Consumer medicine information

Abilify

Aripiprazole

BRAND INFORMATION

Brand name

Abilify

Active ingredient

Aripiprazole

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Abilify.

SUMMARY CMI

ABILIFY™

Consumer Medicine Information (CMI) summary

The full CMI on the next page has more details. If you are worried about using this medicine, speak to your doctor or pharmacist.

1. Why am I using ABILIFY?

ABILIFY contains the active ingredient aripiprazole. ABILIFY is used to treat symptoms of schizophrenia. ABILIFY may be given to treat acute episodes of sustained upward mood swings (mania) in adult patients with Bipolar 1 Disorder. During mania, patients experience episodes of overactivity, elation or irritability.

For more information, see Section 1. Why am I using ABILIFY? in the full CMI.

2. What should I know before I use ABILIFY?

Do not use if you have ever had an allergic reaction to ABILIFY or any of the ingredients listed at the end of the CMI.

Talk to your doctor if you have any other medical conditions, take any other medicines, or are pregnant or plan to become pregnant or are breastfeeding.

For more information, see Section 2. What should I know before I use ABILIFY? in the full CMI.

3. What if I am taking other medicines?

Some medicines may interfere with ABILIFY and affect how it works.

A list of these medicines is in Section 3. What if I am taking other medicines? in the full CMI.

4. How do I use ABILIFY?

  • Unless your doctor gives you other directions, you should take ABILIFY only once a day.
  • Take ABILIFY at about the same time each day.

More instructions can be found in Section 4. How do I use ABILIFY? in the full CMI.

5. What should I know while using ABILIFY?

Things you should do
  • Remind any doctor, dentist or pharmacist you visit that you are using ABILIFY.
  • If you become pregnant while taking ABILIFY, tell your doctor immediately.
Things you should not do
  • Do not give ABILIFY to anyone else, even if their symptoms seem similar or they have the same condition as you.
  • Do not stop taking ABILIFY or lower the dosage, even if you are feeling better, without checking with your doctor.
Driving or using machines
  • Make sure that you know how you react to ABILIFY before you drive a car, operate machinery or do anything else that could be dangerous if you are dizzy or light headed or not alert.
Drinking alcohol
  • Be careful when drinking alcohol while taking ABILIFY.
  • Your doctor may suggest you avoid alcohol while you are being treated with ABILIFY.
Looking after your medicine
  • Store ABILIFY in a cool place where the temperature stays below 30°C.

For more information, see Section 5. What should I know while using ABILIFY? in the full CMI.

6. Are there any side effects?

Common side effects are headache; indigestion; nausea; vomiting; insomnia; constipation; light-headedness; drowsiness; agitation; anxiety; inability to sit or stand still, restless movement of the arms and legs. Serious side effects include seizure; fits or convulsions; fainting; sudden increase in body temperature; sweating.

For more information, including what to do if you have any side effects, see Section 6. Are there any side effects? in the full CMI.



FULL CMI

ABILIFY™

Active ingredient(s): Aripiprazole (Ari-pip-rah-zol)

Consumer Medicine Information (CMI)

This leaflet provides important information about using ABILIFY. You should also speak to your doctor or pharmacist if you would like further information or if you have any concerns or questions about using ABILIFY.

Where to find information in this leaflet:

1. Why am I using ABILIFY?
2. What should I know before I use ABILIFY?
3. What if I am taking other medicines?
4. How do I use ABILIFY?
5. What should I know while using ABILIFY?
6. Are there any side effects?
7. Product details

1. Why am I using ABILIFY?

ABILIFY contains the active ingredient aripiprazole. ABILIFY belongs to a group of medicines called antipsychotic agents which improve the symptoms of certain types of mental illness.

ABILIFY is used to treat symptoms of schizophrenia.

ABILIFY may be given to treat acute episodes of sustained upward mood swings (mania) in adult patients with Bipolar 1 Disorder. During mania, patients experience episodes of overactivity, elation or irritability.

Schizophrenia is a mental illness with disturbances in thinking, feelings and behaviour.

Bipolar disorder is a condition with symptoms such as feeling "high", having excessive amounts of energy, needing much less sleep than usual, talking very quickly with racing ideas and sometimes severe irritability.

Your doctor may have prescribed ABILIFY for another reason. Ask your doctor if you have any questions about why ABILIFY has been prescribed for you.

There is no evidence that ABILIFY is addictive.

This medicine is available only with a doctor's prescription.

ABILIFY is not recommended for use in children under the age of 18, as safety and efficacy have not been established in this age group.

2. What should I know before I use ABILIFY?

Warnings

Do not use ABILIFY if:

  • you are allergic to aripiprazole, or any of the ingredients listed at the end of this leaflet.
  • Always check the ingredients to make sure you can use this medicine.

Symptoms of an allergic reaction include:

  • rash, itching or hives on the skin
  • shortness of breath, wheezing or difficulty breathing
  • swelling of the face, lips, tongue, throat or other parts of the body

Tell your doctor or pharmacist if you have allergies to:

  • any other medicines
  • any other substances such as foods, preservatives or dyes

Do not take ABILIFY after the expiry or use by date printed on the pack.

If you take this medicine after this date has passed, it may not work as well.

Do not take ABILIFY if the packaging is torn or shows signs of tampering.

If this is the case, return it to your pharmacist.

If you are not sure whether you should start taking ABILIFY, talk to your doctor or pharmacist.

Check with your doctor if you:

  • have any other medical conditions especially the following:
    - a reaction to some medicines with a sudden increase in body temperature, sweating, fast heartbeat, muscle stiffness and fluctuating blood pressure, which may lead to coma. This reaction is called neuroleptic malignant syndrome.
    - a reaction to some medicines with abnormal movements of the tongue, or other uncontrolled movements of the mouth, tongue, cheeks or jaw which may progress to the arms and legs. This reaction is called tardive dyskinesia.
    - low blood pressure
    - problems with your heart or blood vessels
    - epilepsy, seizures or fits
    - problems with your oesophagus (food pipe) such as difficulty in swallowing
    - high blood sugar or diabetes mellitus
    - Alzheimer's disease or dementia
    - alcohol or drug abuse or dependence or a history of one of these
    - venous thromboembolism or are at risk of venous thromboembolism
    - have a history of or are at risk of sleep apnea (a sleep disorder where your breathing is interrupted during sleep)
    - lactose intolerance
  • take any medicines for any other condition

Tell your doctor if you have past experience of excessive gambling. Tell your doctor if you or your family/carer notices that you are developing urges or cravings to behave in ways that are unusual for you and you cannot resist the impulse, drive or temptation to carry out certain activities that could harm yourself or others. These are called impulse control disorders and can include behaviours such as addictive gambling, excessive eating or spending, an abnormally high sex drive or preoccupation with an increase in sexual thoughts or feelings.

Your doctor may need to adjust or stop your dose.

All thoughts of suicide must be taken seriously. Tell your doctor or a mental health professional immediately if you have any suicidal thoughts, feelings about hurting yourself or other significant mood changes.

Suicidal thoughts and behaviours have been reported during ABILIFY treatment.

Tell your doctor if you drink alcohol.

Your doctor may advise you to avoid alcohol as it can magnify the side-effects of this medicine.

Aripiprazole may cause sleepiness, fall in blood pressure when standing up, dizziness and changes in your ability to move and balance, which may lead to falls. Caution should be taken.

If you have not told your doctor or pharmacist about any of the above, tell them before you start taking ABILIFY.

During treatment, you may be at risk of developing certain side effects. It is important you understand these risks and how to monitor for them. See additional information under Section 6. Are there any side effects?

Pregnancy and breastfeeding

Check with your doctor if you are pregnant or intend to become pregnant.

ABILIFY is not recommended for use during pregnancy. If you need to take ABILIFY during your pregnancy, your doctor will discuss with you the benefits and risks of taking it. Babies exposed to antipsychotics (including ABILIFY) during the third trimester of pregnancy are at risk of experiencing shaking, muscle stiffness, difficulty in feeding and/or withdrawal symptoms. These symptoms may resolve spontaneously or require additional medical treatment.

Talk to your doctor if you are breastfeeding or intend to breastfeed.

It is recommended that you do not breast-feed while taking ABILIFY, as it may pass into breast milk and therefore there is a possibility that the breast-fed baby may be affected.

3. What if I am taking other medicines?

Tell your doctor or pharmacist if you are taking any other medicines, including any medicines, vitamins or supplements that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines may interfere with ABILIFY and affect how it works. These include:

  • medicines used to treat brain disorders such as, anxiety, depression, mood swings, epilepsy or seizures, Parkinson's disease or insomnia
  • medicines used to treat high blood pressure
  • medicines used to treat fungal infections
  • medicines used to treat heart rhythm disturbances
  • medicines used to treat bacterial or viral infections
  • a medicine called cyclosporin (Neoral®; Sandimmun®)
  • a medicine called cimetidine (Tagamet®; Magicul®)

These medicines may be affected by ABILIFY, or may affect how well it works. Your doctor may need to adjust your dose of Abilify or of the other medicine.

Eating grapefruit or drinking grapefruit juice may affect how ABILIFY works.

Your doctor or pharmacist may have more information on medicines to be careful with or avoid while taking ABILIFY.

Check with your doctor or pharmacist if you are not sure about what medicines, vitamins or supplements you are taking and if these affect ABILIFY.

4. How do I use ABILIFY?

How much to take / use

  • Unless your doctor gives you other directions, you should take ABILIFY only once a day.
  • ABILIFY tablets should be swallowed whole and washed down with a glass of water.
  • Follow the instructions provided and use ABILIFY until your doctor tells you to stop.
  • ABILIFY helps to control your condition but does not cure it. Therefore you must take ABILIFY every day. Improvement in symptoms may take several days to some weeks to occur. Even if you feel better do not stop taking ABILIFY unless your doctor tells you to.

When to take / use ABILIFY

  • Take ABILIFY at about the same time each day.
    Taking the medicine at the same time each day will have the best effect. It will also help you remember when to take it.
  • It does not matter whether you take ABILIFY with or without food.

If you forget to use ABILIFY

ABILIFY should be used regularly at the same time each day. If you miss your dose at the usual time, follow the instructions below:

If it is almost time for your next dose, skip the dose you missed and take your next dose when you are meant to.

Otherwise, take it as soon as you remember, and then go back to taking your medicine as you would normally.

Do not take a double dose to make up for the dose you missed.

