Aripiprazole in patients with bipolar mania and beyond: an update of practical guidance

Partial agonists of dopamine receptors: mechanisms and clinical effects of aripiprazole, brexpiprazole and cariprazine

Aripiprazole, brexpiprazole and cariprazine are partial dopamine (and serotonin) agonists developed as novel antipsychotics. This article discusses their pharmacology, evidence on their licensed and off-licence uses (including psychosis, mania, bipolar depression, Tourette syndrome and autism spectrum disorder) and side-effects. In schizophrenia, they have a low risk of Parkinsonism or hyperprolactinaemia, cause modest increases in body weight and are of moderate efficacy.

Patterns of response to aripiprazole, lithium, haloperidol, and placebo across factor scores of mania

Background

A previous factor analysis of Young Mania Rating Scale and Montgomery-Åsberg Depression Rating Scale items identified composite factors of depression, mania, sleep disturbance, judgment/impulsivity, and irritability/hostility as major components of psychiatric symptoms in acute mania or mixed episodes in a series of trials of antipsychotics. However, it is unknown whether these factors predict treatment outcome.

Methods

Data from six double-blind, randomized, controlled clinical trials with aripiprazole in acute manic or mixed episodes in adults with bipolar I disorder were pooled for this analysis and the previously identified factors were examined for their value in predicting treatment outcome. Treatment efficacy was assessed for aripiprazole (n = 1,001), haloperidol (n = 324), lithium (n = 155), and placebo (n = 694) at baseline, days 4, 7, and 10, and then weekly to study end. Mean change in factor scores from baseline to week 3 was assessed by receiver operating characteristics curves for percentage factor change at day 4 and week 1.

Results

Subjects receiving aripiprazole, haloperidol, and lithium significantly improved mania factor scores versus placebo. Factors most predictive of endpoint efficacy for aripiprazole were judgment/impulsivity at day 4 and mania at week 1. Optimal factor score improvement for outcome prediction was approximately 40% to 50%. Early efficacy predicted treatment outcome across all factors; however, response at week 1 was a better predictor than response at day 4.

Conclusions

This analysis confirms clinical benefits in early treatment/assessment for subjects with bipolar mania and suggests that certain symptom factors in mixed or manic episodes may be most predictive of treatment response.

Antipsychotic switching in bipolar disorders: a systematic review

With the increasingly widespread use of antipsychotics in bipolar disorder (BD), switching among these agents and between antipsychotics and mood stabilizers has become more common, in particular, since the introduction of the novel atypical antipsychotics with mood stabilizer properties. This systematic review aims to provide a comprehensive update of the current literature in BD about the switching of antipsychotics, among them and between them and mood stabilizers, in acute and maintenance treatment. We conducted a comprehensive, computerized literature search using terms related to antipsychotic switching in BD in the PubMed/Medline, PsycINFO, CINAHL database; the Cochrane Library and; the Clinicaltrials.gov web up to January 9th, 2013 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search returned 4160 articles. After excluding duplications, reviews, case reports and studies that did not fulfil the selection criteria, 8 studies were included. Not only have few articles on antipsychotic switching been published but also recruitment in most studies included mixed samples of patients. In general, antipsychotic switching, regardless of the route of drug administration, was well tolerated and no interference was shown in antipsychotic effectiveness during the interchange of drugs. Metabolic improvement was perceived when the switch involved antipsychotics with a low metabolic risk profile. The evidence-base for antipsychotic switching in BD is scant, and little controlled data is available. Switch from quetiapine to lithium and from risperidone to olanzapine has proven successful. Switching to antipsychotics with low metabolic risk had some positive impact on several safety measures. In stabilized patients, the plateau cross-taper switch may be preferred.

A UK panel consensus on the initiation of aripiprazole for the treatment of bipolar mania

OBJECTIVE

The objective of this consensus paper is to provide practical guidance on why and how aripiprazole, with its distinct pharmacological and side effect profile, should be used for treatment of acute bipolar mania.

METHODS

An advisory panel of UK healthcare professionals, with extensive experience of prescribing aripiprazole for acute bipolar mania, met to discuss its use in this setting.

RESULTS

The panel agreed that aripiprazole is effective in treating bipolar mania when prescribed and dosed appropriately, in both the short and long term, as monotherapy or in combination with a mood stabilizer. Unlike other atypical agents, aripiprazole has antimanic effects that are not associated with sedation, which is beneficial for patients, particularly in the long term. If rapid tranquillization is required when initiating aripiprazole in acutely disturbed patients, short-term coprescription of a benzodiazepine is recommended. Most side effects associated with aripiprazole occur within the first 1-3 weeks and are usually transient and easily treatable. Aripiprazole poses low risk of metabolic side effects, sexual dysfunction, and anhedonia, which can facilitate treatment adherence and help improve clinical outcomes.

CONCLUSIONS

Aripiprazole is an effective first-line treatment for acute bipolar mania with a favorable safety/tolerability profile.