Aripiprazole: from pharmacological profile to clinical use

Application of GWAS summary data and drug-induced gene expression profiles of neural progenitor cells in psychiatric drug prioritization analysis

Common psychiatric disorders constitute one of the most substantial healthcare burdens worldwide. However, drug development in psychiatry remains hampered partially due to the lack of approaches to estimating drugs that can simultaneously modulate the expression of a nontrivial fraction of disease susceptibility genes. We proposed a new drug prioritization strategy under the framework of our previously proposed phenotype-associated tissues estimation approach (DESE) by investigating the drugs' selective perturbation effect on disease susceptibility genes. Based on the genome-wide association study summary data and drug-induced gene expression profiles of neural progenitor cells, we applied this strategy to prioritize candidate drugs for schizophrenia, depression and bipolar I disorder and identified several known therapeutic drugs among the top-ranked drug candidates. Also, our results revealed that the disease susceptibility genes involved in the selective gene perturbation analysis were enriched with many biologically sensible function terms and interacted with known therapeutic drugs. Our results suggested that selective gene perturbation analysis could be a promising starting point to prioritize biologically sensible drug candidates under the "one drug, multiple targets" paradigm for the drug development of common psychiatric disorders.

Withdrawal Dyskinesia Associated With Aripiprazole in a Child: A Case Report

Atypical antipsychotics are considered to be better tolerated than typical antipsychotics; however, the risk of drug-induced movement disorders needs to be considered. Aripiprazole, a dopamine partial agonist, is one of the most frequently used atypical antipsychotics in children. In this report, we describe withdrawal dyskinesia after aripiprazole discontinuation in a child with autism spectrum disorder. The patient presented with oral dyskinesia after discontinuation of aripiprazole when he was 13 years old. Dyskinetic movements disappeared after reinitiation of aripiprazole. He developed oral dyskinesia again after a reduction of the aripiprazole dose when he was 14 years old. Dyskinesia gradually disappeared within a few months. Withdrawal dyskinesia associated with aripiprazole has been rarely reported in children. Moreover, there is no large study on the prevalence of dyskinesia associated with aripiprazole discontinuation either in adults or in children. However, relevant cases might be unreported, pretermitted, or regarded as akathisia or symptoms of attention-deficit hyperactivity disorder. The prevalence of withdrawal dyskinesia associated with aripiprazole, especially in children, may be more frequent than thought. Withdrawal dyskinesia is self-limited; however, such dyskinetic movements in children potentially result in irreversible effects that damage the quality of life. As such, physicians should be mindful when changing, reducing, or discontinuing antipsychotics in children.

A descriptive study of aripiprazole, brexpiprazole, and cariprazine exposures in children ages 0 to 5 years reported to United States poison centers

INTRODUCTION

Increased prescribing of antipsychotics and availability of new antipsychotics has resulted in increased exposures in children. Current data on aripiprazole, brexpiprazole, and cariprazine are limited.

METHODS

This was a retrospective database study utilizing the National Poison Data System from 2015 through 2021. We included cases of single substance exposures to aripiprazole, brexpiprazole, cariprazine, or lumateperone in children ages 0 to 5 years old with follow-up to a known outcome. Key outcomes were medical outcomes, clinical effects, and level of care if treated in a healthcare facility.

RESULTS

There were 3,573 aripiprazole, 137 brexpiprazole, 249 cariprazine, and one lumateperone exposure over the period. Primary outcomes were evaluated in 2,655 cases (2,390 aripiprazole, 96 brexpiprazole, and 169 cariprazine). Fifty-one percent were male and 77% were between 0 and 2 years old. Moderate effect was coded in 16.6% of aripiprazole, 23% of brexpiprazole, and 12% of cariprazine exposures. Major effect was coded in 0.6% of aripiprazole, 1% of brexpiprazole, and 2.4% of cariprazine exposures. Duration of symptoms was mostly between 8 and 24 h for 34.6% of aripiprazole, 30% of brexpiprazole, and 32% of cariprazine exposures. Over 60% of the children seen in a health care facility were discharged from the emergency department. The lowest doses resulting in at least a moderate effect and admission to a health care facility was 0.46 mg/kg for aripiprazole, 2.1 mg/kg for brexpiprazole, and 1.9 mg/kg for cariprazine. Important clinical effects included central nervous system depression, tremors, tachycardia, agitation, and vomiting.

CONCLUSION

Reported ingestions of aripiprazole, brexpiprazole, or cariprazine may result in neurologic symptoms like central nervous system depression or seizures in children. The prolonged duration of symptoms resulted in admission for at least a day for many cases. Further research should address optimal monitoring time and location for these exposures.

Co-prescription of aripiprazole on prolactin levels in long-term hospitalized chronic schizophrenic patients with co-morbid type 2 diabetes: A retrospective clinical study

BACKGROUND

One of the most frequent side effects of atypical antipsychotics is hyperprolactinemia (HPRL), and metformin or aripiprazole co-prescription is regarded as an effective therapy option for reducing prolactin (PRL) levels. However, whether either of the two drugs can reduce PRL levels in patients with long-term hospitalized chronic schizophrenia with co-morbid type 2 diabetes (T2DM) has not been adequately reported.

METHODS

In our study, long-term hospitalized chronic schizophrenia patients with co-T2DM who were prescribed olanzapine or risperidone as the primary antipsychotic medication were enrolled. A total of 197 of these cases with co-prescribed aripiprazole were set up as the study group (co-Ari group), and the other 204 cases without co-prescribed aripiprazole were set up as the control group (non-Ari group). The two groups' variations in each target parameter were compared, and the variables affecting PRL levels were examined.

