Skip to Content

Aripiprazole

Pronunciation

Class: Atypical Antipsychotics
ATC Class: N05AX12
VA Class: CN709
Chemical Name: 3,4-Dihydro-7-[4-[4-(2,3-dichlorophenyl)-1-piperazinyl]butoxy]-2(1H)-quinolinone
Molecular Formula: C23H27Cl2N3O2 C36H51Cl2N3O4
CAS Number: 129722-12-9
Brands: Abilify, Aristada

Warning(s)

  • Increased Mortality in Geriatric Patients with Dementia-related Psychosis
  • Geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death.1 28 73 113 114 118 119

  • Analyses of 17 placebo-controlled trials in geriatric patients mainly receiving atypical antipsychotic agents revealed an approximate 1.6- to 1.7-fold increase in mortality compared with that in patients receiving placebo.73 113 118 119

  • Most fatalities appeared to result from cardiovascular-related events (e.g., heart failure, sudden death) or infections (mostly pneumonia).73 118 119

  • Observational studies suggest that conventional or first-generation antipsychotic agents also may increase mortality in such patients.28 113 118 119

  • Antipsychotic agents, including aripiprazole, are not approved for the treatment of dementia-related psychosis.1 73 113 118 119

  • Suicidality
  • Antidepressants increased risk of suicidal thinking and behavior (suicidality) compared with placebo in children, adolescents, and young adults (18–24 years of age) with major depressive disorder and other psychiatric disorders; balance this risk with clinical need.1 76 77 Aripiprazole is not approved for treatment of depression in pediatric patients.1 (See Pediatric Use under Cautions.)

  • In pooled data analyses, risk of suicidality was not increased in adults >24 years of age and apparently was reduced in adults ≥65 years of age with antidepressant therapy compared with placebo.1 76 77

  • Depression and certain other psychiatric disorders are themselves associated with an increased risk of suicide.1 76 77 78

  • Appropriately monitor and closely observe all patients who are started on aripiprazole therapy for clinical worsening, suicidality, or unusual changes in behavior; involve family members and/or caregivers in this process.1 76 77 78 (See Worsening of Depression and Suicidality Risk under Cautions.)

Introduction

Quinolinone derivative;2 5 atypical or second-generation antipsychotic agent.1 2 7 28 89 98

Uses for Aripiprazole

Schizophrenia

Used orally (as aripiprazole) and IM (as extended-release aripiprazole or aripiprazole lauroxil injection) for treatment of schizophrenia.1 2 3 9 89 91 93 118 119 120 121 122

American Psychiatric Association (APA) considers most atypical antipsychotic agents first-line drugs for the management of the acute phase of schizophrenia (including first psychotic episodes).28

Patients who do not respond to or tolerate one drug may be successfully treated with an agent from a different class or with a different adverse effect profile.28 70 71 72 115

Used IM (as immediate-release aripiprazole injection) for acute management of agitation in patients with schizophrenia for whom treatment with aripiprazole is appropriate and who require an IM antipsychotic agent for rapid control of behaviors that interfere with diagnosis and care (e.g., threatening behaviors, escalating or urgently distressing behavior, self-exhausting behavior).1 86 87

Bipolar Disorder

Used orally alone or in conjunction with lithium or valproate for acute treatment of manic and mixed episodes associated with bipolar I disorder with or without psychotic features.1 67 90

Has been used orally as monotherapy or as adjunctive therapy with lithium or valproate for longer-term maintenance treatment of bipolar I disorder;1 112 127 129 130 131 however, aripiprazole's long-term efficacy for this use has been questioned by some clinicians127 and maintenance treatment of bipolar disorder is no longer an FDA-labeled indication for the drug.1

Used IM (as immediate-release aripiprazole injection) for acute management of agitation in patients with bipolar I disorder, manic or mixed, for whom treatment with aripiprazole is appropriate and who require an IM antipsychotic agent for rapid control of behaviors that interfere with diagnosis and care (e.g., threatening behaviors, escalating or urgently distressing behavior, self-exhausting behavior).1 88

Adjunctive Therapy of Major Depressive Disorder

Used orally as adjunctive therapy to antidepressants for acute treatment of major depressive disorder.1 85

Irritability Associated with Autistic Disorder

Used orally for acute treatment of irritability associated with autistic disorder.1 109 110

Tourette's Syndrome

Used orally for treatment of Tourette's syndrome (Gilles de la Tourette’s syndrome).1 124

Aripiprazole Dosage and Administration

General

  • Monitor for possible worsening of depression, suicidality, or unusual changes in behavior, especially at the beginning of therapy or during periods of dosage adjustments.1 76 77 78 (See Boxed Warning and also see Worsening of Depression and Suicidality Risk under Cautions.)

  • When switching from other antipsychotic agents to aripiprazole, abrupt discontinuance of previous agent may be acceptable for some patients with schizophrenia, but gradual discontinuance may be most appropriate for others.1 In all cases, minimize period of overlapping antipsychotic administration.1

Administration

Administer aripiprazole orally1 or by IM injection.1 118 Administer aripiprazole lauroxil by IM injection.119

Establish tolerability with oral aripiprazole prior to initiating IM therapy with extended-release aripiprazole or aripiprazole lauroxil.118 119

Oral Administration

Administer orally as conventional tablets, orally disintegrating tablets, or oral solution once daily without regard to meals.1 (See Food under Pharmacokinetics.)

Orally Disintegrating Tablets

Just prior to administration, peel open blister package; with dry hands, remove orally disintegrating tablet.1 Do not push tablet through foil.1

Place tablet on tongue to dissolve; manufacturer recommends taking without liquid, but may take with liquid, if necessary.1

Do not divide orally disintegrating tablet.1

IM Administration of Immediate-release Aripiprazole Injection

Immediate-release aripiprazole (9.75 mg per 1.3-mL vial) is used for agitation associated with schizophrenia or bipolar mania; do not confuse with extended-release formulations of aripiprazole (Abilify Maintena; available in 300- and 400-mg vials and prefilled syringes) or aripiprazole lauroxil (Aristada; available in 441-, 662-, and 882-mg prefilled syringes) used for schizophrenia.1 118 119

Administer immediate-release aripiprazole injection only by IM injection slowly and deeply into the muscle mass.1

Do not administer IV or sub-Q.1

IM Administration of Extended-release Aripiprazole (Abilify Maintena)

Extended-release IM aripiprazole is available in 300- and 400-mg vials and prefilled syringes; do not confuse this formulation with extended-release aripiprazole lauroxil (Aristada; available in 441-, 662-, and 882-mg prefilled syringes) or the immediate-release IM aripiprazole formulation (9.75 mg/vial) used for agitation associated with schizophrenia and bipolar mania.1 118

Must be administered by a healthcare professional.118

Administer extended-release aripiprazole injection only by deep IM injection slowly into the deltoid or gluteal muscle.118 Do not massage injection site following IM administration.118 Rotate injection sites.118

Administer monthly; allow at least 26 days to elapse between doses.118

Reconstitution

Abilify Maintena is commercially available in 2 types of kits that contain aripiprazole lyophilized powder in either single-use vials or prefilled dual-chamber syringes with all the components required for reconstitution and administration (e.g., sterile water for injection diluent, needles, syringes); consult manufacturer's instructions for use for specific information on preparation, reconstitution, and administration.118

Because entire contents of prefilled dual-chamber syringes should be administered after reconstitution, use single-use vials for dosages <300 mg.118

Following reconstitution, shake prefilled syringe or vials vigorously for 20 or 30 seconds, respectively, to ensure a uniform and homogeneous suspension, which appears opaque and milky-white.118 If using vials, withdraw the appropriate dose of aripiprazole using the syringe supplied by the manufacturer.118 If a vial of reconstituted suspension is not administered immediately, shake the vial vigorously for at least 60 seconds to resuspend the drug; do not store in syringe after reconstitution.118 If using prefilled syringes, inject entire contents immediately following reconstitution (i.e., within 30 minutes).118

IM Administration of Extended-release Aripiprazole Lauroxil (Aristada)

Extended-release aripiprazole lauroxil is available in 441-, 662-, and 882-mg prefilled syringes; do not confuse this formulation with extended-release aripiprazole (Abilify Maintena; available in 300- and 400-mg vials and prefilled syringes) or the immediate-release aripiprazole formulation (9.75 mg/vial) used for agitation associated with schizophrenia and bipolar mania.1 118 119

Must be administered by a healthcare professional.119

Available as kits containing extended-release aripiprazole lauroxil injectable suspension in prefilled syringes and safety needles for IM injection.119 Prior to use, tap the prefilled syringe ≥10 times to dislodge any material that may have settled, then shake vigorously for ≥30 seconds to ensure a uniform suspension.119 If not administered within 15 minutes, shake the syringe again for 30 seconds.119

Administer only by IM injection rapidly and continuously (i.e., within <10 seconds) into the deltoid (for 441-mg doses only) or gluteal muscle (for 441-, 662-, and 882-mg doses).119 Select needle based on injection site; use longer needles in patients with a larger amount of subcutaneous tissue overlaying the injection site muscle.119

Administer monthly; may administer the 882-mg dose monthly or every 6 weeks.119 Allow at least 14 days to elapse between doses.119

Dosage

Aripiprazole oral solution may be given at same dose on mg-per-mg basis as the tablet strengths of the drug up to a dose of 25 mg.1 However, if oral solution is used in patients receiving 30-mg tablets, use a dose of 25 mg of the oral solution.1

Dosing of aripiprazole orally disintegrating tablets is the same as for conventional tablets of the drug.1

Dosage of aripiprazole lauroxil expressed in terms of aripiprazole lauroxil.119

Extended-release aripiprazole lauroxil (Aristada) dosages of 441, 662, and 882 mg IM once monthly correspond to extended-release aripiprazole (Abilify Maintena) dosages of 300, 450, and 600 mg IM once monthly, respectively.119

If used with CYP3A4 inhibitors, CYP2D6 inhibitors, and/or CYP3A4 inducers, dosage adjustment may be required.1 (See Interactions.)

Pediatric Patients

Schizophrenia
Oral

Adolescents ≥13 years of age: Recommended target dosage for acute treatment is 10 mg once daily.1 Therapy has been initiated at 2 mg once daily, with subsequent titration to 5 mg once daily after 2 days and to 10 mg once daily after 2 additional days.1 75 91

Subsequent dosage increases should be made in 5-mg, once-daily increments.1

Dosages of 10 and 30 mg once daily evaluated in clinical trials; the 30-mg daily dosage was not more effective than the 10-mg daily dosage.1 75 91

Although efficacy as maintenance treatment not systematically evaluated in adolescents with schizophrenia, the manufacturer states that such efficacy can be extrapolated from adult data in addition to comparisons of aripiprazole pharmacokinetic parameters in adult and pediatric patients.1 Periodically reassess need for continued therapy.1 (See Pediatric Use under Cautions.)

