%; including erythema, induration, inflammation, hemorrhage, pruritus, rash, swelling), pain at injection site (5%)

Nervous system: Anxiety (≥1%), dizziness (4% to 8%), drowsiness (7% to 9%), dystonia (2%), extrapyramidal reaction (10%), fatigue (dose-related; 1% to 2%), insomnia (≥1%), sedated state (3% to 5%), restlessness (≥1%)

Neuromuscular & skeletal: Arthralgia (4%), back pain (4%), musculoskeletal pain (3%), myalgia (4%), tremor (dose-related; 3%)

Respiratory: Nasal congestion (2%), upper respiratory tract infection (4%)

<1%:

Cardiovascular: Abnormal T waves on ECG, bradycardia, chest discomfort, hypertension, increased blood pressure, presyncope, prolonged QT interval on ECG, sinus tachycardia

Endocrine & metabolic: Decreased serum cholesterol, decreased serum triglycerides, glycosuria, hyperprolactinemia, increased libido, obesity

Gastrointestinal: Bruxism, decreased appetite, dysgeusia, dyspepsia, hyperinsulinism, swollen tongue, upper abdominal pain

Genitourinary: Pollakiuria, urinary incontinence

Hematologic & oncologic: Thrombocytopenia

Hepatic: Abnormal hepatic function tests, hepatotoxicity

Hypersensitivity: Hypersensitivity reaction

Nervous system: Abnormal gait, aggressive behavior, agitation, delayed ejaculation, dystonia (oromandibular), hypersomnia, irritability, lethargy, memory impairment, panic attack, psychotic reaction, seizure, suicidal ideation, syncope, trismus

Neuromuscular & skeletal: Bradykinesia, increased creatinine phosphokinase in blood specimen, joint stiffness, muscle twitching, rhabdomyolysis

Ophthalmic: Blurred vision, oculogyric crisis

Respiratory: Nasopharyngitis

Miscellaneous: Fever

Oral:

>10%:

Endocrine & metabolic: Increased serum glucose (adults: 18%; children and adolescents: 3% to 5%), weight gain (children and adolescents: 3% to 26%; adults: 2% to 8%)

Gastrointestinal: Constipation (adults: 11%; children and adolescents: 2%), nausea (8% to 15%), vomiting (8% to 14%)

Local: Application site rash (Mycite patch: 12%)

Nervous system: Agitation (19%), akathisia (dose-related; 2% to 13%), anxiety (17%), drowsiness (dose-related; children and adolescents: 10% to 26%; adults: 5% to 13%), extrapyramidal reaction (dose-related; children and adolescents: 6% to 27%; adults: 5% to 16%), fatigue (dose-related; children and adolescents: 4% to 22%; adults: 6%), headache (adults: 27%; children and adolescents: 10% to 12%), sedated state (dose-related; children and adolescents: 9% to 21%; adults: 3% to 11%), insomnia (18%)

Neuromuscular & skeletal: Tremor (dose-related; 5% to 12%)

1% to 10%:

Cardiovascular: Orthostatic hypotension (≤4%)

Dermatologic: Skin rash (children and adolescents: ≤2%)

Endocrine & metabolic: Decreased HDL cholesterol (children and adolescents: 4%), increased serum cholesterol (children and adolescents: 1%), increased serum triglycerides (5% to 10%), weight loss (≥1%)

Gastrointestinal: Abdominal distress (2% to 3%), anorexia, decreased appetite (children and adolescents: 5% to 7%), diarrhea (children and adolescents: 4%), dyspepsia (9%), increased appetite (children and adolescents: 7%), sialorrhea (dose-related; children and adolescents; 4% to 8%), stomach discomfort (3%), upper abdominal pain (children and adolescents: 3%), xerostomia (5%)

Genitourinary: Urinary incontinence (≥1%)

Nervous system: Dizziness (3% to 10%), drooling (children and adolescents: 3% to 9%), dystonia (2%), irritability (children and adolescents: 2%), lethargy (adults: 5%; children and adolescents: 3% to 5%), pain (3%), restlessness (5% to 6%)

Neuromuscular & skeletal: Asthenia (≥1%), limb pain (4%), muscle rigidity (children and adolescents: 2%), muscle spasm (2%), myalgia (2%), stiffness (2% to 4%)

