Efficacy with High-Dose Aripiprazole After Olanzapine-Related Metabolic Disturbances

OBJECTIVE: To report a case in which a patient tolerated and responded to high-dose aripiprazole and lost weight after having been on olanzapine for several years; a secondary objective is to discuss the use of aripiprazole dosages at higher than those recommended in the product's labeling. CASE SUMMARY: A 57-year-old man with a 30 year history of schizophrenia had been taking olanzapine for 4 years, with the dosage titrated to 20 mg/day, to control the psychosis. After he had gained significant weight with olanzapine (the highest was 102.7 kg), his treatment was switched to aripiprazole. The patient required a high dose of aripiprazole (60 mg/day) to achieve full control of the psychiatric symptoms, and during aripiprazole therapy, he lost the weight he had gained while on olanzapine, weighing 85.9 kg within 7 months after the therapy switch. DISCUSSION: Dosages of atypical antipsychotics higher than those recommended by the Food and Drug Administration are often used in clinical practice for refractory patients, despite the lack of evidence. The literature available on this subject is limited to small, double-blind trials; open-label trials; and case reports. Although certain patients may benefit from higher doses of atypical antipsychotics, the lack of evidence limits their use. CONCLUSIONS: High-dose aripiprazole (60 mg/day) was well tolerated and controlled this patient's symptoms effectively. In addition, he lost weight that was gained while being treated with olanzapine. High-dose aripiprazole may be beneficial and safe in refractory patients; however, large, double-blind, randomized clinical trials are needed.