This may increase the chance of you getting an unwanted side effect.

If you are not sure what to do, ask your doctor or pharmacist.

If you have trouble remembering to take your medicine, ask your pharmacist for some hints.

If you use too much ABILIFY

If you think that you have used too much ABILIFY, you may need urgent medical attention.

Patients who have taken too much ABILIFY have experienced the following symptoms:

  • drowsiness or sleepiness,
  • high blood pressure
  • rapid heartbeat
  • vomiting
  • reduced level of consciousness

You should immediately:

  • phone the Poisons Information Centre
    (by calling 13 11 26), or
  • contact your doctor, or
  • go to the Emergency Department at your nearest hospital.

You should do this even if there are no signs of discomfort or poisoning.

5. What should I know while using ABILIFY?

Things you should do

  • If you are about to be started on any new medicine, tell your doctor, dentist and pharmacist that you are taking ABILIFY.
  • If you plan to have any kind of surgery that needs a general anaesthetic, tell your doctor or dentist that you are taking ABILIFY.
  • Be sure to keep all of your doctor's appointments so that your progress can be checked.

Call your doctor straight away if you:

  • Become pregnant while taking ABILIFY

Remind any doctor, dentist or pharmacist you visit that you are using ABILIFY.

Things you should not do

  • Do not give ABILIFY to anyone else, even if their symptoms seem similar or they have the same condition as you.
  • Do not take ABILIFY to treat any other complaints unless your doctor or pharmacist tells you to.
  • Do not stop taking ABILIFY or lower the dosage, even if you are feeling better, without checking with your doctor. If you stop taking ABILIFY suddenly your condition may worsen.
  • Do not take more of this medicine and do not take it more often than your doctor has ordered.

Make sure you keep cool in hot weather and keep warm in cool weather.

ABILIFY may affect the way your body reacts to temperature changes. It may prevent sweating, even during heatwaves. You may feel dizzy or faint if you are too hot. To stay cool in hot weather, try to do the following:

  • wear light clothing
  • spend time in air-conditioned environments (or keep windows open and use electric fans)
  • drink plenty of water
  • take cool baths or showers and avoid hot baths and saunas
  • try to restrict exercise or heavy work to cool parts of the day

Driving or using machines

Make sure that you know how you react to ABILIFY before you drive a car, operate machinery or do anything else that could be dangerous if you are dizzy or light headed or not alert.

ABILIFY may cause some people to become drowsy or less alert than they are normally or cause light-headedness, dizziness or tiredness. If this occurs do not undertake the activity.

If ABILIFY makes you feel light-headed, dizzy or faint, be careful when getting up from a sitting or lying position.

Getting up slowly may help.

Drinking alcohol

Tell your doctor if you drink alcohol.

Be careful when drinking alcohol while taking ABILIFY.

Your doctor may suggest you avoid alcohol while you are being treated with ABILIFY.

Looking after your medicine

Store ABILIFY in a cool place where the temperature stays below 30°C.

Heat and dampness can destroy some medicines

Follow the instructions in the carton on how to take care of your medicine properly.

Store it in a cool dry place away from moisture, heat or sunlight; for example, do not store it:

  • in the bathroom or near a sink, or
  • in the car or on window sills.

Keep it where young children cannot reach it.

A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines. Do not keep outdated medicine or medicine no longer needed.

When to discard your medicine

If your doctor tells you to stop taking ABILIFY or the medicine has passed its expiry date, ask your pharmacist what to do with any leftover medicine.

Be sure that any discarded medicine is out of the reach of children.

Getting rid of any unwanted medicine

If you no longer need to use this medicine or it is out of date, take it to any pharmacy for safe disposal.

Do not use this medicine after the expiry date.

6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention.

See the information below and, if you need to, ask your doctor or pharmacist if you have any further questions about side effects.

ABILIFY is generally well-tolerated and the side effects are often hard to distinguish from disease symptoms. It is important that you tell your doctor as soon as possible about any unwanted effects.

Less serious side effects

Less serious side effectsWhat to do
Gastrointestinal related:
  • indigestion
  • vomiting
  • constipation
Pain related:
  • headache
  • chest pain
General well-being related:
  • insomnia
  • light-headedness
  • drowsiness
  • agitation
  • anxiety
  • inability to sit or stand still; restless movement of the arms and legs such as tapping, marching in places, rocking, crossing and uncrossing the legs.
  • feeling dizzy especially when getting up from a lying or sitting position
  • altered or increased sexual interest
  • high blood sugar (excessive thirst, hunger and weakness) or the onset or worsening of diabetes
  • weight gain
  • weight loss
  • loss of appetite
  • excessive sweating
  • drowsiness
  • high blood pressure
  • difficulty swallowing
  • hiccups
  • nausea
Infection related:
  • frequent infections such as fever, severe chills, sore throat or mouth ulcers
Bleeding related:
  • bleeding or bruising more easily than normal
Speech related
  • speech disorder
Bladder related
  • urinary incontinence
Speak to your doctor if you have any of these less serious side effects and they worry you.

Serious side effects

Serious side effectsWhat to do
Pain related:
  • muscle pain, muscle weakness or muscle stiffness
  • painful irreversible erection
General well-being-related
  • seizure, fits or convulsions
  • fainting
  • abnormal movements of the tongue, or other uncontrolled movements of the tongue, mouth, cheeks, eyes or jaw which may progress to the arms and legs
  • sudden increase in body temperature, sweating, fast heart beat, muscle stiffness, high blood pressure and convulsions
  • disorder of body temperature regulation resulting in low body temperature or high body temperature
  • yellowing of the skin and/or eyes, also called jaundice with or without nausea, vomiting, loss of appetite, feeling generally unwell, fever, itching and dark coloured urine
Allergy related
  • rash
  • allergic reaction (rash, itching or hives on the skin; shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue, throat or other parts of the body) with or without fever
Inflammation related
  • inflammation of the pancreas, severe upper stomach pain often with nausea and vomiting
Infection related
  • serious lung infection with fever, chills, shortness of breath, cough, chest pain and blood streaked phlegm
Bladder related
  • difficulty in passing urine
Mental related
  • thoughts or talk about death or suicide; thoughts or talk about self-harm or doing harm to others; any recent attempts at self-harm; an increase in aggressive behaviour, irritability or agitation. If you or someone you know is showing these signs contact your doctor or a mental health advisor right away or go to the nearest hospital for treatment.
Call your doctor straight away, or go straight to the Emergency Department at your nearest hospital if you notice any of these serious side effects.

Tell your doctor if you have obsessive (recurring) thoughts or behaviours or trouble controlling impulsive urges or while taking ABILIFY.

Obsessive compulsive behaviours (feeling the need to check things repeatedly or having certain thoughts repeatedly), gambling urges, sexual urges, compulsive spending, binge or compulsive eating and other urges have occurred in some patients.

Tell your doctor or pharmacist if you notice anything else that may be making you feel unwell.

Other side effects not listed here may occur in some people.

Also, while taking ABILIFY, some elderly patients with dementia have suffered serious side effects such as a "mini" stroke, stroke, pneumonia or heart problems. These serious side effects can be life threatening.

Do not be alarmed by this list of possible side effects.

You may not experience any or only some of them.

Reporting side effects

After you have received medical advice for any side effects you experience, you can report side effects to the Therapeutic Goods Administration online at www.tga.gov.au/reporting-problems. By reporting side effects, you can help provide more information on the safety of this medicine.

Always make sure you speak to your doctor or pharmacist before you decide to stop taking any of your medicines.

7. Product details

This medicine is only available with a doctor's prescription.

What ABILIFY contains

Active ingredient
(main ingredient)		aripiprazole
Other ingredients
(inactive ingredients)

lactose, starch - maize, cellulose - microcrystalline, hydroxypropylcellulose and magnesium stearate.

The following colorants are also present in the tablets:

  • 5mg tablets - indigo carmine CI73015 aluminium lake (not available in New Zealand)
  • 10mg tablets - iron oxide red CI77491
  • 15mg tablets - iron oxide yellow CI77492
  • 20mg tablets - no colourants
  • 30mg tablets - iron oxide red CI77491
Potential allergensABILIFY does not contain sucrose, gluten, tartrazine or any other azo dyes.

Do not take this medicine if you are allergic to any of these ingredients.

What ABILIFY looks like

5mg ABILIFY tablets are blue, rectangular with a bevel edge and are marked on one side with "A-007" and "5" (Not available in New Zealand).

(Aust R 90925)

10mg ABILIFY tablets are pink, rectangular with a bevel edge and are marked on one side with "A-008" and "10".

(Aust R 90997)

15mg ABILIFY tablets are yellow, round with a bevel edge and are marked on one side with "A-009" and "15". (Aust R 90998)

20mg ABILIFY tablets are white to pale yellowish white, round with a bevel edge and are marked on one side with "A-010" and "20".

(Aust R 90999)

30mg ABILIFY tablets are pink, round with a bevel edge and are marked on one side with "A-011" and "30".

(Aust R 91000)

ABILIFY tablets are packed in aluminium blisters in a carton. Each carton contains 30 tablets.

Who distributes ABILIFY

In Australia:

Otsuka Australia Pharmaceutical Pty Ltd
Suite 2.03, Level 2
9 Help Street
Chatswood NSW 2067
Tel: Toll Free 1800 059 606

In New Zealand:

Pharmacy Retailing (NZ) Ltd
trading as Healthcare Logistics
58 Richard Pearse Drive
Airport Oaks
Mangere
Auckland 2022
Tel: Toll free 0800 602 200

This leaflet was prepared in October 2022.

ABILIFY is a trademark of Otsuka Pharmaceutical Co., Ltd.

Published by MIMS December 2022

BRAND INFORMATION

Brand name

Abilify

Active ingredient

Aripiprazole

Schedule

S4

 

1 Name of Medicine

Aripiprazole.

2 Qualitative and Quantitative Composition

Each tablet of Abilify contains aripiprazole as the active ingredient. Abilify is available in 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, and 30 mg tablets.
Abilify tablets contain lactose monohydrate. For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Abilify (aripiprazole) is available as:
2 mg green, unscored, modified rectangular, shallow convex, bevel-edged, tablets, marked on one side with "A-006" and "2";
5 mg blue, unscored, modified rectangular, shallow convex, bevel-edged, tablets, marked on one side with "A-007" and "5";
10 mg pink, unscored, modified rectangular, shallow convex, bevel-edged, tablets, marked on one side with "A-008" and "10";
15 mg yellow, unscored, round, shallow convex, bevel-edged, tablets, marked on one side with "A-009" and "15";
20 mg white to pale yellowish white, unscored, round, shallow convex, bevel-edged, tablets, marked on one side with "A-010" and "20";
30 mg pink, unscored, round, shallow convex, bevel-edged, tablets, marked on one side with "A-011" and "30".
Not all presentations may be available in Australia.