Ophthalmic: Blurred vision (3% to 8%)

Respiratory: Cough (3%), epistaxis (children and adolescents: 2%), nasopharyngitis (children and adolescents: 6% to 9%), pharyngolaryngeal pain (3%)

Miscellaneous: Fever (children and adolescents: 4% to 9%)

<1%:

Cardiovascular: Acute myocardial infarction, angina pectoris, atrial fibrillation, atrial flutter, atrioventricular block, bradycardia, chest pain, choreoathetosis, facial edema, hypertension, hypotension, ischemic heart disease, palpitations, peripheral edema, prolonged QT interval on ECG

Dermatologic: Alopecia, hyperhidrosis, pruritus, skin photosensitivity, urticaria

Endocrine & metabolic: Amenorrhea, change in libido, gynecomastia, hirsutism (children and adolescents), hypoglycemia, hypokalemia, hyponatremia, increased gamma-glutamyl transferase, increased lactate dehydrogenase, increased serum prolactin, menstrual disease

Gastrointestinal: Gastroesophageal reflux disease, tongue spasm (children and adolescents)

Genitourinary: Erectile dysfunction, mastalgia, nocturia, priapism, urinary retention

Hematologic & oncologic: Elevated glycosylated hemoglobin, thrombocytopenia

Hepatic: Hepatitis, increased liver enzymes, increased serum bilirubin, jaundice

Hypersensitivity: Hypersensitivity reaction

Nervous system: Aggressive behavior, anorgasmia, ataxia, catatonia, cogwheel rigidity, delirium, hypertonia, impaired mobility, memory impairment, myasthenia, myoclonus, parkinsonism, seizure, sleep talking (children and adolescents), somnambulism, speech disturbance, tic disorder

Neuromuscular & skeletal: Akinesia, bradykinesia, hypokinesia, rhabdomyolysis

Ophthalmic: Diplopia, oculogyric crisis, photophobia

Renal: Increased blood urea nitrogen, increased creatinine clearance

Respiratory: Dyspnea, nasal congestion

Postmarketing (any indication):

Cardiovascular: Cerebrovascular accident, transient ischemic attacks

Endocrine & metabolic: Diabetic ketoacidosis, hyperglycemia

Gastrointestinal: Dysphagia

Hematologic & oncologic: Agranulocytosis, leukopenia, neutropenia

Hypersensitivity: Anaphylaxis, angioedema

Immunologic: Drug reaction with eosinophilia and systemic symptoms

Nervous system: Impulse control disorder (including pathological gambling, hypersexuality, increased shopping or eating), neuroleptic malignant syndrome, sleep apnea (obstructive) (Health Canada, August 16, 2016; Shirani 2011), suicidal ideation, suicidal tendencies, syncope, tardive dyskinesia

* See Cautions in AHFS Essentials for additional information.

Allergy and Idiosyncratic Reactions

• ARIPiprazole Allergy

Toxicology

• Antipsychotic Agents, Atypical

Metabolism/Transport Effects

Substrate of CYP2D6 (major), CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions Open Interactions

Abiraterone Acetate: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of abiraterone with CYP2D6 substrates that have a narrow therapeutic index whenever possible. When concurrent use is not avoidable, monitor patients closely for signs/symptoms of toxicity. Risk D: Consider therapy modification

Acetylcholinesterase Inhibitors (Central): May enhance the neurotoxic (central) effect of Antipsychotic Agents. Severe extrapyramidal symptoms have occurred in some patients. Risk C: Monitor therapy

Ajmaline: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Alcohol (Ethyl): CNS Depressants may enhance the CNS depressant effect of Alcohol (Ethyl). Risk C: Monitor therapy

Alizapride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Amifampridine: Agents With Seizure Threshold Lowering Potential may enhance the neuroexcitatory and/or seizure-potentiating effect of Amifampridine. Risk C: Monitor therapy

Amisulpride (Oral): May enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, the risk of neuroleptic malignant syndrome may be increased. Risk X: Avoid combination

Amphetamines: Antipsychotic Agents may diminish the stimulatory effect of Amphetamines. Risk C: Monitor therapy

Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Risk C: Monitor therapy

Anti-Parkinson Agents (Dopamine Agonist): Antipsychotic Agents (Second Generation [Atypical]) may diminish the therapeutic effect of Anti-Parkinson Agents (Dopamine Agonist). Management: Consider avoiding atypical antipsychotic use in patients with Parkinson disease. If an atypical antipsychotic is necessary, consider using clozapine, quetiapine, or ziprasidone at lower initial doses, or a non-dopamine antagonist (eg, pimavanserin). Risk D: Consider therapy modification

Aprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Armodafinil: May decrease the serum concentration of ARIPiprazole. Risk C: Monitor therapy

Asunaprevir: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Asunaprevir is contraindicated in combination with drugs metabolized by CYP2D6 for which increased levels are associated with ventricular arrhythmias and sudden death (eg, thioridazine, flecanide, propafenone); use caution with any CYP2D6 substrate. Risk D: Consider therapy modification

Azelastine (Nasal): CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal). Risk X: Avoid combination

Blonanserin: CNS Depressants may enhance the CNS depressant effect of Blonanserin. Management: Use caution if coadministering blonanserin and CNS depressants; dose reduction of the other CNS depressant may be required. Strong CNS depressants should not be coadministered with blonanserin. Risk D: Consider therapy modification

Blood Pressure Lowering Agents: May enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy

Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Brexanolone: CNS Depressants may enhance the CNS depressant effect of Brexanolone. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Bromopride: May enhance the adverse/toxic effect of Antipsychotic Agents. Risk X: Avoid combination

Bromperidol: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Buprenorphine: CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. Risk D: Consider therapy modification

Cabergoline: May diminish the therapeutic effect of Antipsychotic Agents. Risk X: Avoid combination

Cannabidiol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Cannabis: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Chlormethiazole: May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. Risk D: Consider therapy modification

Chlorphenesin Carbamate: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy

CloBAZam: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

CNS Depressants: May enhance the adverse/toxic effect of other CNS Depressants. Risk C: Monitor therapy

Conivaptan: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

CYP2D6 Inhibitors (Moderate): May increase the serum concentration of ARIPiprazole. Management: Monitor for increased aripiprazole pharmacologic effects. Aripiprazole dose adjustments may or may not be required based on concomitant therapy, indication, or dosage form. Consult full interaction monograph for specific recommendations. Risk C: Monitor therapy

CYP2D6 Inhibitors (Strong): May increase the serum concentration of ARIPiprazole. Management: Aripiprazole dose reductions are required for indications other than major depressive disorder. Dose reductions vary based on formulation, initial starting dose, and the additional use of CYP3A4 inhibitors. See full interaction monograph for details. Risk D: Consider therapy modification

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

CYP3A4 Inducers (Strong): May decrease the serum concentration of ARIPiprazole. Management: For indications other than major depressive disorder: double the oral aripiprazole dose over 1 to 2 weeks and closely monitor. Avoid use of strong CYP3A4 inducers for more than 14 days with extended-release injectable aripiprazole. Risk D: Consider therapy modification

CYP3A4 Inhibitors (Moderate): May increase the serum concentration of ARIPiprazole. Management: Monitor for increased aripiprazole pharmacologic effects. Aripiprazole dose adjustments may or may not be required based on concomitant therapy, indication, or dosage form. Consult full interaction monograph for specific recommendations. Risk C: Monitor therapy

CYP3A4 Inhibitors (Strong): May increase the serum concentration of ARIPiprazole. Management: Aripiprazole dose reductions are required for indications other than major depressive disorder. Dose reductions vary based on formulation, CYP2D6 genotype, and use of CYP2D6 inhibitors. See full interaction monograph for details. Risk D: Consider therapy modification

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Risk D: Consider therapy modification

Dacomitinib: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of dacomitinib with CYP2D6 subtrates that have a narrow therapeutic index. Risk D: Consider therapy modification

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Deutetrabenazine: May enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, the risk for akathisia, parkinsonism, or neuroleptic malignant syndrome may be increased. Risk C: Monitor therapy

Dimethindene (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Doxylamine: May enhance the CNS depressant effect of CNS Depressants. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with other CNS depressants is not recommended. Risk C: Monitor therapy