RESULTS

Compared to the non-Ari group, fasting blood glucose (FBG), blood uric acid (UA), total cholesterol (TC), triglyceride (TG), and low-density lipoprotein cholesterol (LDL-C) levels were significantly higher in the co-Ari group, but there was no difference in PRL levels. Co-prescribing aripiprazole had no impact on PRL levels in all patients with co-T2DM, and aripiprazole dose had no impact on PRL levels in the clinical subgroup of the co-Ari group.

CONCLUSION

Aripiprazole not only worsened the severity of index disturbances associated to metabolism in long-term hospitalized chronic schizophrenia patients with co-T2DM on metformin-based hypoglycemic medications but also failed to lower PRL levels.

Effects of Psychotropic Medication on Somatic Sterol Biosynthesis of Adult Mice

Polypharmacy is commonly used to treat psychiatric disorders. These combinations often include drugs with sterol biosynthesis inhibiting side effects, including the antipsychotic aripiprazole (ARI), and antidepressant trazodone (TRZ). As the effects of psychotropic medications are poorly understood across the various tissue types to date, we investigated the effects of ARI, TRZ, and ARI + TRZ polypharmacy on the post-lanosterol biosynthesis in three cell lines (Neuro2a, HepG2, and human dermal fibroblasts) and seven peripheral tissues of an adult mouse model. We found that both ARI and TRZ strongly interfere with the function of 7-dehydrocholesterol reductase enzyme (DHCR7) and lead to robust elevation in 7-dehydrocholesterol levels (7-DHC) and reduction in desmosterol (DES) across all cell lines and somatic tissues. ARI + TRZ co-administration resulted in summative or synergistic effects across the utilized in vitro and in vivo models. These findings suggest that at least some of the side effects of ARI and TRZ are not receptor mediated but arise from inhibiting DHCR7 enzyme activity. We propose that interference with sterol biosynthesis, particularly in the case of simultaneous utilization of medications with such side effects, can potentially interfere with functioning or development of multiple organ systems, warranting further investigation.

Aripiprazole Improved Post-Streptococcal Dyskinesia by Modulating Dopaminergic Activity: A Case Report

This case report aimed to discuss the efficacy of aripiprazole for dyskinesia in patients with functional movement disorder after streptococcal infection, with its biological action of modulating dopamine hyperactivity in the basal ganglia as a dopamine partial agonist. This report has shown that the [18F] N -(3-Fluoropropyl)-2β-carbon ethoxy-3β-(4-iodophenyl) nortropane positron emission tomography findings of the patient revealed that the dopamine hyperactivity in the basal ganglia at baseline was normalized after aripiprazole treatment due to its balancing effect as a dopamine partial agonist.

Aripiprazole treatment for temper outbursts in Prader-Willi syndrome

Background

Prader–Willi syndrome (PWS) is a rare neurodevelopmental disorder based on a loss of paternally expressed genes in chromosome segment 15q11-13. Behavioral traits such as temper outbursts, stereotypic, and ritualistic behavior, as well as an increased risk of psychosis accompany the syndrome, representing a major issue in the treatment of adults with PWS. Up to now, no treatment guideline for these conditions in PWS exist. This study aimed to retrospectively analyze the effect and adverse effects of treatment with aripiprazole for temper outbursts in 10 adults with PWS.

Results

Aripiprazole was prescribed for temper outbursts (n = 10). Treatment outcome was assessed using the Clinical Global Impression-Severity (CGI-S) and -Improvement Scale (CGI-I).

Treatment success (CGI-I < 3) was observed in 70% of cases, with adverse effects from mild to partly serious extent in 60% of cases. The major adverse effect observed was increased daytime sleepiness. In total, 50% of the individuals were treated successfully for temper outbursts. The BMI did not change significantly in the successfully treated group after 6 months of treatment.

Conclusions

Aripiprazole can be a treatment option for temper outbursts in people with PWS. Although a high rate of side effects was detected, their severity led to discontinuation in only 20% of the cases. Furthermore, the absence of weight gain makes aripiprazole interesting especially for the PWS population.

Design, Synthesis and 5-HT1A Binding Affinity of N-(3-(4-(2-Methoxyphenyl)piperazin-1-yl)propyl)tricyclo[3.3.1.13,7]decan-1-amine and N-(3-(4-(2-Methoxyphenyl)piperazin-1-yl)propyl)-3,5-dimethyl-tricylo[3.3.1.13,7]decan-1-amine

Based on previously highlighted structural features, the development of highly selective 5-HT1A receptor inhibitors is closely linked to the incorporation of a 4-alkyl-1-arylpiperazine scaffold on them. In this paper, we present the synthesis of two new compounds bearing the 2-MeO-Ph-piperazine moiety linked via a three carbon atom linker to the amine group of 1-adamantanamine and memantine, respectively. Both were tested for their binding affinity against 5-HT1A receptor. N-(3-(4-(2-methoxyphenyl)piperazin-1-yl)propyl)tricyclo[3.3.1.13,7]decan-1-amine fumarate (8) and N-(3-(4-(2-methoxyphenyl)piperazin-1-yl)propyl)-3,5-dimethyl-tricylo[3.3.1.13,7]decan-1-amine fumarate (10) proved to be highly selective ligands towards 5-HT1A receptor with a binding constant of 1.2 nM and 21.3 nM, respectively, while 5-carboxamidotriptamine (5-CT) (2) was used as an internal standard for this assay with a measured Ki = 0.5 nM.

