Practical prescribing with aripiprazole in schizophrenia: consensus recommendations of a UK multidisciplinary panel

BACKGROUND: The atypical antipsychotic, aripiprazole, differs from other antipsychotics in its pharmacology and clinical outcomes. Aripiprazole's clinical outcomes include beneficial effects on mood, quality of life and cognition; favourable tolerability with low potential for sedation; and a favourable physical health profile, with low potential for weight change, sexual dysfunction or adverse metabolic effects. Such outcomes, particularly cognitive improvements, may allow for greater psychosocial intervention and improved social inclusion. In accordance with the UK NICE guidance on the use of antipsychotic treatment for schizophrenia (2002), aripiprazole may be an appropriate therapeutic option for patients with schizophrenia who are newly diagnosed, in acute relapse or experiencing tolerability problems, adverse metabolic effects or dissatisfaction with their current medication.

SCOPE: A multidisciplinary panel was convened in the UK in October 2006 to discuss and provide practical guidance regarding the potential benefits and risks of prescribing aripiprazole. This report describes the consensus recommendations agreed during the meeting and includes practical guidance on the optimal approach to prescribing aripiprazole, which patients might benefit from aripiprazole and how best to approach initiation of and switching to treatment with aripiprazole. A PubMed/MEDLINE literature search was conducted to support these recommendations.

FINDINGS: To support antipsychotic therapy, a therapeutic partnership should be established between the patient and a well-informed, multidisciplinary care team. Aripiprazole should be initiated at the minimal efficacious dose (10 mg/day) and titrated as required (usually to 15 mg/day) after a minimum of 2 weeks. The primary goal during aripiprazole initiation is to ensure the patient completes the first few days of treatment, with support from concomitant medications if required. Nausea, insomnia and agitation may occur in 10-20% of patients, but are manageable and typically resolve during the first 3-7 days of therapy. The dose of any prior antipsychotic should remain stable until the response to aripiprazole is satisfactory and then the previous antipsychotic should be tapered off slowly over several weeks or more.

CONCLUSION: Patients are more likely to adhere to treatment with aripiprazole--and indeed any other antipsychotic--and derive long-term therapeutic benefits if they and a well-informed care team are involved in the treatment decision, establish a therapeutic partnership, are aware of the transient nature of any adverse events and understand what the potential long-term benefits are.