Bipolar Disorder
Manic or Mixed Episodes: Monotherapy or Combination Therapy
Oral

Children and adolescents ≥10 years of age: Target dosage for acute treatment is 10 mg once daily.1 Recommended initial dosage when given as monotherapy is 2 mg once daily, with subsequent titration to 5 mg once daily after 2 days and to the target dosage of 10 mg once daily after 2 additional days.1

Recommended dosage when aripiprazole is given as adjunctive therapy with lithium or valproate is the same as that for monotherapy.1

Daily dosage may be increased, if necessary, in 5-mg increments.1 In pediatric clinical studies, dosages of 10 and 30 mg daily were effective.1

Irritability Associated with Autistic Disorder
Oral

Children and adolescents 6–17 years of age: Initially, 2 mg once daily, then increase dosage to 5 mg daily, with subsequent increases to 10 or 15 mg daily, if necessary.1 Increase dosage gradually, at intervals of ≥1 week.1 Efficacy established within a dosage range of 5–15 mg daily in clinical studies.1 109 110

Periodically reassess need for continued therapy.1

Tourette's Syndrome
Oral

Children and adolescents 6–18 years of age weighing <50 kg: Initially, 2 mg once daily for 2 days, then increase dosage to 5 mg once daily.1 If optimal control of tics not achieved, may increase dosage to 10 mg once daily.1 Adjust dosage gradually at intervals of ≥1 week.1

Children and adolescents 6–18 years of age weighing ≥50 kg: Initially, 2 mg once daily for 2 days, then increase to 5 mg once daily for 5 days, with a recommended target dosage of 10 mg once daily on day 8.1 If optimal control of tics not achieved, may increase dosage up to 20 mg once daily.1 Adjust dosage gradually in increments of 5 mg daily at intervals of ≥1 week.1

Periodically reassess need for continued maintenance therapy.1

Adults

Schizophrenia
Oral

Initial and target dosage for acute treatment is 10 or 15 mg once daily.1

Dosages ranging from 10–30 mg once daily were effective in clinical trials; dosages exceeding 10–15 mg daily did not result in greater efficacy.1

Adjust dosage at intervals of ≥2 weeks, the time needed to achieve steady-state concentrations.1

Efficacy as maintenance therapy for ≤26 weeks has been demonstrated;1 other clinical experience indicates may be effective for up to 52 weeks.2 9 10 Optimum duration of therapy is not known, but maintenance therapy with antipsychotics is well established.1 28

Periodically reassess need for continued therapy.1

In patients with remitted first or multiple episodes, APA recommends either indefinite maintenance therapy or gradual discontinuance of the antipsychotic with close follow-up and a plan to reinstitute treatment upon symptom recurrence.28 Consider antipsychotic therapy discontinuance only after ≥1 year of symptom remission or optimal response while taking antipsychotic.28 Indefinite maintenance treatment is recommended if multiple previous psychotic episodes or 2 episodes within 5 years.28

IM, Extended-release Aripiprazole (Abilify Maintena)

For patients naive to aripiprazole, establish tolerability with oral aripiprazole prior to initiating extended-release IM aripiprazole therapy; may take up to 2 weeks to fully assess tolerability due to the half-life of oral aripiprazole.118

Usual initial and maintenance dosage: 400 mg IM every month.118 May reduce dosage to 300 mg every month in patients experiencing adverse effects.118

Administer oral aripiprazole 10–20 mg daily (or another oral antipsychotic agent in patients already stable on another oral antipsychotic and known to tolerate aripiprazole) with the first extended-release IM aripiprazole injection and continue oral therapy for 14 days thereafter to ensure adequate therapeutic plasma concentrations are maintained.118

If a dose of extended-release aripiprazole injection is missed, administer the next dose as soon as possible.118 Supplementation with oral aripiprazole may be required depending on the time elapsed (see Table 1).118

Table 1. Recommended Oral Aripiprazole Supplementation Following Missed Doses of Extended-release Aripiprazole Injection118

Dose Missed

No Oral Supplementation Required

Supplementation with Oral Aripiprazole for 14 Days Required with Next IM Dose

2nd or 3rd IM dose

≤5 weeks since last injection

>5 weeks since last injection

4th or subsequent IM doses

≤6 weeks since last injection

>6 weeks since last injection

IM, Extended-release Aripiprazole Lauroxil (Aristada)

For patients naive to aripiprazole, establish tolerability with oral aripiprazole prior to initiating extended-release IM aripiprazole lauroxil therapy; may take up to 2 weeks to fully assess tolerability due to the half-life of oral aripiprazole.119

Depending on individual patient's needs, may initiate therapy at a dosage of 441, 662, or 882 mg every month or 882 mg every 6 weeks by IM injection.119

Administer oral aripiprazole daily with the first IM aripiprazole lauroxil injection and continue oral aripiprazole therapy for 21 days thereafter.119

For patients established on oral aripiprazole 10 mg daily, recommended IM dosage of aripiprazole lauroxil is 441 mg every month.119

For patients established on oral aripiprazole 15 mg daily, recommended IM dosage of aripiprazole lauroxil is 662 mg every month.119

For patients established on oral aripiprazole ≥20 mg daily, recommended IM dosage of aripiprazole lauroxil is 882 mg every month.119

Adjust dosage as needed.119 Consider pharmacokinetics and prolonged-release characteristics of extended-release aripiprazole lauroxil injection when adjusting dose and dosing interval.119

If a dose is missed, administer the next dose as soon as possible.119 Supplementation with oral aripiprazole may be required depending on the dosage and the time elapsed (see Table 2).119

Dosage of oral aripiprazole supplementation should be same as when patient began extended-release aripiprazole lauroxil therapy.119

Table 2. Recommended Oral Aripiprazole Supplementation Following Missed Doses of Aripiprazole Lauroxil Injection119

Dosage of Patient's Last Injection

No Oral Supplementation Required

Supplement with Oral Aripiprazole for 7 Days

Supplement with Oral Aripiprazole for 21 Days

441 mg monthly

≤6 weeks since last injection

>6 and ≤7 weeks since last injection

>7 weeks since last injection

662 mg monthly

≤8 weeks since last injection

>8 and ≤12 weeks since last injection

>12 weeks since last injection

882 mg monthly

≤8 weeks since last injection

>8 and ≤12 weeks since last injection

>12 weeks since last injection

882 mg every 6 weeks

≤8 weeks since last injection

>8 and ≤12 weeks since last injection

>12 weeks since last injection

Bipolar Disorder
Manic or Mixed Episodes: Monotherapy or Combination Therapy
Oral

Monotherapy: Initially, 15 mg once daily.1

Adjunctive therapy to lithium or valproate: Initial dosage of 10–15 mg once daily.1

Recommended target dosage is 15 mg once daily whether the drug is given as monotherapy or as adjunctive therapy with lithium or valproate.1 Based on patient response, may increase dosage to 30 mg once daily.1

Safety of dosages >30 mg daily not established.1

Major Depressive Disorder
Oral

Initially, 2–5 mg once daily as adjunctive acute therapy.1

Gradually adjust dosage in increments of ≤5 mg daily at ≥1-week intervals; the recommended dosage is 5–10 mg once daily.1 Dosages of 2–15 mg daily were effective in clinical trials.1

Periodically reassess need for continued therapy.1

Manufacturer does not recommend aripiprazole dosage adjustment when administered as adjunctive therapy for major depressive disorder concurrently with CYP2D6 inhibitors.1 (See Interactions.)

Acute Agitation in Schizophrenia and Bipolar Mania
IM, Immediate-release Aripiprazole

Initially, 9.75 mg as a single dose.1 Consider lower dose of 5.25 mg when clinically warranted.1

In clinical trials, efficacy was demonstrated with doses of 5.25–15 mg.1 86 87 88 Additional benefit not demonstrated with 15-mg dose compared with 9.75-mg dose.1

Efficacy of repeated doses not systematically evaluated.1 If agitation persists following the initial dose, may administer subsequent doses up to a cumulative daily dose of 30 mg.1 Safety of total doses >30 mg daily or administration more frequently than every 2 hours not systematically evaluated in controlled trials.1

If continued aripiprazole therapy is clinically indicated, oral therapy should replace IM therapy as soon as possible.1

Prescribing Limits

Pediatric Patients

Schizophrenia
Oral

Safety and efficacy of dosages >30 mg daily not established.1 91

Bipolar Disorder
Manic or Mixed Episodes
Oral

Safety and efficacy of dosages >30 mg daily not established.1

Irritability Associated with Autistic Disorder
Oral

Safety and efficacy of dosages >15 mg daily not established.1

Tourette's Syndrome
Oral

Weight <50 kg: Maximum 10 mg daily.1

Weight ≥50 kg: Maximum 20 mg daily.1

Adults

Schizophrenia
Oral

Safety and efficacy of dosages >30 mg daily not established.1

IM, Extended-release Aripiprazole (Abilify Maintena)

Safety and efficacy of dosages >400 mg every month not established.118

IM, Extended-release Aripiprazole Lauroxil (Aristada)

Safety and efficacy of dosages >882 mg every month not established.119

Bipolar Disorder
Manic or Mixed Episodes
Oral

Safety and efficacy of dosages >30 mg daily not established.1

Adjunctive Therapy of Major Depressive Disorder
Oral

Safety and efficacy of dosages >15 mg daily not established.1

Acute Agitation in Schizophrenia and Bipolar Mania
IM

Safety of total dosages >30 mg daily or IM doses given more frequently than every 2 hours not established.1

Special Populations

Hepatic Impairment

Dosage adjustment not required.1 95 118 119

Renal Impairment

Dosage adjustment not required.1 95 118 119

Geriatric Patients

Dosage adjustment not required.1 118 119

Gender, Race, or Smoking Status

Dosage adjustment not required.1 118 119

Poor CYP2D6 Metabolizer Phenotype

For dosage adjustments related to CYP-mediated interactions in populations other than patients with poor CYP2D6 metabolizer phenotype, see Interactions.

Oral Aripiprazole

Reduce oral dosage to 50% of the usual dosage; dosage adjustment not required when used as adjunctive treatment of major depressive disorder.1

If patients who are poor CYP2D6 metabolizers are concomitantly receiving a potent CYP3A4 inhibitor, reduce oral aripiprazole dosage to 25% of the usual dosage.1 (See Interactions.)

Extended-release IM Aripiprazole Injection (Abilify Maintena)

Reduce dosage to 300 mg every month.118

If patients who are poor CYP2D6 metabolizers are concomitantly receiving a potent CYP3A4 inhibitor, reduce dosage of extended-release IM aripiprazole injection to 200 mg every month.118 Dosage adjustment not required for concomitant use <2 weeks.118 (See Interactions.)

Extended-release IM Aripiprazole Lauroxil Injection (Aristada)

Reduce dosage based on patient's established oral dosage.119

If patients who are poor CYP2D6 metabolizers are concomitantly receiving a potent CYP3A4 inhibitor, reduce dosage of extended-release IM aripiprazole lauroxil injection from 662 or 882 mg to 441 mg every month.119 Dosage adjustment not necessary in patients already receiving 441 mg every month, if tolerated.119 Dosage adjustment not required for concomitant use <2 weeks.119 (See Interactions.)

No further dosage adjustment required in patients who are poor CYP2D6 metabolizers receiving a concomitant potent CYP2D6 inhibitor.119 (See Interactions.)

Cautions for Aripiprazole

Contraindications

  • Known hypersensitivity to aripiprazole; hypersensitivity reactions have ranged from pruritus/urticaria to anaphylaxis.1 118 119 (See Sensitivity Reactions under Cautions.)

Warnings/Precautions

Warnings

Increased Mortality in Geriatric Patients with Dementia-related Psychosis

Increased risk of death with use of either conventional (first-generation) or atypical (second-generation) antipsychotics in geriatric patients with dementia-related psychosis.1 28 73 113 114 118 119

Antipsychotic agents, including aripiprazole, are not approved for the treatment of dementia-related psychosis.1 73 113 118 119 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning, see Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis under Cautions, and see Dysphagia under Cautions.)