[Modern possibilities of anti-relapse therapy of schizophrenia (experience with the use of aripiprazole)]

The review is devoted to the actual problem of anti-relapse therapy for schizophrenia. The features of the use, efficiency, tolerability and safety of typical and atypical antipsychotics are discussed. The possibilities of using atypical antipsychotics of the third generation - partial dopamine receptor agonists - on the aripiprazole model are considered. According to numerous studies, aripiprazole, due to its unique pharmacological profile and combination of clinical factors, is the drug of first choice for anti-relapse supportive therapy of schizophrenia.

Metabolic Effects of Aripiprazole and Olanzapine Multiple-Dose Treatment in a Randomised Crossover Clinical Trial in Healthy Volunteers: Association with Pharmacogenetics

Introduction

Aripiprazole and olanzapine are atypical antipsychotics. Both drugs can induce metabolic changes; however, the metabolic side effects produced by aripiprazole are more benign. The aim of the study was to evaluate if aripiprazole and olanzapine alter prolactin levels, lipid and glucose metabolism and hepatic, haematological, thyroid and renal function.

Methods

Twenty-four healthy volunteers received a daily oral dose of 10 mg aripiprazole and 5 mg olanzapine tablets for 5 days in a crossover randomised clinical trial and were genotyped for 51 polymorphisms in 18 genes by qPCR. Drug plasma concentrations were measured by LC–MS. The biochemical and haematological analyses were performed by enzymatic methods.

Results

Olanzapine induced hyperprolactinaemia but aripiprazole did not. Dopamine D3 receptor (DRD3) Ser/Gly and ATP binding cassette subfamily B member 1 (ABCB1) rs10280101, rs12720067 and rs11983225 polymorphisms and cytochrome P450 3A (CYP3A) phenotype had an impact on plasma prolactin levels. C-peptide concentrations were higher after aripiprazole administration and were influenced by catechol-O-methyltransferase (COMT) rs4680 and rs13306278 polymorphisms. Olanzapine and the UDP glucuronosyltransferase family 1 member A1 (UGT1A1) rs887829 polymorphism were associated with elevated glucose levels. CYP3A poor metabolizers had increased insulin levels. Volunteers’ weight decreased significantly during aripiprazole treatment and a tendency for weight gain was observed during olanzapine treatment. Triglyceride concentrations decreased as a result of olanzapine and aripiprazole treatment, and varied on the basis of CYP3A phenotypes and the apolipoprotein C-III (APOC3) rs4520 genotype. Cholesterol levels were also decreased and depended on 5-hydroxytryptamine receptor 2A (HTR2A) rs6314 polymorphism. All hepatic enzymes, platelet and albumin levels, and prothrombin time were altered during both treatments. Additionally, olanzapine reduced the leucocyte count, aripiprazole increased free T4 and both decreased uric acid concentrations.

Conclusions

Short-term treatment with aripiprazole and olanzapine had a significant influence on the metabolic parameters. However, it seems that aripiprazole provokes less severe metabolic changes.

Trial Registration

Clinical trial registration number (EUDRA-CT): 2018-000744-26

Graphical Abstract

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01566-w) contains supplementary material, which is available to authorized users.

The Role of the Dopamine D2 Receptor in Form-Deprivation Myopia in Mice: Studies With Full and Partial D2 Receptor Agonists and Knockouts

Purpose

The purpose of this study was to explore the role and mechanism of D2 receptor (D2R) involvement in myopia development and the effects of the full D2R agonist quinpirole and partial D2R agonist aripiprazole on postnatal refractive development and form-deprivation myopia (FDM).

Methods

C57BL/6 (“B6”) mice, raised either in a visually normal or unilateral form-deprivation environment, were divided into three subgroups, including an intraperitoneally injected (IP) vehicle group and two quinpirole (1 and 10 µg/g body weight) treatment groups. The effects of quinpirole on FDM were further verified in D2R-knockout (KO) mice and corresponding wild-type littermates. Then, the modulation of normal vision development and FDM by aripiprazole (1 and 10 µg/g body weight, IP) was assessed in C57BL/6 mice. All biometric parameters were measured before and after treatments, and retinal cyclic adenosine phosphate (cAMP) and phosphorylated ERK (pERK) levels were analyzed to assess D2R-mediated signal transduction.

Results

Neither quinpirole nor aripiprazole affected normal refractive development. FDM development was inhibited by quinpirole at low dose but enhanced at high dose, and these bidirectional effects were validated by D2R-specificity. FDM development was attenuated by the partial D2R agonist aripiprazole, at high dose but not at low dose. Quinpirole caused a dose-dependent reduction in cAMP levels, but had no effect on pERK. Aripiprazole reduced cAMP levels at both doses, but caused a dose-dependent increase of pERK in the form-deprived eyes.

Conclusions

Reduction of D2R-mediated signaling contributes to myopia development, which can be selectively attenuated by partial D2R agonists that activate D2Rs under the low dopamine levels that occur with FDM.

