Adjunct abilify for neuroleptic induced hyperprolactinemia?

[HarryMTieboutMD]

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I have a patient on Invega Sustenna 234 who is very stable (now that she finally quit smoking weed!) but is complaining of amenorrhea and galactorrhea, and I have read the existing literature on adjunct Abilify as a treatment for neuroleptic induced hyperprolactinemia, and most of the studies (first RCT published in AJP in 2007 Adjunctive treatment with a dopamine partial agonist, aripiprazole, for antipsychotic-induced hyperprolactinemia: a placebo-controlled trial. - PubMed - NCBI) incidentally show a reduction in PRL levels without increased EPS but inconsistent clinical outcomes

Most of my attendings just address hyperprolactinemia with a switch/dose reduction, but has anyone on here 1) used Abilify for this purpose and 2) seen clinically significant results (discharge stops, patient starts menstruating, etc)?

(And in case anyone is wondering she is in a monogamous relationship, and they use protection; I'm going to try to negotiate an IUD/Depo shot nonetheless)

Thanks!

 

[Acyl chloride]

I had a patient with hyperprolactinemia and discharge who had all symptoms resolve within a week of starting ability 5mg. N of one but my attending suggested it based on that and one more paper I believe. Repeat labs were also wnl

 

[Shikima]

Get a prolactin level?

 

[SmallBird]

I have a patient on Invega Sustenna 234 who is very stable (now that she finally quit smoking weed!) but is complaining of amenorrhea and galactorrhea, and I have read the existing literature on adjunct Abilify as a treatment for neuroleptic induced hyperprolactinemia, and most of the studies (first RCT published in AJP in 2007 Adjunctive treatment with a dopamine partial agonist, aripiprazole, for antipsychotic-induced hyperprolactinemia: a placebo-controlled trial. - PubMed - NCBI) incidentally show a reduction in PRL levels without increased EPS but inconsistent clinical outcomes

Most of my attendings just address hyperprolactinemia with a switch/dose reduction, but has anyone on here 1) used Abilify for this purpose and 2) seen clinically significant results (discharge stops, patient starts menstruating, etc)?

(And in case anyone is wondering she is in a monogamous relationship, and they use protection; I'm going to try to negotiate an IUD/Depo shot nonetheless)

Thanks!

Yes and yes - it is dramatic how the prolactin level can plummet with even just a 5mg dose added.

 

[PistolPete]

I really try to limit polypharmacy as much as possible. If she's OK with taking another medication, and Abilify resolves her symptoms, then fine. But definitely ask if she wants to lower the dose or switch to something else.

 

[Merovinge]

I really try to limit polypharmacy as much as possible. If she's OK with taking another medication, and Abilify resolves her symptoms, then fine. But definitely ask if she wants to lower the dose or switch to something else.

Meh this is not at all like using 2 atypicals in the standard garbage pile community psychiatric inpatient unit. This is a very valid, pharmacokinetically informed, effective way to control side effects without any expectations Abilify helps with psychosis, if anything there is concern it would worsen it.

I would start at 2mg of Abilify, recheck prolactin in a month and consider titration to 4-5mg if needed. All of our psychosis docs have had better experiences with Abilify rather than bromocriptine, it works faster and rarely has associated side-effects at the low doses you need.

 

[PistolPete]

Meh this is not at all like using 2 atypicals in the standard garbage pile community psychiatric inpatient unit. This is a very valid, pharmacokinetically informed, effective way to control side effects without any expectations Abilify helps with psychosis, if anything there is concern it would worsen it.

I would start at 2mg of Abilify, recheck prolactin in a month and consider titration to 4-5mg if needed. All of our psychosis docs have had better experiences with Abilify rather than bromocriptine, it works faster and rarely has associated side-effects at the low doses you need.

I wasn't worried about the 2 antipsychotic aspect, since this is a good reason to use 2, more so the "just take one more med" aspect. Maybe it's because I'm in child but I'm always conscientious about adding medication to what may already be a list of 2, 3 or more meds to be taken daily. We know that adherence on average is 50% for each medication prescribed (I.e. On average only 25% of patients will take 2 medications as prescribed).

But yea, Abilify here may be a nice and easy fix.

 

[Merovinge]

I wasn't worried about the 2 antipsychotic aspect, since this is a good reason to use 2, more so the "just take one more med" aspect. Maybe it's because I'm in child but I'm always conscientious about adding medication to what may already be a list of 2, 3 or more meds to be taken daily. We know that adherence on average is 50% for each medication prescribed (I.e. On average only 25% of patients will take 2 medications as prescribed).

But yea, Abilify here may be a nice and easy fix.