4 Clinical Particulars

4.1 Therapeutic Indications

Abilify is indicated for the treatment of schizophrenia including maintenance of clinical improvement during continuation therapy.
Acute treatment of manic or mixed episodes associated with bipolar I disorder in adults as monotherapy and in combination with lithium or valproate.
Maintenance treatment of manic or mixed episodes in bipolar I disorder in adults as monotherapy.

4.2 Dose and Method of Administration

Recommended dosage.

Schizophrenia.

Adults.

The recommended starting dose for Abilify tablets is 10 or 15 mg/day administered orally on a once a day schedule without regard to meals. Doses in the range of 10 to 30 mg/day have been effective in clinical trials. Daily dosage may be adjusted on the basis of individual clinical status within the range of 10 to 30 mg daily. Dosage increases should not be made before 2 weeks, the time needed to achieve steady state. There is no evidence that doses higher than 15 mg/day are more effective than the recommended starting dose of 10 to 15 mg.
The maintenance dose for Abilify tablets is 15 mg/day.
Bipolar I disorder.

Acute treatment. Adults.

The recommended starting and target dose of Abilify tablets is 15 mg as monotherapy or as combination therapy with lithium or valproate given once a day, without regard to meals. The dose can be increased to 30 mg/day based on clinical response. The safety of doses above 30 mg/day has not been evaluated in clinical trials.

Maintenance therapy. Adults.

Patients responding to aripiprazole for an acute or mixed episode may be continued on monotherapy aripiprazole at 15 mg or 30 mg daily for a further 9 weeks. Maintenance of effect has not been demonstrated beyond 26 weeks (see Section 5.1 Pharmacodynamic Properties, Clinical trials).
Patients given aripiprazole for an acute manic or mixed episode may be continued on monotherapy at the same dose. Adjustments of daily dosage, including dose reductions should be considered on the basis of clinical status.

Renal impairment.

No dosage adjustment is required in adult patients with renal impairment.

Hepatic impairment.

No dosage adjustment is required for adult patients with hepatic impairment (Child-Pugh class A, B or C).

Elderly.

No dosage adjustment is required for patients ≥ 65 years of age.

Gender.

No dosage adjustment is required for female adult patients relative to male adult patients.

Concomitant medications.

Dosage adjustment for patients taking Abilify concomitantly with potential CYP3A4 inhibitors.

When concomitant administration of a potent CYP3A4 inhibitor such as ketoconazole, itraconazole, clarithromycin and HIV protease inhibitors with Abilify occurs, the Abilify dose should be decreased. When the CYP3A4 inhibitor is withdrawn from the combination therapy, the Abilify dose should then be increased.

Dosage adjustment for patients taking Abilify concomitantly with potential CYP2D6 inhibitors.

When concomitant administration of potential CYP2D6 inhibitors such as quinidine, fluoxetine or paroxetine with Abilify occurs, the Abilify dose should be halved. When the CYP2D6 inhibitor is withdrawn from the combination therapy, the Abilify dose should then be increased.

Dosage adjustment for patients taking Abilify concomitantly with multiple medications that inhibit CYP3A4 and CYP2D6.

Although no clinical studies have been conducted in which Abilify was taken together with multiple drugs that inhibit CYP3A4 and CYP2D6, consideration should be given to reducing the daily dose of Abilify in individual circumstances.

Dosage adjustment for patients taking Abilify concomitantly with potential CYP3A4 inducers.

When a potent CYP3A4 inducer such as carbamazepine is added to Abilify therapy, the Abilify dose should be increased. Additional dose increases should be based on clinical evaluation. When the CYP3A4 inducer is withdrawn from the combination therapy, the Abilify dose should then be reduced.

Smoking.

No dosage adjustment is required for smoking patients relative to nonsmoking patients.

Switching from other antipsychotics.

Data was prospectively and systematically collected to address the safety of switching from other antipsychotics to Abilify (30 mg/day). These data indicate that any of the following methods can be used safely for switching patients to Abilify from another antipsychotic monotherapy:
immediate discontinuation of the patient's current antipsychotic regimen and immediate initiation of Abilify;
immediate initiation of Abilify while tapering off the current antipsychotic regimen over a 2 week period;
upward titration of Abilify over a 2 week period and simultaneous tapering off of the patient's current antipsychotic regimen over the same 2 week period.

4.3 Contraindications

Abilify is contraindicated in patients who are hypersensitive to aripiprazole or any of the excipients (see Section 6.1 List of Excipients).
For specific information about the contraindications of mood stabilisers, see Section 4.3 Contraindications of the prescribing information for these products when combination with lithium or valproate is indicated.

4.4 Special Warnings and Precautions for Use

Increased mortality in elderly patients with dementia related psychosis.

Elderly patients with dementia related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of seventeen placebo controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug treated patients of between 1.6 to 1.7 times that seen in placebo treated patients. Over the course of a typical 10 week controlled trial, the rate of death in drug treated patients was about 4.5% compared to a rate of about 2.6% in the placebo group. Although the causes of death varied, most of the deaths appeared to be either cardiovascular (e.g. heart failure, sudden death) or infectious (e.g. pneumonia) in nature.
In three placebo controlled trials of Abilify in elderly patients with psychosis associated with Alzheimer's disease, cerebrovascular adverse events (e.g. stroke, transient ischaemic attack), including fatalities, occurred in 1.3% (8/595) of Abilify treated patients compared with 0.6% (2/343) of placebo treated patients during the 10 week double blind period or within 30 days of the last dose for those who discontinued the study during the double blind phase. The all cause mortality rate in the same trials over the same period was 3.5% (21/595) in Abilify treated patients and 1.7% (6/343) in the placebo group.
Abilify is not approved for the treatment of patients with dementia related psychosis.

General.

During antipsychotic treatment, improvement in the patient's clinical condition may take several days to some weeks. Patients should be closely monitored during this period.

Suicide.

The possibility of a suicide attempt is inherent in psychotic illnesses and bipolar I disorder, and close supervision of high risk patients should accompany drug therapy. Prescriptions for Abilify should be written for the smallest quantity consistent with good patient management, in order to reduce the risk of overdose.

Sleep apnoea.

Sleep apnoea and related disorders have been reported in patients treated with aripiprazole, with or without prior history of sleep apnoea.
Aripiprazole should be used with caution in patients who have sleep apnoea or risk factors for developing sleep apnoea, which include overweight/obesity, males, and concomitant use of central nervous system depressants.

Tardive dyskinesia.

The risk of tardive dyskinesia increases with long-term exposure to antipsychotic treatment. If signs and symptoms of tardive dyskinesia appear in a patient on Abilify, a dose reduction or drug discontinuation should be considered. These symptoms can temporally deteriorate or even arise after discontinuation of treatment.

Neuroleptic malignant syndrome.

A potentially fatal symptom complex sometimes referred to as neuroleptic malignant syndrome (NMS) has been reported in association with administration of antipsychotic drugs including Abilify. Rare cases of NMS occurred during aripiprazole treatment in the worldwide clinical database. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status, and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Additional signs may include elevated creatine kinase, myoglobinuria (rhabdomyolysis), and acute renal failure. If a patient develops signs and symptoms indicative of NMS, or presents with unexplained high fever without additional clinical manifestations of NMS, all antipsychotic drugs, including Abilify, must be discontinued.

Seizure.

In short-term, placebo controlled trials, seizures occurred in 0.1% (3/2467) of adult patients treated with aripiprazole.
As with other antipsychotic drugs, Abilify should be used cautiously in patients who have a history of seizure disorder or have conditions associated with seizures.

Falls.

Somnolence, postural hypotension, motor and sensory instability have been reported with the use of antipsychotics, including aripiprazole, which may lead to falls. Caution should be taken when treating patients with diseases, conditions, or who are taking medications that could exacerbate these effects.

Cerebrovascular adverse events, including stroke, in elderly patients with dementia related psychosis.

In placebo controlled clinical studies (2 flexible dose and 1 fixed dose study) of dementia related psychosis, there was an increased incidence of cerebrovascular adverse events (e.g. stroke, transient ischemic attack), including fatalities, in aripiprazole treated patients (mean age: 84 years; range: 78 to 88 years). In the fixed dose study, there was a statistically significant dose response relationship for cerebrovascular adverse events in patients treated with aripiprazole. Aripiprazole is not approved for the treatment of patients with dementia related psychosis. (Also see Section 4.4 Special Warnings and Precautions for Use, Increased mortality in elderly patients with dementia related psychosis, Use in patients with concomitant illness, Safety experience in elderly patients with psychosis associated with Alzheimer's disease.)

Hyperglycaemia and diabetes mellitus.

Hyperglycaemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients with atypical antipsychotics, including Abilify. Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders, the relationship between atypical antipsychotic use and hyperglycaemia related adverse events is not completely understood. However, epidemiological studies suggest an increased risk of treatment emergent hyperglycaemia related adverse events in patients treated with the atypical antipsychotics. Precise risk estimates for hyperglycaemia related adverse events in patients treated with atypical antipsychotics are not available.
Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g. obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycaemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycaemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycaemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of antidiabetic treatment despite discontinuation of the suspect drug.
In patients with significant treatment emergent hyperglycaemia, discontinuation of Abilify should be considered.

Cardiovascular adverse events.

Potentially due to its α1-adrenergic receptor antagonism, Abilify may be associated with orthostatic hypotension.
The incidence of orthostatic hypotension associated events from short-term, placebo controlled trials of adult patients on oral Abilify (n = 2467) included (aripiprazole incidence, placebo incidence): orthostatic hypotension (1%, 0.3%), postural dizziness (0.5%, 0.3%), and syncope (0.5%, 0.4%).
Orthostatic hypotension occurred in 0.8% (112/13,543) of oral aripiprazole treated patients during clinical trials.
As with other atypical antipsychotics, Abilify should be used with caution in patients with known cardiovascular disease (history of myocardial infarction or ischaemic heart disease, heart failure or conduction abnormalities), cerebrovascular disease or conditions which would predispose patients to hypotension (dehydration, hypovolaemia, and treatment with antihypertensive medications).
Cases of venous thromboembolism (VTE) have been reported with antipsychotic drugs. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before treatment with Abilify and preventive measures undertaken.