Partial Agonists and Dual Disorders: Focus on Dual Schizophrenia

Dual disorder is a term applied to patients with an addictive disorder and other mental disorder. Epidemiological studies have established that dual disorders are an expectation rather than an exception. They are difficult to diagnose and treat and constitute a huge burden for both patients and their relatives and society. Current treatments are a combination of those needed to treat the addictive disorder with those focused on the co-occurring psychiatric disorder. Focusing specifically on schizophrenia, growing scientific evidence supports the existence of a shared vulnerability for substance use in these patients and those at risk. Various antipsychotics have been found to be useful in the treatment of psychotic symptoms and disorders; however, few effective treatments have been identified until now for substance use disorders in patients with dual schizophrenia. Partial agonism stands as a new pharmacological option available in recent years. Molecules with this kind of action may act as functional agonists or as antagonists, depending on the surrounding levels of the neurotransmitter. Studies have found their efficacy in schizophrenia, addiction, anxiety and depression. Certain partial agonist antipsychotics seem to have a role in the treatment of dual schizophrenia. That could be the case with cariprazine. Because of its higher affinity for dopaminergic D3 receptors compared to D2, a potential to prevent relapse to addiction, added to its antipsychotic efficacy, has been suggested. Here we briefly review current advances and future directions and introduce some personal insights into the role of partial agonists in co-occurring schizophrenia and substance use.

Antipsychotics drug aripiprazole as a lead against breast cancer cell line (MCF-7) in vitro

Breast cancer is the second leading cause of death among women globally. The existing treatment options for breast cancer are largely associated with severe toxicities, and lower efficacies. Therefore, there is an urgent need for the development of non-toxic effective drugs against breast cancer. For this purpose, drug repositioning strategy was used to evaluate the anti-cancer potential of a library of heterocyclic drugs. The major advantage of drug repurposing is that the pharmacokinetic, pharmacodynamic, and toxicity profiles of drugs are well documented. In the current study, we screened 97 drugs of different chemical classes, and among them aripiprazole, an antipsychotic drug, was found to be sufficiently active against breast cancer cell line MCF-7. Aripiprazole showed a cytotoxicity (IC50 = 12.1 ± 0.40 μM) to MCF-7 cells, comparable to the standard anticancer drug doxorubicin (IC50 = 1.25 ± 0.34 μM). Aripiprazole was also found to be active against other cancer cell lines, including MDA-MB-231 (IC50 = 19.83 ± 0.27 μM), AU565 (IC50 = 18.02 ± 0.44 μM), and BT-474 (IC50 = 36.42 ± 0.12 μM). Aripiprazole significantly inhibited the cell cycle progression at subG0G1 phase, and enhanced apoptosis in MCF-7 breast cancer cells. The drug was also able to significantly increase the nuclear condensation, and modulated the expression of certain genes involved in breast cancer, such as caspases 3, and 9, BAK-1, C-MYC, BCL2L1, BCL-10, and BCL-2. Further studies are needed to explore the effect of aripiprazole on intrinsic and extrinsic pathways of apoptosis in cancer cells.

The effects of aripiprazole and olanzapine on pupillary light reflex and its relationship with pharmacogenetics in a randomized multiple-dose trial

Aims

Pupillography is a noninvasive and cost‐effective method to determine autonomic nerve activity. Genetic variants in cytochrome P450 (CYP), dopamine receptor (DRD2, DRD3), serotonin receptor (HTR2A, HTR2C) and ATP‐binding cassette subfamily B (ABCB1) genes, among others, were previously associated with the pharmacokinetics and pharmacodynamics of antipsychotic drugs. Our aim was to evaluate the effects of aripiprazole and olanzapine on pupillary light reflex related to pharmacogenetics.

Methods

Twenty‐four healthy volunteers receiving 5 oral doses of 10 mg aripiprazole and 5 mg olanzapine tablets were genotyped for 46 polymorphisms by quantitative polymerase chain reaction. Pupil examination was performed by automated pupillometry. Aripiprazole, dehydro‐aripiprazole and olanzapine plasma concentrations were measured by high‐performance liquid chromatography–tandem mass spectrometry.

Results

Aripiprazole affected pupil contraction: it caused dilatation after the administration of the first dose, then caused constriction after each dosing. It induced changes in all pupillometric parameters (P < .05). Olanzapine only altered minimum pupil size (P = .046). Polymorphisms in CYP3A, HTR2A, UGT1A1, DRD2 and ABCB1 affected pupil size, the time of onset of constriction, pupil recovery and constriction velocity. Aripiprazole, dehydro‐aripiprazole and olanzapine pharmacokinetics were significantly affected by polymorphisms in CYP2D6, CYP3A, CYP1A2, ABCB1 and UGT1A1 genes.

Conclusions

In conclusion, aripiprazole and its main metabolite, dehydro‐aripiprazole altered pupil contraction, but olanzapine did not have such an effect. Many polymorphisms may influence pupillometric parameters and several polymorphisms had an effect on aripiprazole, dehydro‐aripiprazole and olanzapine pharmacokinetics. Pupillography could be a useful tool for the determination of autonomic nerve activity during antipsychotic treatment.

Efficacy of Low-Dose Aripiprazole for Treatment of Psychotic Symptoms in a Patient with 22q11.2 Deletion Syndrome

OBJECTIVES

The 22q11.2 deletion syndrome is one of the most prevalent genetic disorders and children suffering from this syndrome have been found to have a substantially greater risk for the development of schizophrenia and bipolar disorder. Psychiatric medications such as antipsychotics are commonly used in individuals with 22q11.2DS.

EXPERIMENTAL DESIGN

This is a case of 13 years male young man suffering from 22q11.2 deletion syndrome. Since adolescence, he presented with behavioural disorders, aggression, verbal abuse, sleep disorders.

PRINCIPAL OBSERVATIONS

The psychiatric examination confirmed the delusional idea, which was repeated in an obsessive way. There were also auditory hallucinations along with reference ideas. Aripiprazole was administered in 8 mg daily which gave more spectacular results and was better tolerated.