Dronabinol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Droperidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Exceptions to this monograph are discussed in further detail in separate drug interaction monographs. Risk D: Consider therapy modification

Duvelisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Risk D: Consider therapy modification

Erdafitinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Erdafitinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Esketamine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Flunitrazepam: CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. Risk D: Consider therapy modification

Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Fosnetupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Guanethidine: Antipsychotic Agents may diminish the therapeutic effect of Guanethidine. Risk C: Monitor therapy

HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Idelalisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Imatinib: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Iohexol: Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iohexol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iohexol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. Risk D: Consider therapy modification

Iomeprol: Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iomeprol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iomeprol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. Risk D: Consider therapy modification

Iopamidol: Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iopamidol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iopamidol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. Risk D: Consider therapy modification

Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Kava Kava: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy

Larotrectinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Lemborexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dosage adjustments of lemborexant and of concomitant CNS depressants may be necessary when administered together because of potentially additive CNS depressant effects. Close monitoring for CNS depressant effects is necessary. Risk D: Consider therapy modification

Lithium: May enhance the neurotoxic effect of Antipsychotic Agents. Lithium may decrease the serum concentration of Antipsychotic Agents. Specifically noted with chlorpromazine. Risk C: Monitor therapy

Lofexidine: May enhance the CNS depressant effect of CNS Depressants. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs. Risk C: Monitor therapy

Lumefantrine: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Mequitazine: Antipsychotic Agents may enhance the arrhythmogenic effect of Mequitazine. Management: Consider alternatives to one of these agents when possible. While this combination is not specifically contraindicated, mequitazine labeling describes this combination as discouraged. Risk D: Consider therapy modification

Methotrimeprazine: CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established. Risk D: Consider therapy modification

Methylphenidate: Antipsychotic Agents may enhance the adverse/toxic effect of Methylphenidate. Methylphenidate may enhance the adverse/toxic effect of Antipsychotic Agents. Risk C: Monitor therapy

Metoclopramide: May enhance the adverse/toxic effect of Antipsychotic Agents. Risk X: Avoid combination

MetyroSINE: CNS Depressants may enhance the sedative effect of MetyroSINE. Risk C: Monitor therapy

MetyroSINE: May enhance the adverse/toxic effect of Antipsychotic Agents. Risk C: Monitor therapy

MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Risk D: Consider therapy modification

Minocycline (Systemic): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Mitotane: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Risk D: Consider therapy modification

Nabilone: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Netupitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Opioid Agonists: CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Orphenadrine: CNS Depressants may enhance the CNS depressant effect of Orphenadrine. Risk X: Avoid combination

Oxomemazine: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

OxyCODONE: CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Palbociclib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Panobinostat: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Risk X: Avoid combination

Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Perampanel: May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. Risk D: Consider therapy modification

Perhexiline: CYP2D6 Substrates (High risk with Inhibitors) may increase the serum concentration of Perhexiline. Perhexiline may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Piribedil: Antipsychotic Agents may diminish the therapeutic effect of Piribedil. Piribedil may diminish the therapeutic effect of Antipsychotic Agents. Management: Use of piribedil with antiemetic neuroleptics is contraindicated, and use with antipsychotic neuroleptics, except for clozapine, is not recommended. Risk X: Avoid combination

Quinagolide: Antipsychotic Agents may diminish the therapeutic effect of Quinagolide. Risk C: Monitor therapy

QuiNINE: May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Rufinamide: May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. Risk C: Monitor therapy

Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Selective Serotonin Reuptake Inhibitors: CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. Risk C: Monitor therapy

Serotonergic Agents (High Risk): May enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonergic agents may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor therapy

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Simeprevir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Sodium Oxybate: May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to combined use. When combined use is needed, consider minimizing doses of one or more drugs. Use of sodium oxybate with alcohol or sedative hypnotics is contraindicated. Risk D: Consider therapy modification

Stiripentol: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Risk D: Consider therapy modification

Sulpiride: Antipsychotic Agents may enhance the adverse/toxic effect of Sulpiride. Risk X: Avoid combination

Suvorexant: CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

Tetrabenazine: May enhance the adverse/toxic effect of Antipsychotic Agents. Risk C: Monitor therapy

Tetrahydrocannabinol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Tetrahydrocannabinol and Cannabidiol: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Thalidomide: CNS Depressants may enhance the CNS depressant effect of Thalidomide. Risk X: Avoid combination

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Trimeprazine: May increase the serum concentration of ARIPiprazole. Risk C: Monitor therapy

Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider therapy modification

Food Interactions

Ingestion with a high-fat meal delays time to peak plasma level. Management: Administer without regard to meals.