Body temperature regulation.

Disruption of the body's ability to increase or reduce core body temperature has been attributed to antipsychotic agents, including Abilify. Appropriate care is advised when prescribing Abilify for patients who will be experiencing conditions which may contribute to an elevation in core body temperature, e.g. exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity or being subject to dehydration.
Patients should be advised regarding appropriate care in avoiding overheating and dehydration.

Dysphagia.

Oesophageal dysmotility and aspiration have been associated with antipsychotic drug use. Abilify and other antipsychotic drugs should be used cautiously in patients at risk of aspiration pneumonia (e.g. elderly patients).

Akathisia.

Class effect.

The presentation of akathisia may be variable and comprises subjective complaints of restlessness and an overwhelming urge to move and either distress or motor phenomena such as pacing, swinging of the legs while seated, rocking from foot to foot, or both. Particular attention should be paid to the monitoring for such symptoms and signs as, left untreated, akathisia is associated with poor compliance and an increased risk of relapse.

Leukopenia, neutropenia and agranulocytosis.

Class effect.

In clinical trial and/or postmarketing experience, events of leukopenia/ neutropenia have been reported temporally related to antipsychotic agents, including Abilify. Agranulocytosis has also been reported.
Possible risk factors for leukopenia/ neutropenia include pre-existing low white blood cell count (WBC) and history of drug induced leukopenia/ neutropenia. Patients with a history of a clinically significant low WBC or drug induced leukopenia/ neutropenia should have their complete blood cell (CBC) monitored frequently during the first few months of therapy and discontinuation of Abilify should be considered at the first sign of a clinically significant decline in WBC in the absence of other causative factors.
Patients with clinically significant neutropenia should be carefully monitored for fever or other symptoms or signs of infection and treated promptly if such symptoms or signs occur. Patients with severe neutropenia (absolute neutrophil count < 1000/mm3) should discontinue Abilify and have their WBC followed until recovery.

Potential for cognitive and motor impairment.

Abilify, like other antipsychotics, may have the potential to impair judgment, thinking, or motor skills. In short-term, placebo controlled trials, somnolence (including sedation) was reported as follows (aripiprazole incidence, placebo incidence): in adult patients (n = 2467) treated with oral Abilify (11%, 6%). Somnolence (including sedation) led to discontinuation in 0.3% (8/2467) of adult patients on oral Abilify in short-term, placebo controlled trials.
Despite the relatively modest increased incidence of these events compared to placebo, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that therapy with Abilify does not affect them adversely.

Pathological gambling and impulse control disorders.

Patients can experience increased urges, particularly for gambling, and the inability to control these urges while taking aripiprazole. Other urges, reported include: increased sexual urges, compulsive spending, binge or compulsive eating, and other impulsive and compulsive behaviours. It is important for prescribers to ask patients or their caregivers specifically about the development of new or increased gambling urges, sexual urges, compulsive spending, binge or compulsive eating, or other urges while being treated with aripiprazole. It should be noted that impulse control symptoms can be associated with the underlying disorder; however, in some cases urges were reported to have stopped when the dose was reduced or the medication was discontinued. Impulse control disorders may result in harm to the patient and others if not recognized. Consider dose reduction or stopping the medication if a patient develops such urges while taking aripiprazole. (See Section 4.8 Adverse Effects (Undesirable Effects)).

Lactose.

This medicinal product contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Use in patients with concomitant illness.

Clinical experience with Abilify in patients with certain concomitant systemic illnesses is limited. (See Section 5.2 Pharmacokinetic Properties, Renal impairment, Hepatic impairment).
Abilify has not been evaluated or used to any appreciable extent in patients with a recent history of myocardial infarction or unstable heart disease. Patients with these diagnoses were excluded from premarketing clinical studies.

Safety experience in elderly patients with psychosis associated with Alzheimer's disease.

In three 10 week, placebo controlled studies of aripiprazole in elderly patients with psychosis associated with Alzheimer's disease (n = 938; mean age: 82.4 years; range: 56 to 99 years), the treatment emergent adverse events that were reported at an incidence of ≥ 5% and aripiprazole incidence at least twice that for placebo were lethargy [placebo 2%, aripiprazole 5%], somnolence (including sedation) [placebo 3%, aripiprazole 8%] and incontinence (primarily urinary incontinence) [placebo 1%, aripiprazole 5%].
The safety and efficacy of Abilify in the treatment of patients with psychosis associated with dementia have not been established. Abilify is not indicated for the treatment of psychosis associated with Alzheimer's disease. (Also see Section 4.4 Special Warnings and Precautions for Use, Increased mortality in elderly patients with dementia related psychosis, Cerebrovascular adverse events, including stroke, in elderly patients with dementia related psychosis).

Concomitant medication.

Patients should be advised to inform their physicians if they are taking, or plan to take, any prescription or over the counter drugs, since there is a potential for interactions. (See Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions; Section 4.2 Dose and Method of Administration).

Use in the elderly.

Placebo controlled studies of Abilify in schizophrenia or bipolar mania did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Of the 13,543 patients treated with oral Abilify in clinical trials, 1073 (8%) were ≥ 65 years old and 799 (6%) were ≥ 75 years old. The majority (81%) of the 1073 patients were diagnosed with dementia of the Alzheimer's type.
Studies of elderly patients with psychosis associated with Alzheimer's disease have suggested that there may be a different tolerability profile in this population compared to younger patients with schizophrenia (see Section 4.4 Special Warnings and Precautions for Use, Increased mortality in elderly patients with dementia related psychosis, Cerebrovascular adverse events, including stroke, in elderly patients with dementia related psychosis, Use in patients with concomitant illness). The safety and efficacy of Abilify in the treatment of patients with psychosis associated with Alzheimer's disease has not been established. Abilify is not indicated for the treatment of psychosis associated with Alzheimer's disease.
Of the 749 patients treated with aripiprazole injection in clinical trials, 99 (13%) were ≥ 65 years old and 78 (10%) were ≥ 75 years old. Almost all of the use in the elderly was in clinical trials for an indication for which registration has not been requested. Placebo controlled studies of aripiprazole injection in patients with agitation associated with schizophrenia did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.
There was no effect of age on the pharmacokinetics of a single, 15 mg dose of Abilify. Aripiprazole clearance was decreased by 20% in elderly subjects (≥ 65 years) compared to younger adult subjects (18 to 64 years), but there was no detectable effect of age in the population pharmacokinetic analysis in schizophrenia patients.

Paediatric use.

The safety and efficacy of Abilify in patients less than 18 years of age have not been established.

Effects on laboratory tests.

A between group comparison for acute, 3 to 6 week, placebo controlled trials in adults revealed no medically important differences between the Abilify and placebo groups in the proportions of patients experiencing potentially clinically significant changes in routine serum chemistry, haematology, or urinalysis parameters. Similarly, there were no Abilify/ placebo differences in the incidence of discontinuations for changes in serum chemistry, haematology, or urinalysis in adult patients.
In a long-term (26 week), placebo controlled trial, there were no statistically significant differences between the aripiprazole and placebo patients in the mean change from baseline in fasting glucose, triglyceride, LDL, and total cholesterol measurements.

4.5 Interactions with Other Medicines and Other Forms of Interactions

CNS drugs (including alcohol).

Given the primary CNS effects of Abilify, caution should be used when Abilify is taken in combination with other centrally acting drugs and alcohol.
Patients should be advised to avoid alcohol while taking Abilify.
Coadministration of lithium titrated upwards from a starting dose of 900 mg until serum lithium concentrations near the upper end of the lithium therapeutic concentration range (1.0 to 1.4 mmol/L) were achieved and maintained for at least 5 days or until dose limiting adverse events were observed and valproate (divalproex sodium) titrated upwards from a starting dose of 250 mg twice daily to achieve serum concentrations within the therapeutic range of 50 to 125 microgram/mL for at least 14 days, with 30 mg Abilify once daily had no clinically significant effects on the pharmacokinetics of aripiprazole. Nor was there any clinically significant change in valproic acid or lithium pharmacokinetics when aripiprazole 30 mg once daily was administered concomitantly for 7 days with either divalproex sodium 500 mg every 12 hours or controlled release lithium 450 mg every 12 hours.
When aripiprazole was administered concomitantly with either valproate, lithium or lamotrigine, there was no clinically important change in valproate, lithium or lamotrigine concentrations.

Antihypertensive agents.

Due to its α1-adrenergic receptor antagonist activity, Abilify has the potential to enhance the effect of certain antihypertensive agents.

Medicines which cause QT prolongation or electrolyte imbalance.

If aripiprazole is administered concomitantly with medicinal products known to cause QT prolongation or electrolyte imbalance, caution should be used.

Inhibitors and inducers of CYP2D6 and CYP3A4.

Aripiprazole is metabolised by multiple pathways primarily involving the CYP2D6 and CYP3A4 enzymes. In clinical studies with healthy subjects, potent inhibitors of CYP2D6 (quinidine) and 3A4 (ketoconazole) decreased oral clearance of aripiprazole by 52% and 38%, respectively. Other potent inhibitors of CYP3A4 and CYP2D6 may be expected to have similar effects. When concomitant administration of quinidine or ketoconazole with aripiprazole occurs, the aripiprazole dose should be halved. When the inhibitor is withdrawn from the combination therapy, the aripiprazole dose should then be increased. (See Section 4.2 Dose and Method of Administration, Concomitant medications).
No data are available for use of Abilify with other inhibitors of CYP3A4 or CYP2D6. Examples of medicines or substances that have the potential to inhibit CYP3A4 or CYP2D6 include, but are not limited to, clarithromycin, erythromycin, itraconazole, fluconazole, ritonavir, indinavir, nefazodone, cyclosporin, amiodarone, cimetidine, fluoxetine, paroxetine and grapefruit juice.
Dose reduction of Abilify should be applied with concomitant administration of potent CYP3A4 inhibitors such as itraconazole, clarithromycin and HIV protease inhibitors, as similar effects to that seen in the clinical studies with ketoconazole may be expected. Dose reduction of Abilify should be applied with concomitant administration of potent CYP2D6 inhibitors such as fluoxetine and paroxetine as similar effects to that seen in the clinical studies with quinidine may be expected (see Section 4.2 Dose and Method of Administration, Concomitant medications).
In a clinical study in patients with schizophrenia or schizoaffective disorder, coadministration of carbamazepine (200 mg twice daily), a potent CYP3A4 inducer, with aripiprazole (30 mg daily) resulted in an approximate 70% decrease in AUC values of both aripiprazole and its active metabolite, dehydroaripiprazole. Other potent inducers of CYP3A4 and CYP2D6 may be expected to have similar effects. When a potent inducer like carbamazepine is added to aripiprazole therapy, the aripiprazole dose should be increased. Other potent inducers of CYP3A4 include, but are not limited to, St. John's wort, phenytoin, rifampicin, efavirenz, and nevirapine. Additional dose increases should be based on clinical evaluation. When the inducer is withdrawn from the combination therapy, the aripiprazole dose should then be reduced. (See Section 4.2 Dose and Method of Administration, Dosage adjustment for patients taking Abilify concomitantly with potential CYP3A4 inducers).