CONCLUSIONS

In the present situation delusional ideas are no longer mentioned, but a cognitive deduction is found. Aripiprazole can be an effective pharmacological solution for the psychotic symptoms in patients suffering from 22q11DS.

Once-Monthly Long-Acting Injectable Aripiprazole for the Treatment of Patients with Schizophrenia and Co-occurring Substance Use Disorders: A Multicentre, Observational Study

AIM

To evaluate the efficacy and impact of long-acting injectable (LAI) aripiprazole in patients with schizophrenia with a coexisting substance use disorder (SUD).

PATIENTS AND METHODS

A multicenter, observational, descriptive and retrospective study was conducted in patients with a DSM-5 diagnosis of schizophrenia who had a coexisting SUD and were treated with LAI-aripiprazole. Disease severity was evaluated with the Clinical Global Impression (CGI) severity scale for schizophrenia, daily functioning and disability were evaluated with the World Health Organisation Disability Assessment Scale (WHODAS-2.0), and the severity of the addiction was evaluated with the Severity of Dependence Scale (SDS).

RESULTS

The sample included 40 patients. Overall, after 6 months of treatment with LAI-aripiprazole at a dose of 400 mg/4 weeks in 77.5% of the patients, we observed significant improvement in the psychopathological symptoms, with a reduction of over 30% in the scores of the five CGI-severity scales. The WHODAS-2.0 mean (standard deviation) score was also significantly reduced from 57.6 (8.2) to 42.3 (4.3) points (p < 0.001). Regarding SUDs, after 6 months of treatment, substance use was stopped in 5 of the 9 patients with cocaine use disorder and in 3 of the 16 patients with alcohol abuse disorder. A significant reduction in the severity of the dependence was observed only in the subgroups of participants with cocaine and alcohol use disorders.

CONCLUSION

Our study suggests that once-monthly LAI-aripiprazole retains its antipsychotic efficacy in patients with schizophrenia and a coexisting SUD and could be useful for the management of cocaine or alcohol use disorders in this population.

Does DRD2 Taq1A Mediate Aripiprazole-Induced Gambling Disorder? A Pharmacogenetic Hypothesis

Second-generation antipsychotics (SGA) are a pharmacological class widely used in psychiatry thanks to their efficacy and good tolerability profile. One of the most used SGA is aripiprazole (ARI) because of its several formulations and safe metabolic and cardiac profile. As reported in a recent review, there are growing numbers of reports about ARI-induced gambling disorder (ARI-induced GD) which should encourage clinicians to use ARI more cautiously. Given the common genetic susceptibility of both GD and ARI's clinical response to a genetic polymorphism on the D2 receptor (DRD2/ANKK1 Taq1A; rs1800497), the hypothesis regarding the origin of this phenomenon could be found in the altered sensitization of dopamine's receptors that certain individuals carry genetically. The identification of a possible genetic susceptibility (detectable by genetic tests) could provide clinicians with an explanation for the ARI-induced GD and the possibility of using genetic screening tools for those cases of suspected predisposition; this would allow the clinician to prescribe ARI with less apprehension. The confirmation of this hypothesis through future pharmacogenetic studies may be useful for clinicians to have a correct understanding of the phenomenon.

Aripiprazole-induced Hepatitis: A Case Report

Aripiprazole is an atypical antipsychotic that acts as a partial agonist of dopamine type 2 receptors as well as 5-HT1A receptors. It is used in the treatment of schizophrenia and in type 1 bipolar disorder for mania. Because aripiprazole is well tolerated with few side effects it is used off-label in other psychotic disorders. The prevalence of abnormal liver function tests with antipsychotic use is 32%, with clinically significant effects in 4% of cases. No cases of aripiprazole-induced liver injury have been published. We report a 28-year-old female who presented with non-affective first-episode psychosis and who was treated with aripiprazole. Initially she was medicated with 10 mg per day, with an increase to 20 mg per day on the 12th day of hospitalization. Nine days after she became icteric, with nausea and had a vomiting episode. Laboratory analysis revealed a very high level of alanine aminotransferase, and minor to moderately high levels of aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, and bilirubin. Aripiprazole was tapered and paliperidone was started with the improvement of clinical and laboratory findings.

Use of atypical antipsychotics and risk of hypertension: A case report and review literature

Atypical antipsychotics is being considered in the treatment of "negative" symptoms of psychoses, such as schizophrenia. In this case report, we presented a case of a patient with psychiatric disorder who developed hypertension soon after starting using atypical antipsychotic. A 53-year-old woman had reported having episodes of tachycardia, nausea, headache and high blood pressure. At the time of the doctor's appointment, the blood pressure was 210/110 mmHg. According to the patient, she made use of simvastatin for dyslipidemia and started taking aripiprazole, an antipsychotic for approximately 40 days before the symptoms. The initial treatment was 20 mg of olmesartan, and examinations were requested. After 2 months, the patient returned with the examinations: altered serum lipids and the other results were normal. Ambulatory blood pressure monitoring showed an average of 24 h of 150/100 mmHg. Blood pressure was measured at the doctor's office; in regular use of 20 mg of olmesartan, it was 156/92 mmHg. The dosage of olmesartan was increased to 40 mg and 1.5 mg of indapamide was initiated. The patient returned after 20 days with a blood pressure of 146/90 mmHg. After approval from the psychiatrist, the Aripiprazole was stopped, and the patient returned 15 days later with blood pressure of 120/80 mmHg. The ambulatory blood pressure monitoring control showed an average of 24 h of 130/78 mmHg. The Dopamine receptors play a role in the regulation of the blood pressure and the alterations in this system can lead to hypertension. D1, D3 and D4 receptors interact with the renin-angiotensin-aldosterone system, while D2 and D5 interact with the sympathetic nervous system in the regulation of PA. The case reported and the literature review bring to light the discussion of the use of atypical antipsychotics and its adverse events. If necessary, the use of these drugs should be followed by careful monitoring of blood pressure.