Gene Testing May Be Considered

• CYP2D6 - ARIPiprazole

Genes of Interest

• Alpha-1A Receptor
• Brain-Derived Neurotropic Factor
• Cytochrome P450 3A4
• Dopamine Receptor D2
• Dopamine Receptor D3
• Serotonin Receptor 1A
• Serotonin Receptor 2A
• Serotonin Receptor 2C

Monitoring Parameters

Mental status; vital signs (as clinically indicated); blood pressure (baseline; repeat 3 months after antipsychotic initiation, then yearly); weight, height, BMI, waist circumference (baseline; repeat at 4, 8, and 12 weeks after initiating or changing therapy, then quarterly; consider switching to a different antipsychotic for a weight gain ≥5% of initial weight); CBC (as clinically indicated; monitor frequently during the first few months of therapy in patients with preexisting low WBC or history of drug-induced leukopenia/neutropenia); electrolytes and liver function (annually and as clinically indicated); personal and family history of obesity, diabetes, dyslipidemia, hypertension, or cardiovascular disease (baseline; repeat annually); fasting plasma glucose level/HbA1c (baseline; repeat 3 months after starting antipsychotic, then yearly); fasting lipid panel (baseline; repeat 3 months after initiation of antipsychotic; if LDL level is normal repeat at 2- to 5-year intervals or more frequently if clinical indicated); changes in menstruation, libido, development of galactorrhea, erectile and ejaculatory function (yearly); abnormal involuntary movements or parkinsonian signs (baseline; repeat weekly until dose stabilized for at least 2 weeks after introduction and for 2 weeks after any significant dose increase); tardive dyskinesia (every 12 months; high-risk patients every 6 months); ocular examination (yearly in patients >40 years; every 2 years in younger patients) (ADA 2004; Lehman 2004; Marder 2004).

Advanced Practitioners Physical Assessment/Monitoring

Assess mental status for depression and suicidal ideation. Assess other medicines patient may be taking; alternate therapy or dosage adjustments may be needed. Obtain vital signs (as clinically indicated); blood pressure (baseline; repeat 3 months after antipsychotic initiation, then yearly); ECG (as needed); weight, height, BMI, waist circumference (baseline; repeat at 4, 8, and 12 weeks after initiating or changing therapy, then quarterly consider switching to a different antipsychotic for a weight gain ≥5% of initial weight). Obtain CBC, electrolytes, liver function tests, glucose, and fasting lipids. Assess for changes in menstruation, libido, development of galactorrhea, erectile dysfunction, tardive dyskinesia, involuntary movements, or parkinsonian signs. Obtain ophthalmic exam (yearly in patients >40 years; every 2 years in younger patients). Assess for extrapyramidal symptoms prior to and during therapy.

Nursing Physical Assessment/Monitoring

Check ordered labs and report abnormalities. Check vitals, BMI, abdominal girth, and weight as ordered. Monitor for depression or suicidal ideation. Educate patient to report signs of depression, changes in movement, vision changes, changes in menstruation, or changes in sexual function. Monitor for extrapyramidal symptoms prior to and periodically during therapy, particularly akathisia (restlessness).

Product Availability

Abilify immediate-release injection (9.75 mg/1.3 mL) has been discontinued in the US for more than 1 year.

Dosage Forms Considerations

Oral solution contains fructose 200 mg and sucrose 400 mg per mL.

