HealthCareMagic is now Ask A Doctor - 24x7 | https://www.askadoctor24x7.com

How To Switch From Abilify To Seroquel Without Any Side Effects?

Posted on Mon, 17 Nov 2014

Question: Can you suggest appropriate switching strategies for going from Abilify 15mg QD to Seroquel eventually titrated to 600mg QD for Bipolar I maintnance? (Dose titration/period of overlap at given doses,etc.)

Answered by Dr. Chintan Solanki (2 hours later)

Brief Answer:
I can suggest but provide some info

Detailed Answer:
Hello,

Thanks for writing to us.

I can suggest how to switch but for that I need some information as below.

Weight of the person suffering from the disorder?

Is there any physical illness like diabetes or hypertension or obesity?

From Abilify 15 mg QD(total 60 mg/day) to Seroquel 600 mg QD(total 2400 mg/day) is quite high dose for seroquel. Is it suggested by a psychiatrist or self attempt?

Are there any concurrent medicines going on?

Total duration and Current condition of the symptoms of bipolar disorder.

Waiting for your reply to guide you specifically.

Regards,

Dr.Chintan Solanki.

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Chintan Solanki (31 minutes later)

Oh, you misunderstood. Where I live in the USA, QD means once daily. 4 times per day would be QID. So the dose I am taking is 15mg Abilify per day and will be titrating up to 600mg Seroquel per day. My weight is 204 pounds. My BMI is around 32. So I am a little overweight. No diabetes and no hypertension. I asked my psychiatrist to change because I can no longer afford Abilify. Generic Seroquel is much less expensive. Concurrent medications are Lamictal 200mg twice daily, Effexor XR 300mg total per day, klonopin 3mg total per day, and Adderall 40mg at 6:00 am and 40mg at noon. Total duration unknown, but diagnosed 2 years ago. Previous psychiatrists diagnosed me with major depression and I took drugs like Paxil, Wellbutrin, Celexa, Lexapro, Cymbalta, and finally Effexor. Initially my new psychiatrist thought i had melancholic type depression and doubled the Effexor. Later came the other current medications. Current symptoms are mild depression and general anxiety. I was recently in a mixed state and she says i have rapid cycling. Of note I began feeling depressed around age 20. Anxiety began as well and steadily worsened for years. This was complicated by substance abuse (alcohol and prescription opioids). I have not used either in over 2 years. It was not until I was 36 that I had a brief period of psychosis limited to hearing voices after a prolonged period of severe stress. I had another brief psychotic episode at age 37, again hearing voices/paranoia. I have not had any psychotic symptoms since then and since starting Abilify. I am asking about how to switch just to get another opinion. I have researched the topic extensively, but cannot find specific guidelines.

Answered by Dr. Chintan Solanki (3 hours later)

Brief Answer:
No specific guidelines but from clinical experience

Detailed Answer:
Hello XXXXXX,

Sorry for misunderstanding. Actually we have practice of writing OD instead of QD.

Thanks for detail information.

Yes, there is no specific guideline in most of the cases to switch from one medicine to another like in case of abilify to seroquel. Most of the cases decided by doctor from clinical experience how to switch. And normally most of the patients switch to abilify from seroquel due to side effects concern of seroquel specifically weight gain while your case is somewhat different.

You can switch in following manner as per my opinion. Different doctors have different approach.

I prefer sustain release (SR) preparation of seroquel but I think plain preparation will be cheaper and you are in need of that.

You can begin with 50 mg seroquel at night with continuing abilify.

On 3rd day you can add more 50 mg at night more.

6th day you can add 50 mg in morning .

9th day you can add 50 mg in noon.

12th day you can reduce to abilify to 10 mg and add more 50 mg seroquel at night. Means seroquel 50 in the morning 50 in the noon and 150 at night.

15th day add more 50 mg seroquel at night.

18th day add 50 mg more seroquel to morning dose.

21st day reduce abilfy to 5 mg and add 50 mg seroquel to noon dose. So seroquel will be 100 in morning, 100 in noon and 200 at night.

24th day add 100 mg seroquel to night dose.

27th day more 100 mg seroquel to night dose.

30th day stop abilify and you will be on seroquel 100 in the morning , 100 in noon and 400 at night.

Now, few comments from my side in regard to these changes.

I prefer gradual titration and sometime patient gets more sedation with seroquel.

Lamicatal can reduce seroquel level through interaction so clinically it should be monitored considering stability and improvement.

Effexor already have side effects profile specifically cardiac EKG changes,
seroquel can add to these side effects, so regular check up and monitoring needed.

Start exercises and diet control to prevent weight gain from seroquel as well to reduce current BMI 32 to target BMI 25.

Best judge is your treating doctor who is aware about your physical, psychological and economical condition.

Hope I have answered your query, I will be happy to answer if still any confusion.
All the best & Regards,
Dr.Chintan Solanki.