Inhibitors and inducers of CYP1A1, CYP1A2, CYP2C9 and CYP2C19.

Aripiprazole is not metabolised by CYP1A1, CYP1A2, CYP2C9 and CYP2C19 in vitro, suggesting that interactions with medications or other factors (e.g. smoking), which are inhibitors or inducers of these enzymes, are unlikely.

Effects of Abilify on substrates for CYP2D6, CYP2C9, CYP2C19, CYP3A4 and CYP1A2.

Aripiprazole and dehydroaripiprazole were weak inhibitors of CYP2C9, CYP2C19, CYP2D6 and CYP3A4 mediated metabolism in vitro (IC50 values 2.4 to 25 microM). Neither aripiprazole nor dehydroaripiprazole inhibited CYP1A2 mediated metabolism in vitro (IC50 value > 50 to 66 microM).
In clinical studies, 10 to 30 mg/day doses of Abilify had no significant effect on metabolism of substrates of CYP2D6 (dextromethorphan), CYP2C9 (warfarin), CYP2C19 (omeprazole, warfarin), and CYP3A4 (dextromethorphan). Thus, Abilify is unlikely to cause clinically important drug interactions mediated by these enzymes.

Famotidine.

There was no significant effect of the H2-antagonist famotidine, a potent gastric acid blocker, on the pharmacokinetics of aripiprazole.

Food.

Abilify can be administered without regard to meals. Following administration of a 15 mg Abilify tablet with a standard high fat meal, the Cmax of aripiprazole and its active metabolite, dehydroaripiprazole, increased by 11%. The AUC of aripiprazole was increased by 18% and that of the active metabolite by 14%. Food delayed Tmax by 3 hours for aripiprazole and 12 hours for the active metabolite.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Aripiprazole had no effect on fertility in female rats treated orally with 2, 6 and 20 mg/kg/day (0.6, 2 and 6 times the MRHD based on mg/m2) for 2 weeks prior to mating through gestation day 7. Drug related effects (persistent dioestrus and increased mating time preimplantation losses, and corpora lutea) observed at all doses were considered the result of perturbed oestrous cyclicity secondary to drug mediated hyperprolactinaemia.
Aripiprazole had no effect on fertility in male rats treated with PO doses of 20, 40 and 60 mg/kg/day (6, 12 and 18 times the MRHD based on mg/m2) for 9 weeks prior to mating through mating. Disturbances of spermatogenesis were seen at 60 mg/kg/day and prostatic atrophy was seen at 40 and 60 mg/kg/day.
(Category C)
Congenital anomalies have been reported; however, a causal relationship with aripiprazole could not be established. In animal studies aripiprazole demonstrated developmental toxicity, including possible teratogenic effects, in rats and rabbits.
Pregnant rats were treated with oral doses of 3, 10 and 30 mg/kg/day (1, 3 and 9 times the MRHD on a mg/m2 basis) of aripiprazole during the period of organogenesis. At 30 mg/kg, treatment was associated with slightly prolonged gestation and a slight delay in foetal development as evidenced by decreased foetal weight, undescended testes and delayed skeletal ossification. There were no adverse effects on embryofoetal or pup survival. Delivered offspring had increased incidences of hepatodiaphragmatic nodules and diaphragmatic hernia at 30 mg/kg (the other doses were not examined for these findings). (A low incidence of diaphragmatic hernia was also seen in the foetuses exposed to 30 mg/kg). Postnatally, decreased pup weight (persisting into adulthood) was seen at 30 mg/kg, delayed vaginal opening was seen at 10 and 30 mg/kg and impaired reproductive performance (decreased fertility rate, corpora lutea, implants and live foetuses, and increased postimplantation loss, likely mediated through effects on female offspring) was seen at 30 mg/kg. Maternal toxicity was seen at 30 mg/kg, which was similar to doses eliciting embryotoxicity.
Pregnant rabbits were treated with oral doses of 10, 30 and 100 mg/kg/day (2, 3 and 11 times human exposure at MRHD based on AUC and 8, 24 and 81 times the MRHD based on mg/m2) of aripiprazole during the period of organogenesis. Decreased maternal food consumption and increased abortions were seen at 100 mg/kg. Treatment caused increased foetal mortality (100 mg/kg), decreased foetal weight (30 mg and 100 mg/kg), increased incidence of a skeletal abnormality (fused sternebrae at 100 mg/kg) and minor skeletal variations (100 mg/kg).
Rats were treated with oral doses of 3, 10 and 30 mg/kg/day (1, 3 and 9 times the MRHD on a mg/m2 basis) of aripiprazole from late gestation through weaning. At 30 mg/kg, maternal toxicity, slightly prolonged gestation, an increase in stillbirths, poor postnatal care/ nursing, and decreases in pup weight (persisting into adulthood) and survival were seen.

Nonteratogenic class effect.

Neonates exposed to antipsychotic drugs (including Abilify) during the third trimester of pregnancy are at risk of experiencing extrapyramidal neurological disturbances and/or withdrawal symptoms following delivery. There have been postmarket reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress and feeding disorder in these neonates. These complications have varied in severity; while in some cases symptoms have been self limited, in other cases neonates have required additional medical treatment or monitoring.
Abilify should be used during pregnancy only if the anticipated benefit outweighs the risk and the administered dose and duration of treatment should be as low and as short as possible.
Patients should be advised to notify their doctors if they become pregnant or intend to become pregnant.
 Aripiprazole and/or its metabolites have been found in the milk of lactating rats. Aripiprazole is excreted in breast milk. Patients should be advised not to breastfeed if they are taking Abilify.

Use in labor and delivery.

The effect of aripiprazole on labour and delivery has not been studied.

4.7 Effects on Ability to Drive and Use Machines

As with other antipsychotics, patients should be cautioned about operating hazardous machinery, including motor vehicles, until they are reasonably certain that Abilify does not affect them adversely.

4.8 Adverse Effects (Undesirable Effects)

Abilify has been evaluated for safety in 13,543 patients who participated in multiple dose clinical trials in schizophrenia (including schizoaffective disorder), bipolar I disorder, major depressive disorder, dementia of the Alzheimer's type, Parkinson's disease, and alcoholism, and who had approximately 7619 patient years of exposure to oral aripiprazole and 749 patients with exposure to aripiprazole injection. A total of 3390 patients were treated with oral aripiprazole for at least 180 days and 1933 patients treated with oral aripiprazole had at least 1 year of exposure.
The conditions and duration of treatment with Abilify (monotherapy and in combination treatment with lithium or valproate) included (in overlapping categories) double blind, comparative and noncomparative open label studies, inpatient and outpatient studies, fixed and flexible dose studies, and short and longer-term exposure.
Adverse events during exposure were obtained by collecting voluntarily reported adverse events, as well as results of physical examinations, vital signs, weights, laboratory analyses and ECG. Adverse experiences were recorded by clinical investigators using terminology of their own choosing. In the tables and tabulations that follow, MedDRA dictionary terminology has been used initially to classify reported adverse events into a smaller number of standardised event categories, in order to provide a meaningful estimate of the proportion of individuals experiencing adverse events.
The stated frequencies of adverse events represent the proportion of individuals who experienced, at least once, a treatment emergent adverse event of the type listed. An event was considered treatment emergent if it occurred for the first time or worsened while receiving therapy following baseline evaluation.
The prescriber should be aware that the figures in the tables and tabulations cannot be used to predict the incidence of side effects in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical trials. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving different treatment uses and investigators. The cited figures, however, do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the adverse event incidence in the population studied.

Oral administration. Adult patients with schizophrenia.

Adverse events associated with discontinuation of treatment in short-term, placebo controlled trials of patients with schizophrenia.

Based on a pool of five placebo controlled trials (four 4 week and one 6 week) in which Abilify was administered to acutely relapsed patients with schizophrenia in doses ranging from 2 to 30 mg/day, there was no difference in the incidence of discontinuation due to adverse events between Abilify treated (7%) and placebo treated (9%) patients. The types of adverse events that led to discontinuation were similar between the Abilify and placebo treated patients.

Adult patients with bipolar I disorder.

Monotherapy. The following findings are based on a pool of 3 week, placebo controlled, bipolar I disorder trials in which oral aripiprazole was administered at doses of 15 mg/day or 30 mg/day.

Adverse reactions associated with discontinuation of treatment.

Overall, in patients with bipolar I disorder, there was little difference in the incidence of discontinuation due to adverse reactions between aripiprazole treated (11%) and placebo treated (10%) patients. The types of adverse reactions that led to discontinuation were similar between aripiprazole treated and placebo treated patients.

Commonly observed adverse reactions.

Commonly observed adverse reactions associated with the use of aripiprazole in patients with bipolar I disorder (incidence of 5% or greater and aripiprazole incidence at least twice that for placebo) are shown in Table 1.

Less common adverse reactions in adults. Adverse events occurring at an incidence of at least 2% among Abilify treated patients in short-term placebo controlled trials.

Table 2 enumerates the pooled incidence, rounded to the nearest percent, of treatment emergent adverse events that occurred during acute therapy (up to 6 weeks in schizophrenia and up to 3 weeks in bipolar mania), 2 or more of patients treated with Abilify (doses ≥ 2 mg/day) and for which the incidence in patients treated with aripiprazole was greater than the incidence in patients treated with placebo in the combined dataset.
An examination of population subgroups did not reveal any clear evidence of differential adverse reaction incidence on the basis of age, gender, or race.
Adult patients with adjunctive therapy with bipolar I disorder. The following findings are based on a placebo controlled trial of adult patients with bipolar I disorder in which aripiprazole was administered at doses of 15 mg/day or 30 mg/day in combination with lithium or valproate.