Worsening of Depression and Suicidality Risk

Possible worsening of depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior in both adult and pediatric patients with major depressive disorder, whether or not they are taking antidepressants; may persist until clinically important remission occurs.1 76 77 78 79 (See Boxed Warning and also see Pediatric Use under Cautions.) However, suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide.1 76 77 78

Appropriately monitor and closely observe patients receiving aripiprazole for any reason, particularly during initiation of therapy (i.e., the first few months) and during periods of dosage adjustments.1 76 77 78

Anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and/or mania may be precursors to emerging suicidality.1 77 78 Consider changing or discontinuing therapy in patients whose depression is persistently worse or in those with emerging suicidality or symptoms that might be precursors to worsening depression or suicidality, particularly if severe, abrupt in onset, or not part of patient’s presenting symptoms.1 76 77 78

Prescribe in smallest quantity consistent with good patient management to reduce risk of overdosage.1 77

Sensitivity Reactions

Allergic and sensitivity reactions (e.g., anaphylactic reaction, angioedema, laryngospasm, pruritus/urticaria, photosensitivity, rash, oropharyngeal spasm) reported in aripiprazole-treated patients.1 118 119 (See Contraindications under Cautions.)

Other Warnings and Precautions

Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis

Increased incidence of adverse cerebrovascular events (cerebrovascular accidents and TIAs), including fatalities, observed in geriatric patients with dementia-related psychosis treated with aripiprazole in several placebo-controlled studies.1 118 Aripiprazole is not approved for the treatment of patients with dementia-related psychosis.1 118 119 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning.)

Impulse Control/Compulsive Behaviors

Serious impulse-control and compulsive behaviors, particularly pathological gambling, reported in adult and pediatric patients treated with aripiprazole.123 132 134 135 136 137 138 In May 2016, FDA reported that 184 cases of impulse-control problems associated with aripiprazole therapy had been identified since November 2002; 89% of the cases involved pathological gambling.123 Other impulse-control and compulsive behaviors (e.g., compulsive or binge eating, compulsive spending or shopping, compulsive sexual behaviors) reported less frequently.123 136 138 Most of the patients had no history of compulsive behaviors and experienced the uncontrollable urges only after beginning aripiprazole treatment.123 137 These urges stopped within days to weeks following aripiprazole dosage reduction or discontinuance; recurrence of compulsive behaviors following rechallenge reported.123 134 136 137 138

Advise patients and caregivers of the risk of uncontrollable urges with aripiprazole and specifically ask patients whether they have developed any new or increased urges while receiving the drug.123 If an aripiprazole-treated patient develops new or increased impulsive or compulsive behaviors, consider reducing the dosage or discontinuing the drug.123 137 (See Advice to Patients.)

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS), a potentially fatal syndrome characterized by hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability, reported with antipsychotic agents, including some rare cases in patients treated with aripiprazole.1 99 100 101 118 119

Immediately discontinue therapy and initiate supportive and symptomatic treatment if NMS occurs.1 118 119 Careful monitoring recommended if therapy is reinstituted following recovery; the risk that NMS can recur must be considered.1 118 119

Tardive Dyskinesia

Tardive dyskinesia, a syndrome of potentially irreversible, involuntary dyskinetic movements, reported with use of antipsychotic agents, including aripiprazole.1 96 97 118 119

Reserve long-term antipsychotic treatment for patients with chronic illness known to respond to antipsychotic agents, and for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate.1 118 119 In patients requiring chronic treatment, use smallest dosage and shortest duration of treatment producing a satisfactory clinical response; periodically reassess need for continued therapy.1 118 119

APA recommends assessing patients receiving atypical antipsychotic agents for abnormal involuntary movements every 12 months; for patients at increased risk for tardive dyskinesia, assess every 6 months.28 Consider discontinuance of aripiprazole if signs and symptoms of tardive dyskinesia appear.1 118 119 However, some patients may require treatment despite the presence of the syndrome.1 118 119

Metabolic Changes

Atypical antipsychotic agents are associated with metabolic changes, including hyperglycemia and diabetes mellitus, dyslipidemia, and weight gain.1 118 119 While all atypical antipsychotics produce some metabolic changes, each drug has its own specific risk profile.1 118 119 (See Hyperglycemia and Diabetes Mellitus, see Dyslipidemia, and also see Weight Gain under Cautions.)

Hyperglycemia and Diabetes Mellitus

Hyperglycemia, sometimes severe and associated with ketoacidosis, hyperosmolar coma, or death, reported in patients receiving atypical antipsychotic agents.1 In short- and longer-term clinical studies in adult and pediatric patients, clinically important differences between oral aripiprazole and placebo in mean change from baseline to end point in serum glucose concentrations not observed.1

Periodically monitor patients with an established diagnosis of diabetes mellitus for worsening of glucose control and perform fasting glucose testing at baseline and periodically in patients with risk factors for diabetes (e.g., obesity, family history of diabetes).1 If manifestations of hyperglycemia occur in any aripiprazole-treated patient, perform fasting blood glucose testing.1 (See Advice to Patients.)

Some patients who developed hyperglycemia while receiving an atypical antipsychotic have required continuance of antidiabetic treatment despite discontinuance of the atypical antipsychotic; in other patients, hyperglycemia resolved with discontinuance of the antipsychotic.1

Dyslipidemia

Undesirable changes in lipid parameters observed in patients treated with some atypical antipsychotics.1 However, aripiprazole generally does not appear to adversely affect the lipid profile.1

Weight Gain

Weight gain observed with atypical antipsychotic therapy.1 Monitoring of weight recommended during aripiprazole therapy.1 (See Hyperglycemia and Diabetes Mellitus under Cautions.)

Orthostatic Hypotension

Risk of orthostatic hypotension associated with adverse effects, including postural dizziness, syncope, and tachycardia, perhaps because of aripiprazole's α1-adrenergic blocking activity.1 118 119 Risk generally appears greatest during initiation of therapy and dosage titration.119

Use with caution in patients with known cardiovascular or cerebrovascular disease and/or conditions that would predispose them to hypotension (e.g., dehydration, hypovolemia, concomitant antihypertensive therapy) and in antipsychotic-naive patients.1 119 In such patients who are receiving extended-release IM aripiprazole lauroxil therapy, consider a lower initial dosage and monitoring of orthostatic vital signs.119

If parenteral benzodiazepine therapy is necessary in patients receiving short-acting IM aripiprazole, monitor patients for possible excessive sedation and orthostatic hypotension.1 (See Specific Drugs under Interactions.)

Leukopenia, Neutropenia, and Agranulocytosis

Leukopenia and neutropenia temporally related to antipsychotic agents, including aripiprazole, reported during clinical trial and/or postmarketing experience.1 102 103 118 119 Agranulocytosis also reported.1 118 119

Possible risk factors for leukopenia and neutropenia include preexisting low WBC count and a history of drug-induced leukopenia or neutropenia.1 102 103 118 119 Monitor CBC frequently during the first few months of therapy in patients with such risk factors.1 118 119 Discontinue aripiprazole at the first sign of a decline in WBC count in the absence of other causative factors.1 118 119

Carefully monitor patients with neutropenia for signs and symptoms of infection (e.g., fever) and treat promptly if they occur.1 118 119 Discontinue aripiprazole if severe neutropenia (ANC <1000/mm3) occurs; monitor WBC until recovery occurs.1 118 119

Seizures

Seizures/convulsions reported in 0.1% of adult and pediatric patients (6–18 years of age) treated with oral aripiprazole and in 0.2% of adults treated with short-acting IM aripiprazole.1

Use with caution in patients with a history of seizures or with conditions known to lower the seizure threshold; such conditions may be more prevalent in patients ≥65 years of age.1 118 119

Cognitive and Motor Impairment

Judgment, thinking, or motor skills may be impaired.1 118 119

Somnolence (including sedation) reported in 11 and 9% of adults treated with oral or short-acting parenteral aripiprazole, respectively, compared with 6% of those receiving placebo in short-term clinical trials.1 Somnolence (including sedation) reported in 24% of pediatric patients (6–17 years of age) receiving aripiprazole compared with 6% of those receiving placebo.1 (See Advice to Patients.)

Body Temperature Regulation

Antipsychotic agents may disrupt ability to reduce core body temperature.1 118 119

Use appropriate caution in patients exposed to conditions that may contribute to an elevation in core body temperature (e.g., dehydration, extreme heat, strenuous exercise, concomitant use of anticholinergic agents).1 118 119

Suicide

Attendant risk with psychotic illnesses, bipolar disorder, and major depressive disorder; closely supervise high-risk patients.1 Prescribe in the smallest quantity consistent with good patient management to reduce the risk of overdosage.1

Dysphagia

Esophageal dysmotility and aspiration associated with the use of antipsychotic agents, including aripiprazole.1 118 119

Aspiration pneumonia is a common cause of morbidity and mortality in geriatric patients, particularly in those with advanced Alzheimer’s dementia.1 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning.) Use with caution in patients at risk for aspiration pneumonia.1 118 119

Phenylketonuria

Each 10- or 15-mg Abilify Discmelt orally disintegrating tablet contains aspartame (NutraSweet), which is metabolized in the GI tract to provide about 1.12 or 1.68 mg of phenylalanine, respectively.1 80 81 82 83 84

Specific Populations

Pregnancy

Category C.1

Risk for extrapyramidal and/or withdrawal symptoms (e.g., agitation, hypertonia, hypotonia, tardive dyskinetic-like symptoms, tremor, somnolence, respiratory distress, feeding disorder) in neonates exposed to antipsychotic agents during the third trimester; monitor neonates exhibiting such symptoms.1 106 107 108 111 118 119 Symptoms varied in severity; some neonates recovered within hours to days without specific treatment, while others have required intensive care unit support and prolonged hospitalization.1 106 107 108 118 119

National Pregnancy Registry for Atypical Antipsychotics: 866-961-2388 and .1 118 119

Lactation

Distributed into milk in humans.1 111 118 119 However, data are insufficient to determine the amount present in human milk, the effects of the drug on breast-fed infants, or the effects on milk production.118 119

Because of the potential for serious adverse reactions to aripiprazole in nursing infants, the manufacturer of aripiprazole tablets, oral solution, and the short-acting IM injection states that a decision should be made whether to discontinue nursing or the drug, taking into consideration the importance of the drug to the woman.1

The manufacturers of extended-release IM formulations of aripiprazole state that the benefit of aripiprazole therapy to the woman as well as the benefits of breast-feeding to the infant should be weighed against the potential risk to the infant from exposure to the drug or from the underlying maternal condition.118 119

Pediatric Use

Safety and efficacy of oral aripiprazole not established in pediatric patients with major depressive disorder.1 Safety and efficacy of immediate-release IM aripiprazole not established for agitation associated with schizophrenia or bipolar mania in pediatric patients.1 Safety and efficacy of extended-release IM aripiprazole and aripiprazole lauroxil not evaluated in pediatric patients <18 years of age.118 119

Safety and efficacy of oral aripiprazole for acute management of schizophrenia in pediatric patients 13–17 years of age established in a placebo-controlled study of 6 weeks' duration.1 91 Efficacy for maintenance treatment not established, but can be extrapolated from adult data and pharmacokinetic comparisons between adult and pediatric populations.1

Safety and efficacy of oral aripiprazole monotherapy for acute management of bipolar mania in pediatric patients 10–17 years of age established in a placebo-controlled study of 4 weeks' duration.1

Efficacy of oral aripiprazole as adjunctive therapy to lithium or valproate for management of manic or mixed episodes associated with bipolar disorder in pediatric patients not systematically evaluated.1 However, efficacy can be extrapolated from adult data and pharmacokinetic comparisons between adult and pediatric populations.1

Safety and efficacy of oral aripiprazole for treatment of irritability associated with autistic disorder in pediatric patients 6–17 years of age established in 2 placebo-controlled clinical studies of 8 weeks’ duration.1 109 110 Efficacy as maintenance treatment not established in a longer-term, placebo-controlled relapse prevention trial in pediatric patients 6–17 years of age.1 133