Cocaine-Induced Psychosis and Asenapine as Treatment: A Case Study

Cocaine-induced psychotic disorder (CIPD) is one of the most serious consequences of cocaine use. Despite the high frequency of CIPD, specific treatment for CIPD has been scarcely researched. Although supportive measures are the first approach, antipsychotic use is often necessary due to clinical severity and CIPD consequences. We report a 38-years-old man with substance use disorders in methadone maintenance treatment who relapsed on cocaine use and presented CIPD that was satisfactorily treated with asenapine. It is important further research on CIPD management, especially on asenapine and other second-generation antipsychotics du to its possible role in its treatment.

Add-on Aripiprazole for Atypical Antipsychotic-induced, Clinically Significant Hyperprolactinemia

BACKGROUND

Antipsychotic treatment-induced hyperprolactinemia is a highly distressing and disabling side effect for patients. The use of add-on aripiprazole has been identified as a possible treatment strategy in this situation. However, data on prolactin changes with add-on aripiprazole in a real-world naturalistic clinical setting from India are sparse.

MATERIALS AND METHODS

The retrospective chart review was conducted at the specialty metabolic clinic at the National Institute of Mental Health and Neurosciences, Bengaluru, India. Sixteen patients (female: male = 13:3) who were on a stable dose of antipsychotic medications, complaining of either sexual dysfunction or menstrual irregularities, were prescribed add-on aripiprazole. The serum prolactin values were obtained before the initiation of aripiprazole and during the follow-up.

RESULTS

Patients were on treatment with risperidone, amisulpride, and olanzapine and had a prolactin level of 87.1 ± 60.7 ng/ml. Add-on aripiprazole treatment was given with a mean dose of 13.8 ± 7.4 mg/day. Patients had a significant reduction in prolactin level (35.6 ± 29.1 ng/ml) following treatment with aripiprazole (P = 0.004).

CONCLUSIONS

Add-on aripiprazole could be a clinically useful strategy in patients who develop antipsychotic-induced hyperprolactinemia.

Does the Time of Drug Administration Alter the Metabolic Risk of Aripiprazole?

Antipsychotic drugs cause metabolic abnormalities through a mechanism that involves antagonism of D₂ dopamine receptors (D₂R). Under healthy conditions, insulin release follows a circadian rhythm and is low at night, and in pancreatic beta-cells, D₂Rs negatively regulate insulin release. Since they are sedating, many antipsychotics are dosed at night. However, the resulting reduction in overnight D₂R activity may disrupt 24 h rhythms in insulin release, potentially exacerbating metabolic dysfunction. We examined retrospective clinical data from patients treated over approximately 1 year with the antipsychotic drug aripiprazole (ARPZ), a D2R partial agonist. To identify effects of timing on metabolic risk, we found cases treated with ARPZ either in the morning (n = 90) or at bedtime (n = 53), and compared hemoglobin A1c, and six secondary metabolic parameters across the two groups. After controlling for demographic and clinical factors, patients treated with ARPZ at night had a significant decrease in HDL cholesterol, while in patients who took ARPZ in the morning had no change. There was a non-significant trend toward higher serum triglycerides in the patients treated with ARPZ at night vs. morning. There were no group differences in hemoglobin A1c, BMI, total cholesterol, LDL cholesterol, or blood pressure. Patients taking APPZ at night developed a worse lipid profile, with lower HDL cholesterol and a trend toward higher triglycerides. These changes may pose additional metabolic risk factors compared to those who take ARPZ in the morning. Interventions based on drug timing may reduce some of the adverse metabolic consequences of antipsychotic drugs.

Comparison of the efficacy and safety of 4 and 2 mg/day brexpiprazole for acute schizophrenia: a meta-analysis of double-blind, randomized placebo-controlled trials

PURPOSE

The purpose of this study was to compare the efficacy and safety of brexpiprazole 4 mg/day (B4) and 2 mg/day (B2) for treating acute schizophrenia.

PATIENTS AND METHODS

We performed three categorical meta-analyses (B4 vs placebo, B2 vs placebo, and B4 vs B2) of double-blind, randomized placebo-controlled trials (DBRCTs) that reported improvements in the Positive and Negative Syndrome Scale (PANSS) scores, response rate, Clinical Global Impression-Improvement and Severity (CGI-I and CGI-S) scores, discontinuation rate, and incidence of individual adverse events.

RESULTS

We identified three DBRCTs with 1,444 patients. Both B4 and B2 were superior to placebo for PANSS total score (B4: standardized mean difference [SMD] =-0.30, 95% CI =-0.43, -0.17; B2: SMD =-0.30, 95% CI =-0.46, -0.13), PANSS negative score, response rate, CGI-S score, and CGI-I score. B2, but not B4, was superior to placebo for the PANSS positive score. However, there was considerable heterogeneity in the meta-analysis for B4's PANSS positive score, which disappeared after excluding a 2018 Japanese study from the meta-analysis that included more patients on a high-dose antipsychotic prior to their participation. A meta-analysis that excluded the data from the abovementioned patients showed B4 to be superior to the placebo in terms of the PANSS positive score (SMD =-0.22, 95% CI =-0.40, -0.03). B2, but not B4, was associated with a lower incidence of all-cause discontinuation compared with placebo. Both B4 and B2 were superior to placebo for discontinuation due to adverse events and schizophrenia, but both were associated with a higher incidence of weight gain compared with placebo. B4 was also associated with a higher risk of extrapyramidal symptoms than B2.