Adverse reactions associated with discontinuation of treatment.

In a study of patients who were already tolerating either lithium or valproate as monotherapy, discontinuation rates due to adverse reactions were 12% for patients treated with adjunctive aripiprazole compared with 6% for patients treated with adjunctive placebo. The most common adverse drug reactions associated with discontinuation in the adjunctive aripiprazole treated compared to placebo treated patients were akathisia (5% and 1%, respectively) and tremor (2% and 1%, respectively).

Commonly observed adverse reactions.

The commonly observed adverse reactions associated with adjunctive aripiprazole and lithium or valproate in patients with bipolar I disorder (incidence of 5% or greater and incidence at least twice that for adjunctive placebo) were: akathisia, insomnia, and extrapyramidal disorder.

Less common adverse reactions in adults with adjunctive therapy in bipolar I disorder.

Table 3 enumerates the incidence, rounded to the nearest percent, of adverse reactions that occurred during acute treatment (up to 6 weeks), including only those reactions that occurred in 2% or more of patients treated with adjunctive aripiprazole (doses of 15 mg/day or 30 mg/day) and lithium or valproate and for which the incidence in patients treated with this combination was greater than the incidence in patients treated with placebo plus lithium or valproate.

Dose related adverse events in short-term, placebo controlled trials in schizophrenia.

Dose response relationships for the incidence of treatment emergent adverse events were evaluated from four trials comparing fixed doses (2, 10, 15, 20, and 30 mg/day) of Abilify to placebo. This analysis, stratified by study, indicated that the only adverse event to have a possible dose response relationship, and then most prominent only with 30 mg, was somnolence (including sedation) [placebo, 7.1%; 10 mg, 8.5%; 15 mg, 8.7%; 20 mg, 7.5%; 30 mg, 12.6%].

Adverse events occurring in long-term controlled trials.

The adverse events reported in a 26 week, double blind trial comparing Abilify and placebo in patients with schizophrenia were generally consistent with those reported in the short-term, placebo controlled trials, except for a higher incidence of tremor [8% (12/153) for Abilify vs. 2% (3/153) for placebo]. In this study, the majority of the cases of tremor were of mild intensity (8/12 mild and 4/12 moderate), occurred early in therapy (9/12 ≤ 49 days), and were of limited duration (7/12 ≤ 10 days). Tremor infrequently led to discontinuation (< 1%) of Abilify. In addition, in a long-term (52 week), active controlled study, the incidence of tremor for Abilify was 5% (40/859). A similar profile was observed in a long-term study in bipolar I disorder.
Weight gain. In placebo controlled trials, there was a slight difference in mean weight change between Abilify and placebo patients (+0.7 kg vs -0.05 kg, respectively, in short-term studies; p ≤ 0.01, and -1.3 kg vs -0.9 kg, respectively, in 26 week study; p = n.s.) and also a difference in the proportion of patients meeting the significant weight gain criterion of ≥ 7% of bodyweight (Abilify 8% compared to placebo 3% in short-term studies; p ≤ 0.01; and Abilify 6% compared to placebo 4% in long-term studies; p = n.s.).
In 3 week trials in adults with bipolar I disorder with monotherapy aripiprazole, the mean weight gain for aripiprazole and placebo patients was 0.1 kg versus 0.0 kg, respectively. The proportion of patients meeting a weight gain criterion of ≥ 7% of bodyweight was aripiprazole (2%) compared to placebo (3%). In the 6 week trial in bipolar I disorder with aripiprazole as adjunctive therapy with either lithium or valproate, the mean weight gain for aripiprazole and placebo patients was 0.6 kg versus 0.2 kg, respectively. The proportion of patients meeting a weight gain criterion of ≥ 7% of bodyweight with adjunctive aripiprazole was 3% compared to adjunctive placebo 4%.
In long-term, double blind, active comparator trials in schizophrenia, Abilify was associated with a higher incidence of significant weight gain (≥ 7% above baseline) compared with haloperidol (20% vs 13%, respectively; p ≤ 0.01; 1.1 kg vs 0.4 kg, respectively; p = n.s.) but a lower incidence of significant weight gain compared to olanzapine (Abilify 13% vs olanzapine 33%; p < 0.001; -0.9 kg vs 3.4 kg; p < 0.001 in a double blind study).
Weight change results (see Table 4) from long-term, double blind, controlled trials in schizophrenia showed that patients with high body mass index (BMI) (> 27) were less likely to have significant weight gain on Abilify than those with low BMI (< 23).
Extrapyramidal symptoms. In the short-term, placebo controlled trials of schizophrenia in adults, the incidence of reported EPS related events excluding events related to akathisia for aripiprazole treated patients was 13% vs 12% for placebo. The incidence of akathisia related events for aripiprazole treated patients was 8% vs 5% for placebo treated patients.
In the short-term, placebo controlled trials in bipolar I disorder in adults, the incidence of reported EPS related events, excluding events related to akathisia, for monotherapy aripiprazole treated patients was 16% versus 8% for placebo and the incidence of akathisia related events for monotherapy aripiprazole treated patients was 13% versus 4% for placebo. In the 6 week, placebo controlled trial in bipolar I disorder for combination therapy with lithium or valproate, the incidence of reported EPS related events, excluding events related to akathisia for patients treated with aripiprazole in combination with lithium or valproate was 15% versus 8% for patients treated with aripiprazole and placebo and the incidence of akathisia related events for patients treated with aripiprazole in combination with lithium or valproate was 19% versus 5% for patients treated with aripiprazole and placebo.
Objectively collected data from those trials on the Simpson Angus Rating Scale (for EPS), the Barnes Akathisia Scale (for akathisia), and the Assessments of Involuntary Movement Scales (for dyskinesias) did not show a difference between aripiprazole and placebo, with the exception of the Barnes Akathisia Scale (aripiprazole, 0.08; placebo, -0.05).
In the adult bipolar I disorder trials with monotherapy aripiprazole, the Simpson Angus Rating Scale and the Barnes Akathisia Scale showed a significant difference between aripiprazole and placebo (aripiprazole, 0.50; placebo, -0.01 and aripiprazole, 0.21; placebo, -0.05). Changes in the Assessment of Involuntary Movement Scales were similar for the aripiprazole and placebo groups. In the bipolar I disorder trials with aripiprazole in combination with either lithium or valproate, the Simpson Angus Rating Scale and the Barnes Akathisia Scale showed a significant difference between adjunctive aripiprazole and combination therapy placebo (aripiprazole, 0.73; placebo, 0.07 and aripiprazole, 0.30; placebo, 0.11). Changes in the Assessment of Involuntary Movement Scales were similar for adjunctive aripiprazole and combination therapy placebo.
In a long-term, double blind, haloperidol controlled study in schizophrenia, the incidence of haloperidol treated patients showing at least one EPS related adverse event, including dystonia, was significantly greater than that of the Abilify group (57% vs 26%; p < 0.001). In a long-term, double blind, olanzapine controlled study, the incidence of olanzapine treated patients showing at least one EPS related adverse event was comparable to Abilify treated patients (15% vs 15%, respectively; p = n.s.).
Dystonia.

Class effect.

Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment. Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue, and/or spasmodic deviations of the eyes, most commonly upward. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups.
ECG changes. Between group comparisons for pooled, acute, placebo controlled trials in patients with schizophrenia or bipolar I disorder revealed no significant differences between oral Abilify and placebo in the proportion of patients experiencing potentially important changes in ECG parameters. In fact, within the dose range of 10 to 30 mg/day, aripiprazole tended to slightly shorten the QTc interval. Abilify was associated with a median increase in heart rate of two beats per minute compared to no increase among placebo patients.
In a 26 week, placebo controlled trial in schizophrenia, there were no significant differences between Abilify and placebo in the proportion of patients experiencing potentially important changes in ECG parameters.

Adverse reactions observed during the premarketing evaluation of oral Abilify.

The following is a list of MedRA terms that reflect adverse reactions reported by adult patients treated with oral aripiprazole at multiple doses ≥ 2 mg/day during any phase of a trial within a database of 13,543 adult patients. The listing does not show adverse events mentioned in Table 1, Table 2, Table 3 or in other sections of this prescribing information. It is important to emphasise that although the events reported occurred with treatment they are not necessarily caused by it. The adverse reactions are classified by system organ class and are according to the following definitions: common adverse reactions are those occurring in at least 1/100 patients; uncommon adverse reactions are those occurring in at least 1/1000, but less than 1/100 patients; rare adverse reactions are those occurring in less than 1/1000 patients, very rare are those occurring in less than 1/10,000 and unknown cannot be estimated from the available data.

Blood and lymphatic system disorders.

Uncommon: leukopenia, neutropenia, thrombocytopenia. Rare: eosinophilia, lymphadenopathy.

Cardiac disorders.

Uncommon: bradycardia, palpitations, cardiopulmonary failure, myocardial infarction, cardiorespiratory arrest, atrioventricular block, extrasystoles, sinus tachycardia, atrial fibrillation, angina pectoris, myocardial ischaemia. Rare: atrial flutter, supraventricular tachycardia, ventricular tachycardia.

Ear and labyrinth disorders.

Rare: ear canal erythema, hypoacusis, vertigo positional, tinnitus.

Endocrine disorders.

Rare: early menarche.

Eye disorders.

Uncommon: dry eye, photophobia, diplopia, eyelid oedema, photopsia. Rare: eye redness, chromatopsia, conjunctivitis, eye disorder, eye movement disorder, gaze palsy, lacrimation increased.

Gastrointestinal disorders.

Uncommon: diarrhoea, gastritis, dysphagia, gastroesophageal reflux disease, swollen tongue, oesophagitis, hypoaesthesia oral. Rare: abdominal distension, abnormal faeces, eructation, faeces discoloured, constipation, gastrointestinal disorder, gastrointestinal pain, glossitis, lip dry, parotid gland enlargement, pruritus ani, tongue discolouration, pancreatitis.

General disorders and administration site conditions.