Safety and efficacy of oral aripiprazole for treatment of Tourette's syndrome in pediatric patients 6–18 years of age established in 2 short-term, placebo-controlled trials of 8 and 10 weeks' duration.1 Efficacy as maintenance therapy not systematically evaluated.1

Mean weight gain of 1.6 kg reported in pediatric patients with schizophrenia or bipolar disorder receiving oral aripiprazole compared with a gain of 0.3 kg in those receiving placebo in 2 short-term studies; from baseline to 24 weeks, mean weight gain was 5.8 kg in aripiprazole-treated patients compared with 1.4 kg in placebo recipients.1 Similar weight gain observed in short-term studies in pediatric patients with Tourette's syndrome or with irritability associated with autistic disorder.1

FDA warns that a greater risk of suicidal thinking or behavior (suicidality) occurred during first few months of antidepressant treatment compared with placebo in children and adolescents with major depressive disorder, obsessive-compulsive disorder (OCD), or other psychiatric disorders based on pooled analyses of 24 short-term, placebo-controlled trials of 9 antidepressant drugs (SSRIs and others).1 77 However, a later meta-analysis of 27 placebo-controlled trials of 9 antidepressants (SSRIs and others) in patients <19 years of age with major depressive disorder, OCD, or non-OCD anxiety disorders suggests that the benefits of antidepressant therapy in treating these conditions may outweigh the risks of suicidal behavior or suicidal ideation.79 No suicides occurred in these pediatric trials.1 77 79

Geriatric Use

Insufficient experience with oral, short-acting IM, and extended-release IM formulations of aripiprazole in patients ≥65 years of age to determine whether they respond differently than younger adults.1 118 Manufacturer states that dosage adjustment of oral and IM aripiprazole formulations based on age alone in geriatric patients is not necessary.1 118

Safety and efficacy of extended-release IM aripiprazole lauroxil not evaluated in patients >65 years of age; manufacturer makes no specific dosage recommendations for geriatric patients.119

Geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death;1 28 73 113 114 118 119 increased incidence of cerebrovascular events also observed with aripiprazole.1 Aripiprazole is not approved for the treatment of patients with dementia-related psychosis.1 118 119 (See Boxed Warning, see Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis under Cautions, and see Dysphagia under Cautions.)

In pooled data analyses, a reduced risk of suicidality was observed in adults ≥65 years of age with antidepressant therapy compared with placebo.1 76 77 (See Boxed Warning and also see Worsening of Depression and Suicidality Risk under Cautions.)

Poor CYP2D6 Metabolizers

Because higher plasma concentrations of aripiprazole are likely, dosage adjustment recommended for patients known to be poor metabolizers of CYP2D6.1 118 119 Approximately 8% of Caucasians and 3–8% of Blacks/African Americans cannot metabolize CYP2D6 substrates and are classified as poor CYP2D6 metabolizers.1 118 119 (See Poor CYP2D6 Metabolizer Phenotype under Dosage and Administration.)

Common Adverse Effects

Oral aripiprazole (adults): Nausea,1 vomiting,1 constipation,1 sedation,1 fatigue,1 headache,1 dizziness,1 akathisia,1 anxiety,1 insomnia,1 restlessness,1 tremor,1 extrapyramidal disorder,1 blurred vision.1

Oral aripiprazole (pediatric patients): Somnolence or sedation,1 headache,1 nausea,1 vomiting,1 tremor,1 extrapyramidal disorder,1 increased appetite,1 fatigue,1 insomnia,1 akathisia,1 nasopharyngitis,1 blurred vision,1 salivary hypersecretion,1 dizziness,1 increased weight.1

IM aripiprazole, immediate-release: Nausea.1

IM aripiprazole, extended-release: Increased weight,118 akathisia,118 injection site pain,118 sedation.118

IM aripiprazole lauroxil, extended-release: Akathisia,119 122 extrapyramidal symptoms (e.g., parkinsonism, dystonia),119 injection site reactions (e.g., pain).119 122

Interactions for Aripiprazole

Aripiprazole is extensively metabolized in the liver principally via dehydrogenation, hydroxylation, and N-dealkylation by CYP2D6 and CYP3A4.1

Drugs Affecting Hepatic Microsomal Enzymes

Potent CYP3A4 inhibitors and/or potent CYP2D6 inhibitors: Potential pharmacokinetic interaction.1

Combination of potent, moderate, and weak CYP3A4 and CYP2D6 inhibitors (e.g., potent CYP3A4 inhibitor with moderate CYP2D6 inhibitor; moderate CYP3A4 inhibitor with moderate CYP2D6 inhibitor): Potential pharmacokinetic interaction.1

Potent CYP3A4 inducers: Decreased systemic exposure to aripiprazole.1

Inhibitors or inducers of CYP isoenzymes 1A1, 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, or 2E1: Pharmacokinetic interaction unlikely.1

Concomitant Drug

Recommended Dosage Adjustment

Potent CYP3A4 inhibitors

Oral aripiprazole: Reduce aripiprazole dosage to 50% of usual dosage; dosage adjustment not required when used as adjunctive treatment of major depressive disorder.1 Increase back to original dosage when the CYP3A4 inhibitor is discontinued.1 Further reduce dosage in patients with poor CYP2D6 metabolizer phenotype.1 (See Poor CYP2D6 Metabolizer Phenotype under Dosage and Administration.)

Extended-release IM aripiprazole injection (Abilify Maintena): Dosage adjustment not necessary if potent CYP3A4 inhibitor is added for <2 weeks.118 For concomitant therapy >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg every month.118 Further dosage reduction in patients with poor CYP2D6 metabolizer phenotype may be necessary.118 (See Poor CYP2D6 Metabolizer Phenotype under Dosage and Administration.)

Extended-release IM aripiprazole lauroxil injection (Aristada): Dosage adjustment not necessary if potent CYP3A4 inhibitor is added for <2 weeks.119 For concomitant therapy >14 days, reduce aripiprazole lauroxil dosage to next available lower strength.119 Dosage reduction not necessary in patients receiving the 441-mg dosage, if tolerated.119 Reduce 882 mg every 6 weeks to 441 mg every 4 weeks.119 Further dosage reduction in patients with poor CYP2D6 metabolizer phenotype may be necessary.119 (See Poor CYP2D6 Metabolizer Phenotype under Dosage and Administration.)

Potent CYP2D6 inhibitors

Oral aripiprazole: Reduce aripiprazole dosage to 50% of usual dosage; dosage adjustment not required when used as adjunctive treatment of major depressive disorder.1 Increase back to original dosage when the CYP2D6 inhibitor is discontinued.1

Extended-release IM aripiprazole injection (Abilify Maintena): Dosage adjustment not necessary if potent CYP2D6 inhibitor is added for <2 weeks.118 For concomitant therapy >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg every month.118

Extended-release IM aripiprazole lauroxil injection (Aristada): Dosage adjustment not necessary if potent CYP2D6 inhibitor is added for <2 weeks.119 For concomitant therapy >14 days, reduce aripiprazole lauroxil dosage to next available lower strength.119 Dosage reduction not necessary in patients receiving 441-mg dosage, if tolerated.119 Reduce 882 mg every 6 weeks to 441 mg every 4 weeks.119

Potent CYP3A4 inhibitors and potent CYP2D6 inhibitors

Oral aripiprazole: Reduce aripiprazole dosage to 25% of usual dosage; dosage adjustment not required when used as adjunctive treatment of major depressive disorder.1 Increase back to original dosage when the CYP3A4 and/or CYP2D6 inhibitor is discontinued.1

Extended-release IM aripiprazole injection (Abilify Maintena): Reduce aripiprazole dosage from 400 to 200 mg every month, or from 300 to 160 mg every month for concomitant therapy >14 days.118

Extended-release IM aripiprazole lauroxil injection (Aristada): Dosage adjustment not required for patients tolerating the 441-mg dosage; however, avoid concomitant use of potent CYP2D6 inhibitors and potent CYP3A4 inhibitors for >2 weeks in patients taking the 662- or 882-mg dosage.119 Dosage adjustment not required for concomitant use <2 weeks.119

Combination of potent, moderate, or weak CYP3A4 and CYP2D6 inhibitors (e.g., potent CYP3A4 inhibitor with moderate CYP2D6 inhibitor; moderate CYP3A4 inhibitor with moderate CYP2D6 inhibitor)

Oral aripiprazole: Reduce aripiprazole dosage to 25% of usual dosage, then adjust dosage to achieve clinical response.1 Increase back to original dosage when the CYP3A4 and/or CYP2D6 inhibitor is discontinued.1

Potent CYP3A4 inducers

Oral aripiprazole: Double dosage of aripiprazole over 1–2 weeks of concomitant therapy.1 Reduce back to original dosage over 1–2 weeks when the CYP3A4 inducer is discontinued.1

Extended-release IM aripiprazole injection (Abilify Maintena): Avoid use of potent CYP3A4 inducers for >14 days.118

Extended-release IM aripiprazole lauroxil injection (Aristada): Increase monthly aripiprazole dosage from 441 to 662 mg when used concomitantly for >2 weeks; dosage adjustment not required in patients receiving 662 or 882 mg every month.119 Dosage adjustment not required for concomitant use <2 weeks.119

Substrates of Hepatic Microsomal Enzymes

Substrates of CYP isoenzymes 2C9, 2C19, 2D6, and 3A4: Clinically important pharmacokinetic interaction unlikely; dosage adjustment not necessary.1 118 119

Specific Drugs

Drug

Interaction

Comments

Alcohol

Possible additive CNS effects118

Oral aripiprazole: No clinically important effects on gross motor skills or stimulus response118

Extended-release IM aripiprazole (Abilify Maintena): Manufacturer recommends avoiding concomitant use118

Specific recommendations concerning alcohol use not provided in the prescribing information for other oral and parenteral formulations of aripiprazole (e.g., Abilify, Aristada)1 119

Anticholinergic agents

Possible disruption of body temperature regulation1 118 119

Use with caution1 118 119

Benzodiazepines (e.g., lorazepam)

Possible increased sedative and orthostatic hypotensive effects1 118 119

Lorazepam: No clinically important effects on pharmacokinetics of either aripiprazole or lorazepam1 118 119

If concomitant use of aripiprazole and benzodiazepines considered necessary, monitor for excessive sedation and orthostatic hypotension; adjust dosages if needed1 118 119

Lorazepam: Routine dosage adjustment of aripiprazole and lorazepam not necessary1 118

Carbamazepine

Carbamazepine (potent CYP3A4 inducer) decreased peak plasma concentrations and AUCs of aripiprazole and dehydro-aripiprazole1 105 118 119

Oral aripiprazole: Double aripiprazole dosage over 1–2 weeks when carbamazepine is added; decrease back to original dosage over 1–2 weeks when carbamazepine is discontinued1

Extended-release aripiprazole (Abilify Maintena): Avoid concomitant use >14 days118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, increase aripiprazole lauroxil dosage from 441 to 662 mg monthly; no dosage adjustment necessary for 662- or 882-mg dosages119

Clarithromycin

Clarithromycin (potent CYP3A4 inhibitor) may increase AUCs of aripiprazole and its active metabolite1

Reduce oral aripiprazole to 50% of usual dosage; if used in combination with potent CYP2D6 inhibitors, reduce oral aripiprazole dosage to 25% of usual dosage1

If used in combination with potent, moderate, and weak CYP3A4 and CYP2D6 inhibitors, initially reduce oral aripiprazole dosage to 25% of usual dosage then adjust dosage based on clinical response1

Dosage adjustment not necessary when aripiprazole used as adjunctive therapy for major depressive disorder1

