Practical guidance for prescribing with aripiprazole in bipolar disorder

BACKGROUND: Aripiprazole differs from other atypical antipsychotics in its pharmacological and clinical profile. SCOPE: As aripiprazole has been available in the USA for bipolar mania since 2004, clinical experience-sharing from clinical and research use of this agent can assist with initiation and administration in practice. The clinical experience-guided recommendations provided herein are based on clinical practice of the author (intended as clinical opinions and general suggestions of the author and/or hypotheses to be scientifically tested) and a review of the literature (based on a PubMed search and limited to double-blind, randomised, controlled clinical trials) to provide the most current aripiprazole studies in bipolar mania. This article is designed to share the experience gained over time by the author on the prescribing of aripiprazole, how best to approach initiation of and switching to aripiprazole, and how and when to use adjunctive medications. FINDINGS: In the treatment of a manic episode, aripiprazole may be initiated at 15 mg/day and adjusted as required (down to 5-10 mg/day or up to 30 mg/day). When switching to aripiprazole, it is frequently advisable to maintain the therapeutic dose of current medication, add aripiprazole 5, 10 or 15 mg/day, and adjust between 10 and 30 mg/day depending on response and tolerability. Only once an effective aripiprazole dose is reached can the prior medication be gradually discontinued. A tolerability profile different from other atypical antipsychotics should be expected. Side-effects, if they occur, are usually manageable and frequently resolve soon after initiation. CONCLUSIONS: Practical guidance for prescribing aripiprazole in bipolar mania is provided to assist clinicians using aripiprazole for the treatment of bipolar mania in real-world practice; for example, with dose selection, for the switching strategies and for the management of side-effects.