Common: asthenia, peripheral oedema, irritability, chest pain. Uncommon: face oedema, angioedema, gait disturbance, adverse event, chills, discomfort, feeling abnormal, mobility decreased. Rare: difficulty in walking, facial pain, swelling, malaise, thirst, chest discomfort, cyst, energy increased, feeling cold, generalised oedema, local swelling, oedema, tenderness, xerosis, hypothermia.

Hepatobiliary disorders.

Rare: hepatitis, jaundice.

Immune system disorders.

Rare: decreased immune responsiveness, hypersensitivity.

Infections and infestations.

Rare: sinusitis, urinary tract infection, body tinea, gastroenteritis viral, herpes simplex, localized infection, lower respiratory tract infection, oral candidiasis, parotitis, gastroenteritis.

Injury, poisoning, and procedural complications.

Common: fall. Uncommon: self mutilation. Rare: heat stroke, injury, muscle strain, clavicle fracture, femoral neck fracture, hip fracture, humerus fracture, mouth injury, open wound.

Investigations.

Common: weight decreased, creatine phosphokinase increased. Uncommon: weight increased, blood creatinine increased, heart rate increased, blood glucose increased, pyrexia, blood prolactin increased, blood urea increased, electrocardiogram QT prolonged, blood bilirubin increased, hepatic enzyme increased. Rare: electrocardiogram abnormal, urine output increased, blood creatine phosphokinase abnormal, orthostatic hypotension, blood urine present, electrocardiogram PR prolongation, electrocardiogram T wave inversion, eosinophil count increased, head lag abnormal, heart rate irregular, physical examination, urine ketone body present, white blood cell count increased, blood lactate dehydrogenase increased, glycosylated haemoglobin increased, gamma glutamyl transferase increased.

Metabolism and nutrition disorders.

Uncommon: hyperlipidaemia, anorexia, diabetes mellitus (including blood insulin increased, carbohydrate tolerance decreased, diabetes mellitus noninsulin dependent, glucose tolerance impaired, glycosuria, glucose urine, glucose urine present), hyperglycaemia, hypokalaemia, hypoglycaemia, polydipsia, increased appetite, dehydration, hyponatraemia. Rare: diabetic ketoacidosis, hyperuricaemia.

Musculoskeletal and connective tissue disorders.

Uncommon: muscle rigidity, musculoskeletal rigidity, muscle tightness, muscle spasms, muscular weakness, mobility decreased. Rare: bone pain, nuchal rigidity, sensation of heaviness, flank pain, jaw disorder, kyphosis, osteoarthritis, rhabdomyolysis.

Neoplasms benign, malignant and unspecified (including cysts and polyps).

Rare: oral neoplasm, skin papilloma.

Nervous system disorders.

Common: coordination abnormal. Uncommon: memory impairment, cerebrovascular accident, hypokinesia, hypotonia, myoclonus, hypertonia, akinesia, bradykinesia, drooling, cogwheel rigidity, dystonia, disturbance in attention, dizziness postural, dysarthria, paraesthesia, parkinsonism, psychomotor hyperactivity, hypoaesthesia, speech disorder, tardive dyskinesia. Rare: burning sensation, convulsion, depressed level of consciousness, dysgeusia, akinaesthesia, ataxia, bradykinesia, coma, dysphasia, facial palsy, judgment impaired, loss of consciousness, migraine, neuroleptic malignant syndrome, paraesthesia circumoral, sleep phase rhythm disturbance, grand mal convulsion, choreoathetosis, unresponsive to verbal stimuli.

Psychiatric disorders.

Common: suicidal ideation. Uncommon: aggression, loss of libido, suicide attempt, hostility, libido increased, anger, anorgasmia, delirium, intentional self injury, completed suicide, tic, homicidal ideation, depression, confusional state, nightmare, mania, abnormal dreams, hallucination auditory, nervousness, hallucination, apathy, thinking abnormal, bruxism. Rare: catatonia, sleep walking, bradyphrenia, delirium, depressed mood, disorientation, euphoric mood, logorrhea, mental status changes, mood altered, panic attack, sleep disorder, blunted affect, cognitive deterioration, delusional perception, insomnia, eating disorder, emotional distress, impulsive behaviour, asthenia, mood swings, psychomotor retardation, somatoform disorder.

Renal and urinary disorders.

Uncommon: nocturia, polyuria, pollakiuria, incontinence, urinary retention. Rare: proteinuria, bladder discomfort, chromaturia, enuresis, micturition urgency, oliguria, urethral discharge, urinary hesitation.

Reproductive system and breast disorders.

Uncommon: erectile dysfunction, amenorrheaf, breast pain, menstruation irregularf. Rare: genital pruritus femalef, vulvovaginal discomfortf, pelvic pain, breast discharge, sexual dysfunction, gynaecomastia, priapism.

Respiratory, thoracic and mediastinal disorders.

Common: nasal congestion, dyspnoea, pneumonia aspiration. Uncommon: hiccups, epistaxis. Rare: dry throat, rhinorrhoea, sinus congestion, hoarseness, nasal dryness, painful respiration, paranasal sinus hypersecretion.

Skin and subcutaneous tissue disorders.

Common: rash (including erythematous, exfoliative, generalised, macular, maculopapular, papular rash, acneiform, allergic contact, exfoliative seborrheic dermatitis, neurodermatitis, and drug eruption), hyperhidrosis. Uncommon: pruritus, photosensitivity reaction, alopecia, urticaria. Rare: decubitus ulcer, face oedema, pemphigus, psoriasis, dry skin.

Social circumstances.

Rare: smoker.

Vascular disorders.

Common: hypertension. Uncommon: hypotension, hot flush. Rare: flushing, hyperaemia.
f (Female) indicates incidence based on gender total.

Postmarketing experience.

The following adverse reactions have been identified during postapproval use of Abilify. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to establish a causal relationship to drug exposure: occurrences of allergic reaction (anaphylactic reaction, angioedema, laryngospasm, pruritus/ urticaria, or oropharyngeal spasm), and blood glucose fluctuation. Very rare occurrences of increased AST, increased ALT and hiccups have been reported.

Endocrine disorders.

Very Rare: Diabetic hyperosmolar coma.

Psychiatric disorders.

Uncommon: hypersexuality. Unknown: pathological gambling, impulse control disorders, obsessive compulsive disorders, eating disorders, somnambulism (sleepwalking) and related behaviours including sleep-related eating disorder.

Nervous system disorders.

Very Rare: Restless legs syndrome.

Eye disorders.

Unknown: oculogyric crisis.

Vascular disorders.

Very Rare: Syncope.

Skin and subcutaneous tissue disorders.

Very Rare: Drug reaction with eosinophilia and systemic symptoms (DRESS).

Investigations.

Uncommon: Blood prolactin decreased.

Drug abuse and dependence.

Abilify has not been systematically studied in humans for its potential for abuse, tolerance or physical dependence. In self administration studies in rats and monkeys, Abilify demonstrated marginal to no abuse potential. In physical dependence studies in rats and monkeys, modest withdrawal symptoms were observed upon abrupt cessation of dosing. While the clinical trials did not reveal any tendency for any drug seeking behaviour, these observations were not systematic and it is not possible to predict on the basis of this limited experience the extent to which a CNS active drug will be misused, diverted, and/or abused once marketed. Consequently, patients should be evaluated carefully for a history of drug abuse and such patients should be observed closely for signs of Abilify misuse or abuse (e.g. development of tolerance, increases in dose, drug seeking behaviour).

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.

4.9 Overdose

Human experience.

In clinical studies and postmarketing experience, accidental or intentional acute overdosage of aripiprazole alone was identified in adult patients with estimated doses up to 1260 mg with no fatalities. The potentially medically important signs and symptoms observed in adult patients who overdosed with aripiprazole alone at doses up to 1260 mg included lethargy, blood pressure increased, somnolence, tachycardia and vomiting. In addition, reports of accidental overdose with aripiprazole alone (up to 195 mg) in children have been received. The potentially medically serious signs and symptoms reported include somnolence and transient loss of consciousness. In the patients who were evaluated in hospital settings, there were no reported observations indicating a clinically significant adverse change in vital signs, laboratory assessments or ECG.

Management of overdose.

No specific information is available on the treatment of overdose with Abilify. The possibility of multiple drug involvement should be considered. Therefore, cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring to detect possible arrhythmias. Otherwise, management of overdose should concentrate on supportive therapy, maintaining an adequate airway, oxygenation and ventilation, and management of symptoms. Close medical supervision and monitoring should continue until the patient recovers.

Charcoal.

In the event of an overdose of Abilify, an early charcoal administration may be useful in partially preventing the absorption of aripiprazole. In a single dose study in which 15 mg of aripiprazole was administered to fully compliant, fully conscious, healthy, male volunteers and followed by activated charcoal (50 g) administered one hour after Abilify, aripiprazole AUC and Cmax was decreased by 51 and 41%, respectively, compared to historical controls, suggesting that charcoal may be effective for overdose management.

Haemodialysis.

Although there is no information on the effect of haemodialysis in treating an overdose with Abilify, haemodialysis is unlikely to be useful in overdose management, since aripiprazole is not eliminated unchanged by the kidneys and is highly bound to plasma proteins.
For information on the management of overdose, contact the Poisons Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Aripiprazole is a novel antipsychotic agent with unique pharmacologic properties.

Mechanism of action.

The mechanism of action of Abilify, as well as other drugs having efficacy in schizophrenia, is unknown. However, it has been proposed that the efficacy of Abilify is mediated through a combination of partial agonist activity at dopamine D2 and serotonin 5HT1A-receptors and antagonist activity at serotonin 5HT2A-receptors.
Abilify activity is primarily due to the parent drug, aripiprazole.
Aripiprazole exhibited higher affinity binding in vitro for dopamine D2 and D3, serotonin 5HT1A and 5HT2A-receptors (Ki values of 0.3, 0.8, 1.7 and 3.4 nanoM, respectively), than for dopamine D4, serotonin 5HT2C and 5HT7, α1-adrenergic and histamine H1-receptors (Ki values of 44, 15, 39, 57 and 61 nanoM, respectively) and the serotonin reuptake site (Ki value of 98 nanoM). Aripiprazole exhibited no appreciable affinity for muscarinic receptors (IC50 > 1000 nanoM).
The predominant metabolite in human plasma, dehydroaripiprazole, has been shown to have a similar affinity for dopamine D2 and D3-receptors (Ki values 0.4 and 0.5 nanoM, respectively) as the parent compound and a much lower affinity for the other receptor subtypes.
Aripiprazole exhibited antagonist properties in animal models of dopaminergic hyperactivity and agonist properties in animal models of dopaminergic hypoactivity.
Interaction with receptors other than dopamine and serotonin subtypes may explain some of the other clinical effects of Abilify.