Extended-release aripiprazole (Abilify Maintena): If used concomitantly >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg monthly;118 if used in combination with potent CYP2D6 inhibitors, reduce dosage from 400 to 200 mg or 300 to 160 mg monthly118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, reduce aripiprazole lauroxil dosage to next available lower strength; dosage reduction not necessary in patients tolerating 441-mg dosage.119 Reduce 882 mg every 6 weeks to 441 mg every 4 weeks.119 Avoid concomitant use of potent CYP3A4 inhibitors (e.g., clarithromycin) and potent CYP2D6 inhibitors for >2 weeks in patients taking the 662- or 882-mg dosages; no dosage adjustment necessary for 441-mg dosage, if tolerated119

Increase aripiprazole dosage when the CYP3A4 and/or CYP2D6 inhibitor is discontinued1

Dextromethorphan

No clinically important change in dextromethorphan (CYP2D6 and CYP3A4 substrate) pharmacokinetics observed1 118 119

Dextromethorphan dosage adjustment not necessary1 118 119

Escitalopram

No substantial effect on pharmacokinetics of escitalopram (CYP2C19 and CYP3A4 substrate)1 104

Escitalopram dosage adjustment not necessary1

Famotidine

Possible decreased peak concentration and AUC of aripiprazole; unlikely to be clinically important1

Aripiprazole dosage adjustment not necessary1

Fluoxetine

Fluoxetine (potent CYP2D6 inhibitor) expected to increase aripiprazole AUC1

Aripiprazole did not substantially affect fluoxetine pharmacokinetics1 104

Oral aripiprazole: Reduce aripiprazole to 50% of usual dosage; if used in combination with potent CYP3A4 inhibitors, reduce aripiprazole dosage to 25% of usual dosage; if used in combination with potent, moderate, or weak CYP3A4 inhibitors, reduce aripiprazole dosage to 25% of usual dosage then adjust to achieve clinical response; dosage adjustment not necessary when used as adjunctive therapy for major depressive disorder1

Extended-release aripiprazole (Abilify Maintena): If used concomitantly >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg monthly; in combination with potent CYP3A4 inhibitors, reduce dosage from 400 to 200 mg or 300 to 160 mg monthly118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, reduce aripiprazole lauroxil dosage to next available lower strength; no dosage adjustment necessary in patients tolerating 441-mg dosage; reduce 882 mg every 6 weeks to 441 mg every 4 weeks; dosage adjustment not necessary for concomitant use <2 weeks; avoid concomitant use of potent CYP2D6 inhibitors (e.g., fluoxetine) and potent CYP3A4 inhibitors for >2 weeks in patients taking the 662- or 882-mg dosage119

Increase aripiprazole dosage when the CYP2D6 and/or CYP3A4 inhibitor is discontinued1

Hypotensive agents

Possible additive hypotensive effects1 118 119

Use with caution; monitor BP and adjust dosage of antihypertensive agent(s), if necessary1 118 119

Itraconazole

Potent CYP3A4 inhibitors (e.g., itraconazole) may increase AUCs of aripiprazole and its active metabolite1

Reduce oral aripiprazole to 50% of usual dosage; if used in combination with potent CYP2D6 inhibitors, reduce oral aripiprazole dosage to 25% of usual dosage1

If used in combination with potent, moderate, and weak CYP3A4 and CYP2D6 inhibitors, initially reduce oral aripiprazole dosage to 25% of usual dosage then adjust dosage based on clinical response1

Dosage adjustment not necessary when aripiprazole used as adjunctive therapy for major depressive disorder1

Extended-release aripiprazole (Abilify Maintena): If used concomitantly >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg monthly; if used in combination with potent CYP2D6 inhibitors, reduce dosage from 400 to 200 mg or 300 to 160 mg monthly118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, reduce aripiprazole lauroxil dosage to next available lower strength; dosage reduction not necessary in patients tolerating 441-mg dosage.119 Reduce 882 mg every 6 weeks to 441 mg every 4 weeks.119 Avoid concomitant use of potent CYP3A4 inhibitors (e.g., itraconazole) and potent CYP2D6 inhibitors for >2 weeks in patients taking the 662- or 882-mg dosages; no dosage adjustment necessary for 441-mg dosage, if tolerated119

Increase aripiprazole dosage when the CYP3A4 and/or CYP2D6 inhibitor is discontinued1

Ketoconazole

Ketoconazole (potent CYP3A4 inhibitor) substantially increased AUCs of aripiprazole and its active metabolite1

Reduce oral aripiprazole to 50% of usual dosage; if used in combination with potent CYP2D6 inhibitors, reduce oral aripiprazole dosage to 25% of usual dosage1

If used in combination with potent, moderate, and weak CYP3A4 and CYP2D6 inhibitors, initially reduce oral aripiprazole dosage to 25% of usual dosage then adjust dosage based on clinical response1

Dosage adjustment not necessary when aripiprazole used as adjunctive therapy for major depressive disorder1

Extended-release aripiprazole (Abilify Maintena): If used concomitantly >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg monthly; if used in combination with potent CYP2D6 inhibitors, reduce dosage from 400 to 200 mg or 300 to 160 mg monthly118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, reduce aripiprazole lauroxil dosage to next available lower strength; dosage reduction not necessary in patients tolerating 441-mg dosage.119 Reduce 882 mg every 6 weeks to 441 mg every 4 weeks.119 Avoid concomitant use of potent CYP3A4 inhibitors (e.g., ketoconazole) and potent CYP2D6 inhibitors for >2 weeks in patients taking the 662- or 882-mg dosages; no dosage adjustment necessary for 441-mg dosage, if tolerated119

Increase aripiprazole dosage when the CYP3A4 and/or CYP2D6 inhibitor is discontinued1

Lamotrigine

Concomitant use with aripiprazole apparently well tolerated;92 pharmacokinetic interaction unlikely1 92

Lamotrigine dosage adjustment not necessary1 92

Lithium

Clinically important pharmacokinetic interaction unlikely1

Dosage adjustment of aripiprazole and lithium not necessary1

Omeprazole

No substantial effect on pharmacokinetics of omeprazole (CYP2C19 substrate)1

Omeprazole dosage adjustment not necessary1

Paroxetine

Paroxetine (potent CYP2D6 inhibitor) expected to increase aripiprazole AUC1

Aripiprazole did not substantially affect paroxetine pharmacokinetics1 104

Paroxetine dosage adjustment not necessary1 104

Oral aripiprazole: Reduce aripiprazole to 50% of usual dosage; if used in combination with potent CYP3A4 inhibitors, reduce aripiprazole dosage to 25% of usual dosage; if used in combination with potent, moderate, or weak CYP3A4 inhibitors, reduce aripiprazole dosage to 25% of usual dosage then adjust to achieve clinical response; dosage adjustment not necessary when used as adjunctive therapy for major depressive disorder1

Extended-release aripiprazole (Abilify Maintena): If used concomitantly >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg monthly; in combination with potent CYP3A4 inhibitors, reduce dosage from 400 to 200 mg or 300 to 160 mg monthly118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, reduce aripiprazole lauroxil dosage to next available lower strength; no dosage adjustment necessary in patients tolerating 441-mg dosage; reduce 882 mg every 6 weeks to 441 mg every 4 weeks; dosage adjustment not necessary for concomitant use <2 weeks; avoid concomitant use of potent CYP2D6 inhibitors (e.g., paroxetine) and potent CYP3A4 inhibitors for >2 weeks in patients taking the 662- or 882-mg dosage119

Increase aripiprazole dosage when the CYP2D6 and/or CYP3A4 inhibitor is discontinued1

Quinidine

Quinidine (potent CYP2D6 inhibitor) increased aripiprazole AUC but decreased AUC of dehydro-aripiprazole1

Oral aripiprazole: Reduce aripiprazole to 50% of usual dosage; if used in combination with potent CYP3A4 inhibitors, reduce aripiprazole dosage to 25% of usual dosage; if used in combination with potent, moderate, or weak CYP3A4 inhibitors, reduce aripiprazole dosage to 25% of usual dosage then adjust to achieve clinical response; dosage adjustment not necessary when used as adjunctive therapy for major depressive disorder1

Extended-release aripiprazole (Abilify Maintena): If used concomitantly >14 days, reduce aripiprazole dosage from 400 to 300 mg or from 300 to 200 mg monthly; in combination with potent CYP3A4 inhibitors, reduce dosage from 400 to 200 mg or 300 to 160 mg monthly118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, reduce aripiprazole lauroxil dosage to next available lower strength; no dosage adjustment necessary in patients tolerating 441-mg dosage; reduce 882 mg every 6 weeks to 441 mg every 4 weeks; dosage adjustment not necessary for concomitant use <2 weeks; avoid concomitant use of potent CYP2D6 inhibitors (e.g., quinidine) and potent CYP3A4 inhibitors for >2 weeks in patients taking the 662- or 882-mg dosage119

Increase aripiprazole dosage when the CYP2D6 and/or CYP3A4 inhibitor is discontinued1

Rifampin

Potent CYP3A4 inducers expected to decrease AUCs of aripiprazole and its active metabolite1

Oral aripiprazole: Double aripiprazole dosage over 1–2 weeks when rifampin is added; decrease back to original dosage over 1–2 weeks when rifampin is discontinued1

Extended-release aripiprazole (Abilify Maintena): Avoid concomitant use >14 days118

Extended-release aripiprazole lauroxil (Aristada): If used concomitantly >2 weeks, increase aripiprazole lauroxil dosage from 441 to 662 mg monthly; no dosage adjustment necessary for 662- or 882-mg dosages119

Sertraline

Aripiprazole did not substantially affect sertraline pharmacokinetics1 104 118 119

Dosage adjustment of aripiprazole and sertraline not necessary1 118 119

Valproate

Clinically important pharmacokinetic interaction unlikely1

Dosage adjustment of aripiprazole and valproate not necessary1

Venlafaxine

No effect on pharmacokinetics of venlafaxine (CYP2D6 substrate) or O-desmethylvenlafaxine1 104

Venlafaxine dosage adjustment not necessary1

Warfarin

No clinically important effect on warfarin (CYP2C9 and CYP2C19 substrate) pharmacokinetics1

Warfarin dosage adjustment not necessary1

Aripiprazole Pharmacokinetics

Absorption

Bioavailability

Absolute oral bioavailability of conventional tablets is 87%.1

Peak plasma concentrations achieved within 3–5 hours after oral administration of conventional tablets; steady-state concentrations of aripiprazole and dehydro-aripiprazole achieved within 14 days.1

Orally disintegrating tablets and conventional tablets are bioequivalent.1

Well absorbed when administered as oral solution; plasma aripiprazole concentrations are higher after administration of oral solution than conventional tablets at equivalent doses.1 (See Dosage under Dosage and Administration.)

