All about Abilify
- mrs&mrs
- Jan 21, 2024
- 5 min read
Abilify or aripiprazol is an antipsychotic medication. It is one of my favorites and the one I would choose for myself if I became psychotic and needed an antipsychotic.
Aripiprazol is a second generation antipsychotic (see post on antipsychotics) but it is a little bit different than the other antipsychotics in that group. I plan to explain more about how anitpsychotics work in a later post but to put it simply antipsychotics are dopamine receptor antagonists. That means that they block dopamine receptors so that dopamine can't activate them. Aripiprazol on the other hand is a partial agonist for the dopamine receptor, which means that when aripiprazole binds to the dopamine receptors it partially activates them instead of only blocking. This hinders dopamine from binding to the receptors and fully activate them but by the partial activation, aripiprazol should theoretically have less side effects than other antipsychotics that are full blockers for the dopamine receptors.
Abilify can be used for psychotic disorders like schizophrenia, both in the acute and maintenance phase. It also has indications for bipolar disorder and depression but the focus here today is on patients with psychosis.
Benefits to using aripiprazol.
#1 Most importantly in my opinion aripiprazol has a better side effect profile than many of the other antipsychotics. This is the reason I would choose it for myself and why I prefer it as a first choice maintenance treatment for young patients with psychosis. Weight gain and metabolic syndrome is much less common and if there is weight gain it seems to be much less than with the other ones. Aripiprazol is also not sedating which can be a huge benefit for some.
#2 Theoretically, because of the parital dopamine receptor agonism, aripiprazol increases dopamine concentrations in brain areas where they are too low. Therefore, still theoretically, aripiprazol could improve cognitive and negative symptoms in schizophrenia while other antipsychotics might rather worsen these symptoms than improve.
#3 Aripiprazol can be used to treat hyperprolactinemia (high levels of prolactin in the blood) caused by other antipsychotics. In these cases it is better to use low doses, 1-5mg a day.
Possible problem with using aripiprazol.
Akathisia is quite common with aripiprazol and in my clinical experience it is much more common with aripiprazol than most of the other antipsychotics, including both typical and atypical ones. This side effect can be very intolerable for the patients, it is difficult to treat with other medications and I feel that it does not usually get better with time. I sometimes try lowering the dose of aripiprazol but most of the time I end up switching to another antipsychotic when akathisia is present and bad. The other EPS are not common with aripiprazol.
Forms and dosing.
Aripiprazol is available as tablets and as a long-acting injection, they also have a short-acting injection which is just like a single dose but I have never prescribed that form.
The usual starting dose when using tablets is 10mg once daily, usually I prescribe aripiprazol in the morning since it isn't sedating. Still there are some patients who get drowsy from it and then I recommend taking it in the evening. I used to start with a lower dose, 5-7,5mg for a few days, but I feel it just delayes getting the patients to an effective dose and I have not been seeing more side effects in the beginning with 10mg than I did with the lower starting doses. So these days I just start all my patients on 10mg. The maximum dose is 30mg. I can only recall one patient who I prescribed that high for. For most patients I feel 10-20mg a day does the trick, that is their psychotic symptoms improve and sometimes they reach full remission and side effects not too bothersome.
The aripiprazole long-acting injection (Abilify maintena in Iceland) is 400mg and given once every four weeks. This seems to be a one-size-fit-all dose, so the intramuscular dose is not dependent on the previously prescribed dose in tablets. This seems to work fine in most cases but I have had patients who have needed the Abilify maintena with a shorter interval, up to 3 weeks in between, and for some patients 300mg every four weeks is enough and helps keep side effects to a minimum.
A case:
A 20 year old man, admitted with first-episode psychosis. No previous psychiatric history and no family history of mental illness. Has been using both kannabis and amphetamine for a few years. Admitted involuntarily after having arrived to the psychiatric emergency department with the police. His family called for assistance because he was threatening at home, they were very scared of him and he had plans to set fire to the family home to rid it of "the demons". He was floridly psychotic on admission. Very delusional and had both visual and auditory hallucinations, mostly demon-related. His thought was also very disturbed but he was mostly calm and cooperative on the ward and displayed no violence.
I treated this young man with aripiprazol tablets, started with 10mg and later increased to 15mg. He tolerated the medicine very well, complained of no side effects while on the ward and his psychosis got better quite fast. Within a month he was without any psychotic symptoms and had insight into his illness and need for further treatment. I had referred him to an outpatient unit and he was ready to be discharged. We had a discussion about treatment with tablets or long-acting injection with aripiprazol and decided to start him on Abilify maintena the day before his planned discharge. He got 400mg and was supposed to take the tablets for 2 more weeks and then stop as recommended in guidelines.
He got the injection on Tuesday, was discharged on a Wednesday and on Friday he arrived at the psychiatric emergency department with intolerable akathisia, the worst I have ever seen. I was very surprised because he had already been treated with aripiprazol tablets for almost 4 weeks in doses that are supposed to be equivalent to the maintena without any side effects. We treated his akathisia as best we could (I plan to do a later post on how to treat akathisia), stopped the aripiprazol tablets and started a switch to another antipsychotic. He never got another injection of Abilify maintena but maintained his remission on a different long-acting injection and as far as I know he has been doing well for years now, not had a relapse and never been admitted to the psychiatric ward again.
Take home: Akathisia does happen with aripiprazol and it can be really bad. Still most patients do well on aripiprazol without serious side effects. In almost all cases it is worth the shot because of the preferable side effect profile and possible positive effects on cognitive and negative symptoms.
Disclaimer: Cases are based on actual events and patients I have encountered. Details have been changed in ways that neither readers nor the patients themselves would be able to identify the person the case is based on.
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