CONCLUSION

Both B4 and B2 benefitted patients with schizophrenia, particularly those who were not previously on high-dose antipsychotics. Both the regimens were well-tolerated, but carried a risk of weight gain and extrapyramidal symptoms, although the latter risk was higher for B4 than B2.

Spotlight on once-monthly long-acting injectable aripiprazole and its potential as maintenance treatment for bipolar I disorder in adult patients

The lack of long-term medication adherence is a challenge in the treatment of bipolar disorder, particularly during the maintenance phase when symptoms are less prominent. The rate of nonadherence is ~20%-60% depending on how strict a definition is used. Nonadherence worsens the course of bipolar disorder and can add hundreds of thousands of dollars to the lifetime cost of treating the illness. Long-acting injectable (LAI) medication is an attractive alternative to daily dosing of oral medication, especially among patients who are ambivalent about treatment. The purpose of this paper is to review the evidence for the safety and efficacy of LAI aripiprazole, which was recently approved for the treatment of bipolar disorder. The approval was based on a single double-blind, placebo-controlled, multisite trial that recruited participants from 103 sites in 7 countries. A total of 731 participants with bipolar disorder were enrolled in the study. Out of that total, 266 were successfully stabilized on LAI aripiprazole and entered the randomization phase. Treatment-emergent adverse events were, for the most part, mild to moderate. Akathisia was the most common adverse event, which, combined with restlessness, was experienced by 23% of the sample. At the end of the 52-week study period, nearly twice as many LAI-treated participants remained stable compared to those treated with placebo. Stability during the maintenance phase is arguably the most important goal of treatment. It is during this period of relative freedom from symptoms that patients are able to build a meaningful and satisfying life. The availability of a new treatment agent, particularly one that has the potential to enhance long-term adherence, is a welcome development.

Aripiprazole-induced Tardive Dyskinesia in 13 Years Old Girl Successfully Treated with Biperiden: A Case Report

In the last years second-generation antipsychotics are increasingly prescribed in the pediatric population for the treatment of several psychiatric disorders. Among the long term adverse effects, extrapyramidal symptoms (EPS) are less reported compared to first-generation antipsychotics. Tardive dyskinesia (TD) is a iatrogenic rare syndrome characterized by persistent slow writhing and sudden involuntary movements mainly involving the oral-buccal-lingual area with masticatory movements. We report a young girl with mood disorders accompanied by mild intellectual disability and behavioral problems who had TD after treatment with Aripiprazole, which responded to Biperiden therapy.

Classics in Chemical Neuroscience: Aripiprazole

Aripiprazole was the first antipsychotic developed to possess agonist properties at dopamine D₂ autoreceptors, a groundbreaking strategy that presented a new vista for schizophrenia drug discovery. The dopamine D₂ receptor is the crucial target of all extant antipsychotics, and all developed prior to aripiprazole were D₂ receptor antagonists. Extensive blockade of these receptors, however, typically produces extrapyramidal (movement) side effects, which plagued first-generation antipsychotics, such as haloperidol. Second-generation antipsychotics, such as clozapine, with unique polypharmacology and D₂ receptor binding kinetics, have significantly lower risk of movement side effects but can cause myriad additional ones, such as severe weight gain and metabolic dysfunction. Aripiprazole's polypharmacology, characterized by its unique agonist activity at dopamine D₂ and D₃ and serotonin 5-HT_1A receptors, as well as antagonist activity at serotonin 5-HT_2A receptors, translates to successful reduction of positive, negative, and cognitive symptoms of schizophrenia, while also mitigating risk of weight gain and movement side effects. New observations, however, link aripiprazole to compulsive behaviors in a small group of patients, an unusual side effect for antipsychotics. In this review, we discuss the chemical synthesis, pharmacology, pharmacogenomics, drug metabolism, and adverse events of aripiprazole, and we present a current understanding of aripiprazole's neurotherapeutic mechanisms, as well as the history and importance of aripiprazole to neuroscience.

Dose Trends of Aripiprazole from 2004 to 2014 in Psychiatric Inpatients in Korea

Objective

Although aripiprazole has been widely used to treat various psychiatric disorders, little is known about the adequate dosage for Asian patients in clinical practice. Hence, we evaluated the initial and maximum doses of aripiprazole from 2004 to 2014 to estimate the appropriate dosage for Korean psychiatric inpatients in clinical practice.

Methods

In this retrospective study, we reviewed the medical records of patients who were hospitalized in five university hospitals in Korea from March 2004 to December 2014. The psychiatric diagnosis according to the text revision of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition during index hospitalization and the initial and maximum doses of aripiprazole were evaluated.

Results

There were 74 patients in Wave 1 (2004–2006), 201 patients in Wave 2 (2007–2010), and 353 patients in Wave 3 (2011–2014). The initial doses of aripiprazole in all diagnostic groups were significantly lower in Wave 3 than in Wave 2. The maximum doses of aripiprazole in each diagnostic group were not significantly different among Waves 1, 2, and 3.

Conclusion

The relatively low initial doses of aripiprazole documented in our study may reflect a strategy by clinicians to minimize the side effects associated with aripiprazole use, such as akathisia.

Long-Acting Injectable Antipsychotics in Schizophrenia: Literature Review and Practical Perspective, with a Focus on Aripiprazole Once-Monthly

INTRODUCTION

Prevention of relapse is a major challenge in schizophrenia, a disease characterized by poor adherence to antipsychotic medication leading to multiple rehospitalizations and a substantial burden-of-care.