Oral solution-to-tablet ratios of geometric mean maximum plasma concentrations and AUCs were 122 and 114%, respectively.1

Immediate-release IM aripiprazole (Abilify): Peak plasma concentrations following IM administration achieved within 1–3 hours and are 19% higher than those achieved following oral administration of conventional tablets.1 Absolute IM bioavailability of a 5-mg dose is 100%.1 Systemic exposure over 24 hours is similar following IM and oral administration; however, AUC was 90% higher within first 2 hours after IM than after oral tablet administration.1

Extended-release IM aripiprazole (Abilify Maintena): Peak plasma concentrations following multiple IM doses achieved within a median of 4 days with deltoid administration and 5–7 days with gluteal administration.118 Although single-dose IM administration into the deltoid results in 31% higher peak plasma concentrations compared with the gluteal site, extent of absorption similar for both injection sites.118 At steady state, AUCs and peak plasma concentrations similar for both deltoid and gluteal injection sites.118

Extended-release IM aripiprazole lauroxil (Aristada): Following IM administration, aripiprazole appears in systemic circulation in 5–6 days and is continually released for an additional 36 days.119 Plasma concentrations of aripiprazole increase with consecutive doses and reach steady-state concentrations following the fourth monthly injection.119 When administered with oral aripiprazole for 21 days following the first injection, therapeutic plasma concentrations of aripiprazole achieved within 4 days.119 IM injection into the deltoid and gluteal areas results in similar systemic exposures; these injection sites are interchangeable.119

Food

Administration of conventional tablets with a high-fat meal delayed rate but not extent of absorption.1

Distribution

Extent

Large volume of distribution following IV administration indicates extensive extravascular distribution.1

Distributed into milk.1 111 118 119

Plasma Protein Binding

Aripiprazole and its major metabolite, dehydro-aripiprazole, are >99% bound, principally to albumin.1

Elimination

Metabolism

Extensively metabolized in the liver principally via dehydrogenation, hydroxylation, and N-dealkylation by CYP2D6 and CYP3A4.1

Extended-release IM aripiprazole lauroxil (Aristada): Aripiprazole lauroxil is a prodrug of aripiprazole and is probably converted by enzyme-mediated hydrolysis to N-hydroxymethyl aripiprazole, which is then hydrolyzed to aripiprazole.119

Elimination Route

Following oral administration, approximately 18% and <1% excreted unchanged in feces and urine, respectively; IM administration is not expected to alter metabolic pathways.1

Half-life

Oral aripiprazole: 75 hours.1

Dehydro-aripiprazole: 94 hours.1

Extended-release aripiprazole (Abilify Maintena): Following multiple, once-monthly IM administration, about 30 days for the 300-mg dosage and 47 days for the 400-mg dosage.118

Extended-release aripiprazole lauroxil (Aristada) 441, 662, and 882 mg administered IM every 4 weeks: About 29–35 days.119

Special Populations

Pediatric patients 10–17 years of age: Pharmacokinetics similar to those in adults after correcting for body weight differences.1

Stability

Storage

Oral

Tablets

25°C (may be exposed to 15–30°C).1

Orally Disintegrating Tablets

25°C (may be exposed to 15–30°C).1

Oral Solution

25°C (may be exposed to 15–30°C).1 After opening, can use for up to 6 months (but not beyond expiration date).1

Parenteral

Immediate-release Aripiprazole Injection (e.g., Abilify)

25°C (may be exposed to 15–30°C).1 Store in original carton until time of use; protect from light.1 Discard any unused portion.1

Extended-release Aripiprazole (e.g., Abilify Maintena)

Prefilled dual-chamber syringe: <30°C.118 Do not freeze.118 Protect syringe from light; store in original package until time of use.118

Vial: 25°C (may be exposed to 15–30°C).118

Extended-release Aripiprazole Lauroxil (e.g., Aristada)

20–25°C (may be exposed to 15–30°C).119

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Drug Compatibility
Syringe Compatibility (Immediate-release Aripiprazole Injection [e.g., Abilify]) HID

Compatible

Lorazepam

Actions

  • Exact mechanism of action in schizophrenia, bipolar disorder, major depressive disorder, irritability associated with autistic disorder, Tourette's syndrome, and agitation associated with schizophrenia or bipolar mania has not been fully elucidated; may involve the drug’s activity at dopamine D2 and serotonin type 1 (5-HT1A) and type 2 (5-HT2A) receptors.1 2 3 4 5 6 7

  • Demonstrates partial agonist activity at D2 and 5-HT1A receptors and antagonist activity at 5-HT2A receptors.1 2 3 4 5 6 7 89 The major active metabolite, dehydro-aripiprazole, exhibits affinity for D2 receptors similar to that of the parent compound.1

  • Antagonism at other receptors (e.g., α1-adrenergic receptors, histamine H1 receptors) may contribute to other therapeutic and adverse effects (e.g., orthostatic hypotension, somnolence).1 89

Advice to Patients

  • Importance of providing copy of written patient information (medication guide) each time aripiprazole is dispensed.1 76 77 78 118 119 Importance of advising patients to read the patient information before taking aripiprazole and each time the prescription is refilled.1 76 118 119

  • Importance of advising patients and caregivers that geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death.1 28 73 98 113 118 119 Inform patients and caregivers that aripiprazole is not approved for treating geriatric patients with dementia-related psychosis.1 73 98 118 119

  • Risk of suicidality; importance of patients, family, and caregivers being alert to and immediately reporting emergence of suicidality, worsening depression, manic or hypomanic symptoms, irritability, agitation, or unusual changes in behavior, especially during the first few months of therapy or during periods of dosage adjustment.1 76 77 78

  • Risk of somnolence and impairment of judgment, thinking, or motor skills; avoid driving, operating machinery, or performing hazardous tasks until effects on the individual are known.1 118 119

  • Importance of avoiding alcohol during extended-release IM aripiprazole (Abilify Maintena) therapy.118

  • Importance of informing patients and caregivers about the risk of NMS; importance of immediately contacting clinician or seeking emergency medical attention if signs and symptoms of this rare but potentially life-threatening syndrome develop (e.g., high fever, muscle stiffness, sweating, fast or irregular heart beat, change in BP, confusion, kidney damage).1 118 119

  • Importance of informing patients of risk of tardive dyskinesia if chronic use is contemplated.1 98 118 119 Importance of informing patients to report any muscle movements that cannot be stopped to a healthcare professional.98 118 119

  • Risk of leukopenia/neutropenia.1 118 119 Importance of advising patients with a preexisting low WBC count or history of drug-induced leukopenia/neutropenia of need for CBC monitoring during aripiprazole therapy.1 118 119

  • Importance of informing patients and caregivers about the risk of metabolic changes (e.g., hyperglycemia and diabetes mellitus, dyslipidemia, weight gain) and the need for specific monitoring for such changes.1 118 119 Importance of patients and caregivers being aware of the symptoms of hyperglycemia and diabetes mellitus (e.g., increased thirst, increased urination, increased appetite, weakness).1 118 119

  • Importance of asking patients whether they have developed any new or increased urges or compulsive behaviors (e.g., gambling urges, sexual urges, uncontrolled spending or shopping, binge eating) while receiving aripiprazole.123 Advise patients or their caregivers to promptly report any such urges that seem out of the ordinary; also advise patients not to abruptly stop taking aripiprazole without first consulting their clinician.123

  • Risk of orthostatic hypotension and syncope, especially when initiating or reinitiating treatment or increasing the dosage.1 118 119

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular disease, diabetes mellitus, seizures).1 98

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 108 Importance of clinicians informing patients about the benefits and risks of taking antipsychotics during pregnancy (see Pregnancy under Cautions).1 108 Importance of advising patients not to stop taking aripiprazole if they become pregnant without consulting their clinician; abruptly discontinuing antipsychotic agents may cause complications.108 Importance of advising patients not to breast-feed during aripiprazole therapy.1

  • Importance of avoiding overheating or dehydration.1 118 119

  • For patients taking aripiprazole orally disintegrating tablets, importance of not removing a tablet from the blister package until just before administering a dose; importance of peeling blister open with dry hands and placing tablet on tongue to dissolve and be swallowed with saliva.1

  • Importance of informing patients with phenylketonuria that aripiprazole orally disintegrating 10- and 15-mg tablets (Abilify Discmelt) contain 1.12 and 1.68 mg of phenylalanine, respectively.1

  • Importance of being aware that aripiprazole oral solution contains 400 mg of sucrose and 200 mg of fructose per mL.1

  • Importance of informing patients of other important precautionary information.1 118 119 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

ARIPiprazole

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Solution

5 mg/5 mL*

Abilify

Otsuka

Tablets

2 mg*

Abilify

Otsuka

5 mg*

Abilify

Otsuka

10 mg*

Abilify

Otsuka

15 mg*

Abilify

Otsuka

20 mg*

Abilify

Otsuka

30 mg*

Abilify

Otsuka

Tablets, orally disintegrating

10 mg*

Abilify Discmelt

Otsuka

15 mg*

Abilify Discmelt

Otsuka

Parenteral

For injectable suspension, extended-release, for IM use

300 mg

Abilify Maintena (available as kit containing either a single-dose vial, sterile water for injection, needles, and syringe or a prefilled dual-chamber syringe, sterile water for injection, and needles)

Otsuka (also promoted by Lundbeck)

400 mg

Abilify Maintena (available as kit containing either a single-dose vial, sterile water for injection, needles, and syringe or a prefilled dual-chamber syringe, sterile water for injection, and needles)

Otsuka (also promoted by Lundbeck)

Injection, for IM use only

7.5 mg/mL (9.75 mg)

Abilify

Otsuka

ARIPiprazole Lauroxil

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injectable suspension, extended-release, for IM use

441 mg/1.6 mL

Aristada (available as kit containing prefilled syringe and needles)

Alkermes

662 mg/2.4 mL

Aristada (available as kit containing prefilled syringe and needles)

Alkermes

882 mg/3.2 mL

Aristada (available as kit containing prefilled syringe and needles)

Alkermes

AHFS DI Essentials. © Copyright 2017, Selected Revisions February 2, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

1. Otsuka America Pharmaceutical, Inc. Abilify (aripiprazole) tablets, orally disintegrating tablets, oral solution, and injection prescribing information. Rockville, MD; 2016 Jan.

2. McGavin JK, Goa KL. Aripiprazole. CNS Drugs. 2002; 16:779-86. [PubMed 12383035]

3. Kane JM, Carson WH, Saha AR et al. Efficacy and safety of aripiprazole and haloperidol versus placebo in patients with schizophrenia and schizoaffective disorder. J Clin Psychiatry. 2002; 63:763-71. [PubMed 12363115]

4. Goodnick PJ, Jerry JM. Aripiprazole: profile on efficacy and safety. Expert Opin Pharmacother. 2002; 3:1773-81. [PubMed 12472374]

5. Jordan S, Koprivica V, Chen R et al. The antipsychotic aripiprazole is a potent, partial agonist at the human 5-HT1A receptor. Eur J Pharmacol. 2002; 441:137-40. [PubMed 12063084]

6. Stahl SM. Dopamine system stabilizers, aripiprazole, and the next generation of antipsychotics, part 2. Illustrating their mechanism of action. J Clin Psychiatry. 2001; 62:923-24. [PubMed 11780870]

7. Kelleher JP, Centorrino F, Albert MJ et al. Advances in atypical antipsychotics for the treatment of schizophrenia. New formulations and new agents. CNS Drugs. 2002;16:249-61.

8. Otsuka America Pharmaceutical, Inc., Rockville, MD, and Bristol-Myers Squibb, Co., Princeton, NJ: Personal communication.

9. Janicak PG, Glick ID, Marder SR et al. The acute efficacy of aripiprazole across the symptom spectrum of schizophrenia: a pooled post hoc analysis from 5 short-term studies. J Clin Psychiatry. 2009; 70:25-35. [PubMed 19192472]

10. Anon. Aripiprazole (Abilify) for schizophrenia. Med Lett Drugs Ther. 2003; 45:15-6. [PubMed 12592215]

11. Eli Lilly and Company. Zyprexa (olanzapine) tablets and Zyprexa Zydis (olanzapine) orally disintegrating tablets prescribing information. Indianapolis, IN; 2004 Sep 22.

12. Eli Lilly and Company. Lilly announces FDA notification of class labeling for atypical antipsychotics regarding hyperglycemia and diabetes. Indianapolis, IN; 2003 Sep 17. Press release.

13. Cunningham F, Lambert B, Miller DR et al. Antipsychotic induced diabetes in veteran schizophrenic patients. In: Abstracts of the 1st International Conference on Therapeutic Risk Management and 19th International Conference on Pharmacoepidemiology, Philadelphia, PA, 2003 Aug 21-24. Pharmacoepidemiol Drug Saf. 2003; 12(suppl 1): S154-5.