While that is true overall for adherence, rates are much higher for palpable problems. ABx course when people are acutely symptomatic have adherence rates around 90% for example. If your breasts start dropping milk and someone says take this pill to make that go away, I would wager adherence would also be much higher than baseline.

 

[PistolPete]

While that is true overall for adherence, rates are much higher for palpable problems. ABx course when people are acutely symptomatic have adherence rates around 90% for example. If your breasts start dropping milk and someone says take this pill to make that go away, I would wager adherence would also be much higher than baseline.

I'm sure you're right! 🙂

 

[michaelrack]

won't abilify theoretically interfere with the effect of the first antipsychotic (due to its partial agonist activity at D2 receptors)?? It might be reasonable to start abilify slowly and then do a long cross-taper with the original antipsychotic, perhaps with a goal of ending up on the Abilify LAI.

 

[SmallBird]

won't abilify theoretically interfere with the effect of the first antipsychotic (due to its partial agonist activity at D2 receptors)?? It might be reasonable to start abilify slowly and then do a long cross-taper with the original antipsychotic, perhaps with a goal of ending up on the Abilify LAI.

This does seem to be possible too - I recall a case that developed some transient worsening of their symptoms in the first days of being on the combination. Possibly the issue is that D2 receptors have been upregulated due to chronic antagonism, giving ability a lot of places to bind to. But at low doses this isn't always an issue and when it is, it seems to be transient. Of course I don't have a ton of data, this is based on 4 or 5 cases.

What I've wondered about is the consequences of the prolactin being too low - abilify doesn't so much normalize it as drive it into the floor. I seem to remember that prolactin is important for stuff too.

 

[HarryMTieboutMD]

Thanks for all the replies- I was mostly looking for anecodatal experiences with clinical improvement rather than just PRL levels

 

[SmallBird]

Thanks for all the replies- I was mostly looking for anecodatal experiences with clinical improvement rather than just PRL levels

Yeah, in case it wasn't clear, this was associated with clinical improvement both in terms of amenorrhea, but in one case the patient was experiencing visual impairment and had a pituitary mass on MRI - it became undetectable with abilify!

 

[Merovinge]

won't abilify theoretically interfere with the effect of the first antipsychotic (due to its partial agonist activity at D2 receptors)?? It might be reasonable to start abilify slowly and then do a long cross-taper with the original antipsychotic, perhaps with a goal of ending up on the Abilify LAI.

Theoretically, absolutely, and certainly no one is suggesting higher dose Abilify as a dual therapy. I believe it is somewhat known to have some preference for the tuberoinfandibular pathway and even in the severe schizophrenia cases I have seen they remain stable with the addition of Abilify. That said it would be great if they could just take Maintena but there are certainly a group of patients who have sx control on risperidone/invega and not Abilify.

 

[SmallBird]

Theoretically, absolutely, and certainly no one is suggesting higher dose Abilify as a dual therapy. I believe it is somewhat known to have some preference for the tuberoinfandibular pathway and even in the severe schizophrenia cases I have seen they remain stable with the addition of Abilify. That said it would be great if they could just take Maintena but there are certainly a group of patients who have sx control on risperidone/invega and not Abilify.

Wouldn't it be great if we had better answers to these questions though? It wouldn't take another CATIE, just a few $100 000 for a well controlled study with a few months of follow-up. But I guess soon we will have the Connectome and then this won't be important anymore?

 

[thoffen]

I would certainly try to use the minimum dose of aripiprazole possible to get prolactin back in the normal range. Both have high affinity for D2 (reported Ki's differ, so it's hard to say for sure), but aripiprazole is generally considered to be a higher affinity. Certainly there's a lot more going on than just D2 activity, but I would be cautious in disrupting efficacy for someone who is responding to Sustenna.

 

[TexasPhysician]

I have a patient on Invega Sustenna 234 who is very stable (now that she finally quit smoking weed!) but is complaining of amenorrhea and galactorrhea, and I have read the existing literature on adjunct Abilify as a treatment for neuroleptic induced hyperprolactinemia, and most of the studies (first RCT published in AJP in 2007 Adjunctive treatment with a dopamine partial agonist, aripiprazole, for antipsychotic-induced hyperprolactinemia: a placebo-controlled trial. - PubMed - NCBI) incidentally show a reduction in PRL levels without increased EPS but inconsistent clinical outcomes

Most of my attendings just address hyperprolactinemia with a switch/dose reduction, but has anyone on here 1) used Abilify for this purpose and 2) seen clinically significant results (discharge stops, patient starts menstruating, etc)?

(And in case anyone is wondering she is in a monogamous relationship, and they use protection; I'm going to try to negotiate an IUD/Depo shot nonetheless)

Thanks!

Yes. Did this many times in residency.