Above answer was peer-reviewed by : Dr. Ashwin Bhandari

Follow up: Dr. Chintan Solanki (6 hours later)

Thank you for the detailed answer. I do have a question as to why it is good to take a month to get off Abilify? Won't the 2 drugs be competing for some of the same receptors? Here is what my psychiatrist is doing the switch: reduce Abilify to 10mg for 1 week, then reduce it to 5 mg for 1 week then stop. At the same time (when I first start taking only 10mg Abilify, start Seroquel 300mg at night for 2 nights, then take 600mg Seroquel at night from then on. So I taper off Abilify over 2 weeks, while reaching target dose of Seroquel in 3 days. What do you think of this approach?

Answered by Dr. Chintan Solanki (4 hours later)

Brief Answer:
Abilify can be reduced fast but seroquel cant be increased so fast

Detailed Answer:
Thanks for follow up and good questions.

Aripiprazole(Abilify) and quetiapine(Seroquel) both are anti-psychotics and both deal with Serotonin and dopamine systems. However mechanism of action differs somewhat. Abilify is partial D2 agonist, partial 5-HT1A agonist and 5-HT2A antagonist while Seroquel is 5HT2A and D2 antagonist and 5HT1A partial agonist. In addition Seroquel is Alpha 1 and H1 antagonist. This last binding is responsible for cardiac related side effects like postural hypotension which can be prevented by slow titration.

I have already mentioned that different doctors follow different approach from their clinical experience. In USA Seroquel used in higher doses and patient of US origin may be tolerating well while in country where I practice, XXXXXXX we use lower side doses as patients from XXXXXXX origin tolerate less.

I agree with reducing abilify faster but not with increasing Seroquel so fast. In many patients Seroquel cause excessive sedation and/or postural hypotension which sometime can lead to physical injury if by chance person falls.If patient can tolerate Seroquel well, 600 mg dose can be titrated in 15 days under medical supervision. In previous recommendation just add more 50mg at night on 6th and 9th day. And 50 mg more in day time dose and 100 mg more in night time dose on 12th and 15th day.

I hope you got your answers, if still any query,you are welcome.

Regards,

Dr.Chintan Solanki.

Above answer was peer-reviewed by : Dr. Vinay Bhardwaj

Follow up: Dr. Chintan Solanki (1 hour later)

Thank you for your very specific suggestions and explanations. I am a pharmacist, but had never dealt with this particular question before. I searched everywhere for guidance but found very little. I tend to agree with you. I assumed Abilify could be stopped relatively quickly due to its long half-life. And typical titration scheduled for Seroquel beginners is usually a daily increase over a minimum of 4 days depending on target dose. I have never seen any recommendations to start at 300mg, especially if patient is on other psychotropic meds. I wondered if at these high totration doses there would be antagonistic interactions between the 2 drugs with respect to receptor binding? I believe Abilify has a higher affinity for the D2 receptor and an occupancy of about 80%,whereas Seroquel has a lower affinity and occupies fewer receptors (40-60%)? So you have partial agonism blocking both endogenous dopamime and Seroquel from binding, while providing some D2 dopaminergic tone due to the partial agonism. What are the implications involving these two drugs at other receptors both pre and post-synaptically? And what about Effexor and Adderall thrown in the mix. Anything you can tell me about these and other receptors (like 5HT7, NE transporter, etc.) would be helpful as my curiosity has increases now that I am the patient.

Answered by Dr. Chintan Solanki (10 hours later)

Brief Answer:
You need to read a book for such detail informatio

Detailed Answer:
Hi,

Thanks for questions again. I can understand your curiosity. Queries mentioned by you require detail, long and elaborate answers which is practically not possible to write here. I will try my best to explain specifically in brief.

Here issue is replacing one medicine with the other, not that giving both drugs simultaneously. So we need to worry about antagonistic interaction between two.

Yes you are right abilify has very high affinity for D2 and D3 receptors while seroquel has low affinity as well as it dissociates very early from receptors.
For other receptors binding implication I am sending you link to read which I found appropriate and useful.

http://psychopharmacologyinstitute.com/antipsychotics/aripiprazole/mechanism-of-action-aripiprazole/

http://en.wikipedia.org/wiki/Aripiprazole

http://psychopharmacologyinstitute.com/antipsychotics/quetiapine/mechanism-of-action/

http://en.wikipedia.org/wiki/Quetiapine

Your question, “And what about Effexor and Adderall thrown in the mix.” I am not clear what do you want to know exactly. Is it to mix both drug by breaking them or is it to take them simultaneously one after another?

For great detail of all drugs action on receptors, you can refer to a book, Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical implication ...By XXXXXXX M. Stahl

Hope I have answered your query.

Regards,
Dr.Chintan Solanki.

Note: For further guidance on mental health, Click here.

Above answer was peer-reviewed by : Dr. Bhagyalaxmi Nalaparaju