14. Novartis Pharmaceuticals. Clozaril (clozapine) prescribing information. East Hanover, NJ; 2003 Dec.

15. AstraZeneca Pharmaceuticals. Seroquel (quetiapine fumarate) tablets prescribing information. Wilmington, DE; 2004 Jul.

16. Janssen Pharmaceutica. Risperdal (risperidone) tablets and oral solution prescribing information. Titusville, NJ; 2003 Oct.

17. Pfizer Inc. Geodon (ziprasidone) prescribing information. New York, NY; 2004 Aug.

18. Lewis-Hall F. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. Princeton, NJ: Bristol-Myers Squibb Company; 2004 Mar 25. From FDA website.

19. Bess AL, Cunningham SR. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2004 Apr 1. From the FDA website.

20. Eisenberg P. Dear health care professional letter regarding safety data on Zyprexa (olanzapine) – hyperglycemia and diabetes. Indianapolis, IN: Eli Lilly and Company; 2004 Mar 1. From the FDA website.

21. Macfadden W. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. Wilmington, DE: AstraZeneca Pharmaceuticals; 2004 Apr 22. From the FDA website.

22. Mahmoud RA. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. Titusville, NJ: Janssen Pharmaceutica, Inc; 2004. From the FDA website.

23. Clary CM. Dear health care practitioner letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. New York NY: Pfizer Global Pharmaceuticals; 2004 Aug. From the FDA website.

24. Cunningham F, Lambert B, Miller DR et al. Antipsychotic induced diabetes in veteran schizophrenic patients. In: Abstracts of the 1st International Conference on Therapeutic Risk Management and 19th International Conference on Pharmacoepidemiology, Philadelphia, PA, 2003 Aug 21-24. Pharmacoepidemiol Drug Saf. 2003; 12(suppl 1): S154-5.

25. American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity.. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004; 27:596-601. [PubMed 14747245]

26. Melkersson K, Dahl ML. Adverse metabolic effects associated with atypical antipsychotics. Drugs. 2004; 64:701-23. [PubMed 15025545]

27. Citrome LL, Jaffe AB. Relationship of atypical antipsychotics with development of diabetes mellitus. Ann Pharmacother. 2003; 37:1849-57. [PubMed 14632602]

28. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004; 161(2 Suppl):1-56.

29. Sumiyoshi T, Roy A, Anil AE et al. A comparison of incidence of diabetes mellitus between atypical antipsychotic drugs. J Clin Psychopharmacol. 2004; 24:345-8. [PubMed 15118492]

30. Expert Group. ’Schizophrenia and Diabetes 2003’ expert consensus meeting, Dublin, 3–4 October 2003: consensus summary. Br J Psychiatry. 2004; 47(Suppl):S112-4.

31. Marder SR, Essock SM, Miller AL et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry. 2004; 161:1334-49. [PubMed 15285957]

32. Holt RI. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2086-7. [PubMed 15277449]

33. Citrome L, Volavka J. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2087-8. [PubMed 15277450]

34. Isaac MT, Isaac MB. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2088. [PubMed 15277451]

35. Boehm G, Racoosin JA, Laughren TP et al. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2088-9. [PubMed 15277452]

36. Barrett EJ. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to Holt, Citrome and Volevka, Isaac and Isaac, and Boehm et al. Diabetes Care. 2004; 27:2089-90.

37. Fuller MA, Shermock KM, Secic M et al. Comparative study of the development of diabetes mellitus in patients taking risperidone and olanzapine. Pharmacotherapy. 2002; 23:1037-43.

38. Koller EA, Cross JT, Doraiswamy PM et al. Risperidone-associated diabetes mellitus: a pharmacovigilance study. Pharmacotherapy. 2003; 23:735-44. [PubMed 12820816]

39. Koller EA, Weber J, Doraiswamy PM et al. A survey of reports of quetiapine-associated hyperglycemia and diabetes mellitus. J Clin Psychiatry. 2004; 65:857-63. [PubMed 15291665]

40. Ananth J, Johnson KM, Levander EM et al. Diabetic ketoacidosis, neuroleptic malignant syndrome, and myocardial infarction in a patient taking risperidone and lithium carbonate. J Clin Psychiatry. 2004; 65:724. [PubMed 15163265]

41. Torrey EF, Swalwell CI. Fatal olanzapine-induced ketoacidosis. Am J Psychiatry. 2003; 160:2241. [PubMed 14638601]

42. Wehring HJ, Kelly DL, Love RC et al. Deaths from diabetic ketoacidosis after long-term clozapine treatment. Am J Psychiatry. 2003; 160:2241-2. [PubMed 14638600]

43. Koro CE, Fedder DO, L’Italien GJ et al. Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study. BMJ. 2002; 325:243. [PubMed 12153919]

44. Citrome LL. Efficacy should drive atypical antipsychotic treatment. BMJ. 2003; 326:283. [PubMed 12561827]

45. Anon. Which atypical antipsychotic for schizophrenia?. Drug Ther Bull. 2004; 42:57-60. [PubMed 15310154]

46. Anon. Atypical antipsychotics and hyperglycaemia. Aust Adv Drug React Bull. 2004; 23:11-2.

47. Sussman N. The implications of weight changes with antipsychotic treatment. J Clin Psychopharmacol. 2003; 23 (Suppl 1):S21-6.

48. Gianfrancesco F, Grogg A, Mahmoud R et al. Differential effects of antipsychotic agents on the risk of development of type 2 diabetes mellitus in patients with mood disorders. Clin Ther. 2003; 25:1150-71. [PubMed 12809963]

49. Bushe C, Leonard B. Association between atypical antipsychotic agents and type 2 diabetes: review of prospective clinical data. Br J Psychiatry Suppl. 2004; 47:S87-93. [PubMed 15056600]

50. Cavazzoni P, Mukhopadhyay N, Carlson C et al. Retrospective analysis of risk factors in patients with treatment-emergent diabetes during clinical trials of antipsychotic medications. Br J Psychiatry Suppl. 2004; 47:s94-101. [PubMed 15056601]

51. Gianfrancesco FD, Grogg AL, Mahmoud RA et al. Differential effects of risperidone, olanzapine, clozapine, and conventional antipsychotics on type 2 diabetes: findings from a large health plan database. J Clin Psychiatry. 2002; 63:920-30. [PubMed 12416602]

52. Etminan M, Streiner DL, Rochon PA. Exploring the association between atypical neuroleptic agents and diabetes mellitus in older adults. Pharmacotherapy. 2003; 23:1411-15. [PubMed 14620387]

53. Leslie DL, Rosenheck RA. Incidence of newly diagnosed diabetes attributable to atypical antipsychotic medications. Am J Psychiatry. 2004; 161:1709-11. [PubMed 15337666]

54. Sernyak MJ, Leslie DL, Alarcon RD et al. Association of diabetes mellitus with use of atypical neuroleptics in the treatment of schizophrenia. Am J Psychiatry. 2002; 159:561-6. [PubMed 11925293]

55. Geller WK, MacFadden W. Diabetes and atypical neuroleptics. Am J Psychiatry. 2003; 160:388. [PubMed 12562601]

56. Gianfrancesco FD. Diabetes and atypical neuroleptics. Am J Psychiatry. 2003; 160:388-9; author reply 389. [PubMed 12562599]

57. Lamberti JS, Crilly JF, Maharaj K. Prevalence of diabetes mellitus among outpatients with severe mental disorders receiving atypical antipsychotic drugs. J Clin Psychiatry. 2004; 65:702-6. [PubMed 15163259]

58. Lee DW, Fowler RB. Olanzapine/risperidone and diabetes risk. J Clin Psychiatry. 2003; 64:847-8; author reply 848. [PubMed 12934988]

59. Reviewer comments (personal observations).

60. AstraZeneca. Wayne, PA: Personal communication.

61. Eli Lilly and Company. Indianapolis, IN: Personal communication.

62. Novartis Pharmaceuticals Corporation. East Hanover, NJ: Personal communication.

63. Janssen Pharmaceuticals. Titusville, NJ: Personal communication.

64. Citrome LL. The increase in risk of diabetes mellitus from exposure to second generation antipsychotic agents. Drugs Today (Barc). 2004; 40:445-64. [PubMed 15319799]

65. Citrome L, Jaffe A, Levine J et al. Relationship between antipsychotic medication treatment and new cases of diabetes among psychiatric inpatients. Psychiatr Serv. 2004; 55:1006–13.

66. Otsuka America Pharmaceutical, Inc. Abilify (aripiprazole) tablets prescribing information. Rockville, MD; 2004 Sep.

67. Keck PE Jr, Marcus R, Tourkodimitris S et al. A placebo-controlled, double-blind study of the efficacy and safety of aripiprazole in patients with acute bipolar mania. Am J Psychiatry. 2003; 160:1651-8. [PubMed 12944341]

68. American Psychiatric Association. DSM-IV: diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:273-86.

69. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002; 159(4 Suppl):1-50.

70. Citrome L. New antipsychotic medications: what advantages do they offer? Postgrad Med. 1997; 101:207-10, 213, 214. (IDIS 380687)

71. Lieberman JA. Atypical antipsychotic drugs as a first-line treatment of schizophrenia: a rationale and hypothesis. J Clin Psychiatry. 1996; 57(Suppl 11):68-71. [PubMed 8941173]

72. Lahti AC, Tamminga CA. Recent developments in the neuropharmacology of schizophrenia. Am J Health-Syst Pharm. 1995; 52(Suppl 1):S5-8. [PubMed 7749964]

73. Food and Drug Administration. Public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. Rockville, MD; 2005 Apr 11. From the FDA website.

74. Bristol-Myers Squibb, Co. and Otsuka Pharmaceutical, Inc. Abilify granted approval for new indication. Princeton, NJ and Tokyo; 2005 Mar 7. Press release from website.

75. Bristol-Myers Squibb Company, Princeton, NJ: Personal communication.

76. Food and Drug Administration. FDA news: FDA proposes new warnings about suicidal thinking, behavior in young adults who take antidepressant medications. Rockville, MD; 2007 May 2. From the FDA web site.

77. Food and Drug Administration. Antidepressant use in children, adolescents, and adults: class revisions to product labeling. Rockville, MD; 2007 May 2. From the FDA web site.

78. Food and Drug Administration. Revisions to medication guide: antidepressant medicines, depression and other serious mental illnesses and suicidal thoughts or actions. Rockville, MD; 2007 May 2. From the FDA web site.

79. Bridge JA, Iyengar S, Salary CB. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007; 297:1683-96. [PubMed 17440145]

80. American Medical Association Council on Scientific Affairs. Aspartame: review of safety issues. JAMA. 1985; 254:400-2. [PubMed 2861297]

81. Gossel TA. A review of aspartame: characteristics, safety and uses. US Pharm. 1984; 9:26,28-30.

82. Food and Drug Administration. Aspartame as an inactive ingredient in human drug products; labeling requirements. Proposed rule. [21 CFR Part 201] Fed Regist. 1983; 48:54993-5. (lDIS 178728)

83. Food and Drug Administration. Food additives permitted for direct addition to food for human consumption; aspartame. Final rule. [21 CFR Part 172] Fed Regist. 1983; 48:31376-82. (IDIS 172957)

84. Anon. Aspartame and other sweeteners. Med Lett Drugs Ther. 1982; 24:1-2. [PubMed 7054648]

85. Berman RM, Marcus RN, Swanink R et al. The efficacy and safety of aripiprazole as adjunctive therapy in major depressive disorder: a multicenter, randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2007; 68:843-53. [PubMed 17592907]

86. Tran-Johnson TK, Sack DA, Marcus RN et al. Efficacy and safety of intramuscular aripiprazole in patients with acute agitation: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2007; 68:111-9.