Abilify Mycite is a drug-device combination product comprised of aripiprazole tablets embedded with an Ingestible Event Marker (IEM) sensor intended to track drug ingestion.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Prefilled Syringe, Intramuscular:

Abilify Maintena: 300 mg (1 ea); 400 mg (1 ea)

Solution, Oral:

Generic: 1 mg/mL (150 mL)

Suspension Reconstituted ER, Intramuscular:

Abilify Maintena: 300 mg (1 ea); 400 mg (1 ea)

Tablet, Oral:

Abilify: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg [contains corn starch, fd&c blue #2 aluminum lake]

Abilify MyCite: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg [contains corn starch, fd&c blue #2 aluminum lake]

Generic: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg

Tablet Disintegrating, Oral:

Generic: 10 mg, 15 mg

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Suspension Reconstituted ER, Intramuscular:

Abilify Maintena: 300 mg (1 ea); 400 mg (1 ea)

Tablet, Oral:

Abilify: 2 mg, 5 mg [contains corn starch, fd&c blue #2 aluminum lake]

Abilify: 10 mg, 15 mg, 20 mg, 30 mg [contains corn starch]

Generic: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg

Anatomic Therapeutic Chemical (ATC) Classification

• N05AX12

Generic Available (US)

May be product dependent

Pricing: US

Prefilled Syringe (Abilify Maintena Intramuscular)

300 mg (per each): $2,047.26

400 mg (per each): $2,729.68

Solution (ARIPiprazole Oral)

1 mg/mL (per mL): $7.06 - $7.07

Suspension Reconstituted ER (Abilify Maintena Intramuscular)

300 mg (per each): $2,047.26

400 mg (per each): $2,729.68

Tablet, orally-disintegrating (ARIPiprazole Oral)

10 mg (per each): $41.89

15 mg (per each): $41.89

Tablets (Abilify MyCite Oral)

2 mg (per each): $66.00

5 mg (per each): $66.00

10 mg (per each): $66.00

15 mg (per each): $66.00

20 mg (per each): $66.00

30 mg (per each): $66.00

Tablets (Abilify Oral)

2 mg (per each): $35.68

5 mg (per each): $35.68

10 mg (per each): $35.68

15 mg (per each): $35.68

20 mg (per each): $50.45

30 mg (per each): $50.45

Tablets (ARIPiprazole Oral)

2 mg (per each): $30.74 - $32.11

5 mg (per each): $31.83 - $32.11

10 mg (per each): $31.87 - $32.11

15 mg (per each): $30.74 - $32.11

20 mg (per each): $32.00 - $45.41

30 mg (per each): $37.44 - $45.41

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Aripiprazole is a quinolinone antipsychotic which exhibits high affinity for D2, D3, 5-HT1A, and 5-HT2A receptors; moderate affinity for D4, 5-HT2C, 5-HT7, alpha1 adrenergic, and H1 receptors. It also possesses moderate affinity for the serotonin reuptake transporter; has no affinity for muscarinic (cholinergic) receptors. Aripiprazole functions as a partial agonist at the D2 and 5-HT1A receptors, and as an antagonist at the 5-HT2A receptor (de Bartolomeis 2015).

Pharmacodynamics/Kinetics

Note: In pediatric patients 10 to 17 years of age, the pharmacokinetic parameters of aripiprazole and dehydro-aripiprazole have been shown to be similar to adult values when adjusted for weight.

Onset of action: Initial: 1 to 3 weeks.

Absorption:

IM: Extended-release: Slow, prolonged.

Oral: Well absorbed.

Distribution: Vd: 4.9 L/kg.

Protein binding: ≥99%, primarily to albumin.

Metabolism: Hepatic dehydrogenation, hydroxylation and N-dealkylation via CYP2D6, CYP3A4 (dehydro-aripiprazole metabolite has affinity for D2 receptors similar to the parent drug and represents 40% of the parent drug exposure in plasma) (Sheehan 2010).

Bioavailability: Tablet: 87%; Note: Orally disintegrating tablets are bioequivalent to tablets; oral solution to tablet ratio of geometric mean for peak concentration is 122% and for AUC is 114%.

Half-life elimination: Aripiprazole: 75 hours; dehydro-aripiprazole: 94 hours; IM, extended release (terminal): ~30 to 47 days (dose-dependent).

CYP2D6 poor metabolizers: Aripiprazole: 146 hours.

Time to peak, plasma:

IM: Extended release (after multiple doses): 4 days (deltoid administration); 5 to 7 days (gluteal administration).

Tablet: 3 to 5 hours; high-fat meals delay time to peak by 3 hours for aripiprazole and 12 hours for dehydro-aripiprazole.