METHODS

We narratively review published clinical data from the development of long-acting injectable (LAI) formulations of antipsychotic drugs and examine the comparative effectiveness of oral versus LAIs in schizophrenia, with a focus on the second-generation LAI antipsychotic aripiprazole. Evidence is presented from studies with naturalistic/pragmatic as well as explanatory trial designs, supported by the clinical experience of the authors.

RESULTS

LAI formulations of antipsychotic drugs offer advantages over oral medications and there is good evidence for their use as a first-choice treatment and in younger patients. Key phase III studies have shown aripiprazole once-monthly 400 mg (AOM 400) to be effective and well tolerated, with high rates of adherence and low rates of impending relapse. In a recent randomized trial with a "naturalistic" study design more representative of routine clinical practice, AOM 400 was well tolerated and had significantly greater effectiveness than paliperidone LAI overall and in younger patients aged ≤35 years.

CONCLUSION

Results across the "full spectrum" of efficacy in traditional clinical trials as well as those encompassing the concept of effectiveness in a more naturalistic setting of real-life clinical practice support the use of AOM 400 as a valid long-term treatment option in schizophrenia overall, as well as earlier in the treatment course, and not solely in situations of poor adherence or when oral antipsychotics have failed.

Neuroleptic Drugs and PACAP Differentially Affect the mRNA Expression of Genes Encoding PAC1/VPAC Type Receptors

Several lines of evidence suggest that pituitary adenylate cyclase-activating polypeptide (PACAP) is a neuropeptide playing an important role as a neuromodulator. It has been indicated that PACAP is associated with mental diseases, and that regulation of the PACAPergic signals could be a potential target for the treatment of such psychiatric states as schizophrenia. Recent studies have suggested that action of neuroleptic drugs is mediated not only by dopaminergic and serotonergic neurotransmission, but also via neuropeptides which may act both as neurotransmitters and as neuromodulators. The present study examines whether currently-used neuroleptics influence the action of PACAP receptors, whose expression is altered in a schizophrenic patient. Real-time polymerase chain reaction (PCR) was used to examine the effects of haloperidol, olanzapine and amisulpride on the expression of genes coding PAC1/VPAC type receptors in the T98G glioblastoma cell line, as an example of an in vitro model of glial cells. PAC1 mRNA expression fell after 24-h incubation with haloperidol or olanzapine; however the effect was not maintained after 72 h, and haloperidol even up-regulated PAC1 mRNA expression in a dose-dependent manner. All the examined drugs decreased VPAC2 mRNA expression, especially after 72-h incubation. Haloperidol (typical neuroleptic) was distinctly more potent than atypical neuroleptic drugs (olanzapine and amisulpride). In addition, PACAP increased PAC1 and VPAC2 mRNA expression. In conclusion, our findings suggest PACAP receptors may be involved in the mechanism of typical and atypical neuroleptic drugs.

Palmar hyperhidrosis treated by noninvasive ultrasound stellate ganglion block

Focal palmar hyperhidrosis is a common and often debilitating eccrine sweat gland disorder with negative impact on quality of life and self-esteem. For treatment of recalcitrant cases, a stellate ganglion block is a nonsurgical alternative. Although this method has only a temporary effect, surgical risks can be avoided. The usual way to perform the block is by ultrasound-guided injection of local anesthetics. Here we describe the use of therapeutic ultrasound at 0.8 MHz for stellate ganglion block. Ultrasound was applied for 1 min unilaterally every other day for 6 days. The efficacy was monitored by video capillaroscopy and Minor's iodine starch test. Treatment was well tolerated and no adverse effects were noted. Sweating was stopped and capillary blood flow increased. The effect lasted for several weeks.

Safety and efficacy of aripiprazole for the treatment of pediatric Tourette syndrome and other chronic tic disorders

Tourette syndrome is a childhood-onset chronic tic disorder characterized by multiple motor and vocal tics and often accompanied by specific behavioral symptoms ranging from obsessionality to impulsivity. A considerable proportion of patients report significant impairment in health-related quality of life caused by the severity of their tics and behavioral symptoms and require medical intervention. The most commonly used medications are antidopaminergic agents, which have been consistently shown to be effective for tic control, but are also associated with poor tolerability because of their adverse effects. The newer antipsychotic medication aripiprazole is characterized by a unique mechanism of action (D2 partial agonism), and over the last decade has increasingly been used for the treatment of tics. We conducted a systematic literature review to assess the available evidence on the efficacy and safety of aripiprazole in pediatric patients with Tourette syndrome and other chronic tic disorders (age range: 4–18 years). Our search identified two randomized controlled trials (involving 60 and 61 participants) and ten open-label studies (involving between six and 81 participants). The majority of these studies used two validated clinician-rated instruments (Yale Global Tic Severity Scale and Clinical Global Impression scale) as primary outcome measures. The combined results from randomized controlled trials and open-label studies showed that aripiprazole is an effective, safe, and well-tolerated medication for the treatment of tics. Aripiprazole-related adverse effects (nausea, sedation, and weight gain) were less frequent compared to other antidopaminergic medications used for tic management and, when present, were mostly transient and mild. The reviewed studies were conducted on small samples and had relatively short follow-up periods, thus highlighting a need for further trials to assess the long-term use of aripiprazole in pediatric patients with Tourette syndrome and other chronic tic disorders with measurement of its efficacy using both clinician-rated and self-report scales.