87. Andrezina R, Josiassen RC, Marcus RN et al. Intramuscular aripiprazole for the treatment of acute agitation in patients with schizophrenia or schizoaffective disorder: a double-blind, placebo-controlled comparison with intramuscular haloperidol. Psychopharmacol. 2006; 188:281-92.

88. Zimbroff DL, Marcus RN, Manos G et al. Management of acute agitation in patients with bipolar disorder: efficacy and safety of intramuscular aripiprazole. J Clin Psychopharmacol. 2007; 27:171-6. [PubMed 17414241]

89. El-Sayeh HG, Morganti C. Aripiprazole for schizophrenia (review). Cochrane Database of Syst Rev. 2006;2:CD004578.

90. Vieta E, T’joen C, McQuade RD et al. Efficacy of adjunctive aripiprazole to either valproate or lithium in bipolar mania patients partially nonresponsive to valproate/lithium monotherapy: a placebo-controlled study. Am J Psychiatry. 2008; AiA:1-9.

91. Findling RL, Robb A, Nyilas M et al. A multiple-center, randomized, double-blind, placebo-controlled study of oral aripiprazole for treatment of adolescents with schizophrenia. Am J Psychiatry. 2008; 165:1432-41. [PubMed 18765484]

92. Schieber FC, Boulton DW, Balch AH et al. A non-randomized study to investigate the effects of the atypical antipsychotic aripiprazole on the steady-state pharmacokinetics of lamotrigine in patients with bipolar I disorder. Hum Psychopharmacol. 2009; 24:145-52. [PubMed 19132712]

93. Kane JM, Crandall DT, Marcus RN et al. Symptomatic remission in schizophrenic patients treated with aripiprazole or haloperidol for up to 52 weeks. Schizophr Res. 2007; 95:143-50. [PubMed 17644313]

94. Kinon BJ, Stauffer VL, Kollack-Walker S et al. Olanzapine versus aripiprazole for the treatment of agitation in acutely ill patients with schizophrenia. J Clin Psychopharmacol. 2008; 28:601-7. [PubMed 19011427]

95. Mallikaarjun S, Shoaf SE, Boulton DW et al. Effects of hepatic or renal impairment on the pharmacokinetics of aripiprazole. Clin Pharmacokinet. 2008; 47:533-42. [PubMed 18611062]

96. Maytal G, Ostacher M, Stern TA. Aripiprazole-related tardive dyskinesia. CNS Spect. 2006; 11:435-9.

97. Abbasian C, Power P. A case of aripiprazole and tardive dyskinesia. J Psychopharmacol. 2009; 23:214-5. [PubMed 18515468]

98. Food and Drug Administration. Patient information sheet: aripiprazole (marketed as Abilify). 2006 Sep 6.

99. Srephichit S, Sanchez R, Bourgeois JA. Neuroleptic malignant syndrome and aripiprazole in an antipsychotic-naive patient. J Clin Psychopharmacol. 2006; 26:94-5. Letter. [PubMed 16415717]

100. Brunelle J, Guigueno S, Gouin P et al. Aripiprazole and neuroleptic malignant syndrome. J Clin Psychopharmacol. 2007; 27:212-4. Letter. [PubMed 17414250]

101. Croarkin PE, Emslie GJ, Mayes TL. Neuroleptic malignant syndrome associated with atypical antipsychotics in pediatric patients: a review of published cases. J Clin Psychiatry. 2008; 69:1157-65. [PubMed 18572981]

102. Qureshi SU, Rubin E. Risperidone- and aripiprazole-induced leukopenia: a case report. Prim Care Companion J Clin Psychiatry. 2008; 10:482-3. [PubMed 19287562]

103. Yalcin DO, Goka E, Aydemir MC et al. Is aripiprazole the only choice of treatment of the patients who developed anti-psychotic agents-induced leucopenia and neutropenia? A case report. J Psychopharmacol. 2008; 22:333-5. [PubMed 18208928]

104. Boulton D, Balch A, Royzman K et al. The pharmacokinetics of standard antidepressants with aripiprazole as adjunctive therapy: studies in healthy subjects and in patients with major depressive disorder. J Psychopharmacol. 2008; Oct 2:[epub ahead of print].

105. Citrome L, Macher J-P, Salazar DE et al. Pharmacokinetics of aripiprazole and concomitant carbamazepine. J Clin Psychopharmacol. 2007; 27:279-83. [PubMed 17502775]

106. Sexson WR, Barak Y. Withdrawal emergent syndrome in an infant associated with maternal haloperidol therapy. J Perinatol. 1989; 9:170-2. [PubMed 2738729]

107. Coppola D, Russo LJ, Kwarta RF Jr. et al. Evaluating the postmarketing experience of risperidone use during pregnancy: pregnancy and neonatal outcomes. Drug Saf. 2007; 30:247-64. [PubMed 17343431]

108. US Food and Drug Administration. FDA drug safety communication: Antipsychotic drug labels updated in use during pregnancy and risk of abnormal muscle movements and withdrawal symptoms in newborns. Rockville, MD; 2011 Feb 22. From the FDA website: .

109. Marcus RN, Owen R, Kamen L et al. A placebo-controlled, fixed-dose study of aripiprazole in children and adolescents with irritability associated with autistic disorder. J Am Acad Child Adolesc Psychiatry. 2009; 48:1110-9. [PubMed 19797985]

110. Owen R, Sikich L, Marcus RN et al. Aripiprazole in the treatment of irritability in children and adolescents with autistic disorder. Pediatrics. 2009; 124:1533-40. [PubMed 19948625]

111. Watanabe N, Kasahara M, Sugibayashi R et al. Perinatal use of aripiprazole: a case report. J Clin Psychopharmacol. 2011; 31:377-9. [PubMed 21532364]

112. Marcus R,, Khan A, Rollin L et al. Efficacy of aripiprazole adjunctive to lithium or valproate in the long-term treatment of patients with bipolar I disorder with an inadequate response to lithium or valproate monotherapy: a multicenter, double-blind, randomized study. Bipolar Dis. 2011; 13:133-44.

113. US Food and Drug Administration. Information for Healthcare Professionals: Conventional antipsychotics. Rockville, MD; 2008 Jun 16. From the FDA website: .

114. Banerjee S. The use of antipsychotic medication for people with dementia: time for action. A report for the Minister of State for Care Services. United Kingdom Department of Health. From the website: .

115. Volavka J, Citrome L. Oral antipsychotics for the treatment of schizophrenia: heterogeneity in efficacy and tolerability should drive decision-making. Expert Opin Pharmacother. 2009; 10:1917-28. [PubMed 19558339]

116. McIntyre RS. Pharmacology and efficacy of asenapine for manic and mixed states in adults with bipolar disorder. Expert Rev Neurother. 2010; 10:645-9. [PubMed 20420486]

117. Vanda Pharmaceuticals Inc. Fanapt (iloperidone) tablets prescribing information. Rockville, MD; 2011 Mar.

118. Otsuka America Pharmaceutical, Inc. Abilify Maintena (aripiprazole) for extended-release injectable suspension prescribing information. Rockville, MD; 2016 Jan.

119. Alkermes, Inc. Aristada (aripiprazole lauroxil) extended-release injectable suspension prescribing information. Waltham, MA; 2016 Jan.

120. Kane JM, Peters-Strickland T, Baker RA et al. Aripiprazole once-monthly in the acute treatment of schizophrenia: findings from a 12-week, randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2014; 75:1254-60. [PubMed 25188501]

121. Kane JM, Sanchez R, Perry PP et al. Aripiprazole intramuscular depot as maintenance treatment in patients with schizophrenia: a 52-week, multicenter, randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2012; 73:617-24. [PubMed 22697189]

122. Meltzer HY, Risinger R, Nasrallah HA et al. A randomized, double-blind, placebo-controlled trial of aripiprazole lauroxil in acute exacerbation of schizophrenia. J Clin Psychiatry. 2015; 76:1085-90. [PubMed 26114240]

123. US Food and Drug Administration. FDA drug safety communication: FDA warns about new impulse-control problems associated with mental health drug aripiprazole (Abilify, Abilify Maintena, Aristada). 2016 May 3. From FDA website.

124. Yoo HK, Joung YS, Lee JS et al. A multicenter, randomized, double-blind, placebo-controlled study of aripiprazole in children and adolescents with Tourette's disorder. J Clin Psychiatry. 2013; 74:e772-80. [PubMed 24021518]

125. Keck PE, Calabrese JR, McQuade RD et al. A randomized, double-blind, placebo-controlled 26-week trial of aripiprazole in recently manic patients with bipolar I disorder. J Clin Psychiatry. 2006; 67:626-37. [PubMed 16669728]

126. Keck PE, Calabrese JR, McIntyre RS et al. Aripiprazole monotherapy for maintenance therapy in bipolar I disorder: a 100-week, double-blind study versus placebo. J Clin Psychiatry. 2007; 68:1480-91. [PubMed 17960961]

127. Tsai AC, Rosenlicht NZ, Jureidini JN et al. Aripiprazole in the maintenance treatment of bipolar disorder: a critical review of the evidence and its dissemination into the scientific literature. PLoS Med. 2011; 8:e1000434. [PubMed 21559324]

128. Otsuka America Pharmaceutical, Inc. Abilify (aripiprazole) tablets, orally disintegrating tablets, oral solution, and injection prescribing information. Rockville, MD; 2011 Feb.

129. Otuska Medical Information, Princeton, NJ: Personal communication.

130. McIntyre RS, Yoon J, Jerrell JM et al. Aripiprazole for the maintenance treatment of bipolar disorder: a review of available evidence. Neuropsychiatr Dis Treat. 2011; 7:319-23. [PubMed 21655345]

131. Yatham LN. A clinical review of aripiprazole in bipolar depression and maintenance therapy of bipolar disorder. J Affect Disord. 2011; 128 Suppl 1:S21-8. [PubMed 21220077]

132. Gaboriau L, Victorri-Vigneau C, Gérardin M et al. Aripiprazole: a new risk factor for pathological gambling? A report of 8 case reports. Addict Behav. 2014; 39:562-5. [PubMed 24315783]

133. Findling RL, Mankoski R, Timko K et al. A randomized controlled trial investigating the safety and efficacy of aripiprazole in the long-term maintenance treatment of pediatric patients with irritability associated with autistic disorder. J Clin Psychiatry. 2014; 75:22-30. [PubMed 24502859]

134. Gavaudan G, Magalon D, Cohen J et al. Partial agonist therapy in schizophrenia: relevance to diminished criminal responsibility. J Forensic Sci. 2010; 55:1659-62. [PubMed 20579229]

135. Grall-Bronnec M, Sauvaget A, Perrouin F et al. Pathological gambling associated with aripiprazole or dopamine replacement therapy. J Clin Psychopharmacol. 2016; 36:63-70. [PubMed 26658263]

136. Mété D, Dafreville C, Paitel V et al. Aripiprazole, gambling disorder and compulsive sexuality [French; with English abstract]. Encephale. 2016; 42:281-3. [PubMed 26923999]

137. Cohen J, Magalon D, Boyer L et al. Aripiprazole-induced pathological gambling: a report of 3 cases. Curr Drug Saf. 2011; 6:51-3. [PubMed 21241242]

138. Roxanas MG. Pathological gambling and compulsive eating associated with aripiprazole. Aust N Z J Psychiatry. 2010; 44:291. [PubMed 20180730]

HID. Handbook on injectable drugs. 18th ed. McEvoy GK, ed. Bethesda, MD: American Society of Health-System Pharmacists; 2014.

Hide