Excretion: Feces (55%, ~18% of the total dose as unchanged drug; 37% of the total dose as changed drug); urine (25%, <1% of the total dose as unchanged drug; 25% of the total dose as changed drug) (Sheehan 2010)

Pharmacodynamics/Kinetics: Additional Considerations

Renal function impairment: In severe renal impairment (CrCl <30 mL/minute), Cmax increased by 36% (aripiprazole) and 53% (dehydro-aripiprazole), but AUC was 15% lower for aripiprazole and 7% higher for dehydro-aripiprazole.

Hepatic function impairment: AUC increased by 31% in mild hepatic impairment and by 8% in moderate impairment, and decreased by 20% in severe impairment.

Geriatric: In patients ≥65 years of age who were administered a single oral dose, clearance was 20% lower than that observed in younger patients.

Gender: Cmax and AUC are 30% to 40% higher in women than in men.

CYP 2D6 metabolizers: 60% higher exposure to aripiprazole and active metabolites in poor CYP 2D6 metabolizers compared to extensive metabolizers (Sheehan 2010).

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Dental Health Professional Considerations

Aripiprazole works differently from the classic antipsychotics, such as chlorpromazine, in that it does not appear to block central dopaminergic receptors, but rather seems to be a stabilizer of dopamine-serotonin central systems. The risk of extrapyramidal reactions such as pseudoparkinsonism, acute dystonic reactions, akathisia, and tardive dyskinesia are low and the frequencies reported are similar to placebo. Aripiprazole may be associated with neuroleptic malignant syndrome (NMS).

Effects on Dental Treatment

Key adverse event(s) related to dental treatment: Infrequent occurrence of toothache, xerostomia, and changes in salivation including drooling (normal salivary flow resumes upon discontinuation) have been reported. Rare occurrence of bruxism, dysgeusia, dystonia (oromandibular), tongue tremors, and trismus have also been reported. For additional rare considerations, see Dental Health Professional Considerations.

Effects on Bleeding

No information available to require special precautions

Related Information

• Agents Approved for Bipolar Disorder
• Antipsychotic Receptor Profile
• Beers Criteria 2019: Potentially Inappropriate Medication Use in Older Adults ≥65 Years of Age
• Comparison of Antipsychotic Adverse Effects
• Drugs With Actionable Pharmacogenomic Recommendations
• Long-Acting Antipsychotics
• Relative Infant Dose

Index Terms

BMS 337039; OPC-14597

FDA Approval Date

June 01, 2012

References

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Brand Names: International

Abdin (PH); Abilia (EG); Abilify (AE, AT, AU, BB, BE, BG, BH, BR, CH, CL, CN, CO, CY, CZ, DE, DK, EE, EG, ES, FI, FR, GB, GR, HK, HR, HU, ID, IE, IL, IS, IT, JO, JP, KR, LB, LT, LU, MT, MX, NL, NO, PH, PL, PT, PY, RO, RU, SA, SE, SG, SI, SK, TH, TR, TW, VE, VN, ZA); Abilify Discmelt (PH); Abilify Maintena (BE, HK, MY, RO, SG, TH); Abilify OD (JP); Abilify ODT (NZ); Antredamin (CR, DO, GT, HN, NI, PA, SV); Apalife (MY, TH); Apilipex (EG); Arian (MY); Arika (TW); Arilex (CL); Arilobe (EG); Arinia (BD, ID); Aripi (ID); Aripipan (LB); Aripizole (KR); Ariple (TW); Ariply (IL); Aripra (KR); Ariski (ID); Aristab (BR); Arive (IN); Arixind (AR); Arizol (UY); Arizole (LK, TW); Arizopress (PH); Arlemide (AR); Atfren (CR, DO, GT, HN, NI, PA, SV); Atypral (LB); Azymol (PE, PY); Bisoza (LK, PH); Groven (AR); Ilimit (EC, PE, PY, UY); Irazem (AR); Lemilvo (IE); Mactril (LK); Pipzol (LK, UA); Poziats (VN); Siblix (AR); Siznil (BD); Sizopra (BD, LK); Viza (CL); Xalipro (LB); Xarip (BD); Zedan (PK)

Last Updated 5/2/20