Clinical trials.

Schizophrenia.

The efficacy of Abilify in the treatment of schizophrenia was evaluated in six short-term (4 and 6 week), placebo controlled trials of inpatients, four of which also included an active control group consisting of either risperidone (one trial) or haloperidol (three trials). Studies were not powered to allow for a comparison of Abilify and the active comparators. Efficacy was also documented in two long-term trials, one of 52 weeks duration, which compared Abilify to haloperidol and one of 26 weeks duration, which compared Abilify to placebo. Patients in these trials met DSM-III/IV criteria for schizophrenia or schizoaffective disorder.
Several instruments were used for assessing psychiatric signs and symptoms. The Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS) are both multi-item inventories of general psychopathology used to evaluate the effects of drug treatment in schizophrenia. The BPRS Psychosis Cluster (core score), a subset of the BPRS that can also be derived from the PANSS, is used to assess actively psychotic patients. The Clinical Global Impression (CGI) assessment reflects the impression of a skilled observer, fully familiar with the manifestations of schizophrenia, about the overall clinical state of the patient.
Four short-term, fixed dose trials were well controlled and powered to statistically demonstrate the efficacy of Abilify over placebo. The results of these trials are described below.

Trial 1.

In a 4 week, placebo controlled trial (n = 414) involving administration of 2 fixed doses of Abilify (15 or 30 mg/day) and haloperidol (10 mg/day) in acutely relapsed patients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder, Abilify 15 mg/day was superior to placebo with clinically meaningful changes in PANSS total, PANSS positive and negative subscales, CGI severity, CGI improvement and PANSS derived BPRS core scores. The 30 mg dose was superior to placebo for all parameters except PANSS negative subscale.

Trial 2.

In a 4 week, placebo controlled trial (n = 404) involving administration of 2 fixed doses of Abilify (20 or 30 mg/day) and risperidone (6 mg/day) in acutely relapsed patients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder, both doses of Abilify were superior to placebo with clinically meaningful changes in the PANSS total, PANSS positive and negative subscales, CGI severity, CGI improvement and PANSS derived BPRS core scores.

Trial 3.

In a 6 week, placebo controlled trial (n = 420) involving administration of 3 fixed doses of Abilify (10, 15 or 20 mg/day) in acutely relapsed patients with a DSM-IV diagnosis of schizophrenia, all Abilify dose groups were superior to placebo with clinically meaningful changes in the PANSS total score, the PANSS positive and negative subscales, the CGI severity and improvement scales and the PANSS derived BPRS core score.

Trial 4.

In a 6 week trial (n = 367) comparing three fixed doses of Abilify (2, 5 or 10 mg/day) to placebo, in acutely relapsed patients with a DSM-IV diagnosis of schizophrenia, the 10 mg dose of Abilify was superior to placebo in the PANSS total score, the primary outcome measure of the study. In addition, the 10 mg dose was also superior to placebo in the PANSS positive subscale and the CGI severity score. Although the 5 mg dose of Abilify did not reach significance in the PANSS total score or the PANSS positive subscale, it was superior to placebo in the PANSS negative subscale and the CGI severity scale. The 2 mg dose did not reach significance in any of these outcome measures.
Two initial placebo controlled trials were conducted to explore the efficacy of Abilify. The first one (trial 5) was a placebo controlled, 4 week ascending dose trial of Abilify (5 to 30 mg/day) in 103 patients diagnosed with schizophrenia according to the DSM-III-R criteria with acute schizophrenic relapse and a history of response to antipsychotic drugs. In this trial, Abilify differentiated from placebo in the PANSS total score, the PANSS positive subscale and the CGI severity scale. The second one (trial 6) was a placebo controlled, 4 week, fixed dose trial of Abilify (2, 10 or 30 mg/day) in 272 patients diagnosed with schizophrenia according to the DSM-IV criteria with acute schizophrenic relapse and a history of response to antipsychotic drugs. Statistical significance was reached only for the 30 mg dose on the PANSS total score, the PANSS positive subscale and the CGI severity and improvement scales.
Thus, the efficacy of 10 mg, 15 mg, 20 mg and 30 mg was established in two studies for each dose. Among these doses there was no evidence that the higher dose groups offered any advantage over the lowest dose group. Broad efficacy was established across a variety of endpoints with an onset of action as early as week 1 for positive symptoms at doses of 15 mg and higher.
Table 5 summarises the results across all six trials.
A 52 week, haloperidol controlled, long-term, maintenance trial (n = 1294) was conducted in patients with acute relapse of chronic schizophrenia. In this trial involving the administration of Abilify 30 mg/day and haloperidol 10 mg/day, with a one time option to decrease Abilify to 20 mg/day and haloperidol to 7 mg/day, Abilify was at least comparable to haloperidol in time to failure to maintain response in responders. Based on patients who responded at any time during the 52 week study (610/853, 72% in the Abilify group and 298/430, 69% in the haloperidol group), there was a 12% lower risk of subsequent failure with Abilify relative to haloperidol (relative risk: 0.881, 95% CI: 0.645 to 1.204). Abilify was comparable to haloperidol in time to failure to maintain response in all randomised patients. Patients in the Abilify group had a 14% lower risk of failure compared with the haloperidol group (relative risk: 0.858, 95% CI: 0.721, 1.021). Abilify was statistically superior to haloperidol in the analysis of the proportion of patients on treatment and in response at weeks 8, 26 and 52 (prespecified key time points). At week 52, 40% of Abilify patients were still on study and in response compared to 27% of haloperidol patients (p < 0.001). Abilify treated patients had a statistically significant lower risk (31%) of discontinuations due to lack of efficacy or adverse event relative to haloperidol treated patients (relative risk 0.692; 95% CI: 0.573 to 0.837). There were no significant differences between Abilify and haloperidol groups in terms of change from baseline PANSS total scores, PANSS positive subscores, CGI severity or improvement scores. Abilify did result in a significantly greater improvement in the PANSS negative subscores at weeks 26 and 52 and the MADRS total score at weeks 8, 26 and 52. [Mean change PANSS negative subscale score (week 26: p = 0.029; 95% CI: -1.52, -0.08) (week 52: p = 0.011; 95% CI: -1.73, -0.23). Mean change MADRS total score (week 8: p = 0.027; 95% CI: -1.74, -0.11) (week 26: p = 0.22; 95% CI: -1.95, -0.15) (week 52: p = 0.031; 95% CI: -1.97, -0.09)].
To further demonstrate the maintenance effects of Abilify, a double blind study was conducted in chronic, symptomatically stable schizophrenic patients (n = 310) randomised to Abilify 15 mg or placebo and followed for 26 weeks. Patients were observed for "impending psychotic relapse", defined as CGI improvement score ≥ 5 (minimally worse) or scores ≥ 5 (moderately severe) on the hostility or uncooperativeness items of the PANSS on two consecutive days or ≥ 20% increase in the PANSS total score. Patients in the placebo group experienced a higher relapse rate and/or relapsed sooner than those in the Abilify group. From 4 weeks onwards there were noticeably more relapses in the placebo group than the Abilify group. Kaplan-Meier estimates showed that the estimated probability of not experiencing relapse prior to week 26 was 39% in the placebo group versus 63% in the Abilify group [relative risk Abilify: placebo = 0.50 (95% CI = 0.35, 0.71; p ≤ 0.01)]. The number of relapses was significantly lower in the Abilify group compared to placebo (34% vs 57%, RR = 0.59, 95% CI: 0.45, 0.75; p ≤ 0.01).
No trials have been conducted in patients with first episode schizophrenia or treatment resistant schizophrenia. Thus, efficacy in these groups of patients has not been established.

Bipolar I disorder.

Acute manic and mixed episodes. Adults.

Monotherapy.

The efficacy of Abilify in the treatment of acute manic episodes was established in four 3 week, placebo controlled trials in hospitalised adult patients who met the DSM-IV criteria for bipolar I disorder with manic or mixed episodes. These studies included adult patients with or without psychotic features and two of the studies also included adult patients with or without a rapid cycling course.
The primary instrument used for assessing manic symptoms was the Young Mania Rating Scale (Y-MRS), an 11 item clinician rated scale traditionally used to assess the degree of manic symptomatology (irritability, disruptive/ aggressive behaviour, sleep, elevated mood, speech, increased activity, sexual interest, language/ thought disorder, thought content, appearance, and insight) in a range from 0 (no manic features) to 60 (maximum score). A key secondary instrument included the Clinical Global Impression-Bipolar (CGI-BP) scale.
In the four positive, 3 week, placebo controlled trials (n = 268; n = 248; n = 480; n = 485) which evaluated Abilify in a range of 15 mg to 30 mg, once daily (with a starting dose of 15 mg/day in two studies and 30 mg/day in two studies). Abilify was superior to placebo in the reduction of Y-MRS total score and CGI-BP severity of illness score (mania). In the two studies with a starting dose of 15 mg/day, 48% and 44% of patients were on 15 mg/day at endpoint. In the two studies with a starting dose of 30 mg/day, 86% and 85% of patients were on 30 mg/day at endpoint.

Combination therapy with lithium or valproate.

The efficacy of adjunctive Abilify with concomitant lithium or valproate in the treatment of manic or mixed episodes was established in a 6 week, placebo controlled study (n = 384) with a 2 week lead in mood stabiliser monotherapy phase in adult patients who met DSM-IV criteria for bipolar 1 disorder. This study included patients with manic or mixed episodes and with or without psychotic features.
Adult patients were initiated on open label lithium (0.6 mEq/L to 1.0 mEq/L) or valproate (50 microgram/mL to 125 microgram/mL) at therapeutic serum levels, and remained on stable doses for 2 weeks. At the end of 2 weeks, patients demonstrating inadequate response (Y-MRS total score ≥ 16 and ≤ 25% improvement on the Y-MRS total score) to lithium or valproate were randomised to receive either aripiprazole (15 mg/day or an increase to 30 mg/day as early as day 7) or placebo as adjunctive therapy with open label lithium or valproate. In the 6 week placebo controlled phase, adjunctive Abilify starting at 15 mg/day with concomitant lithium or valproate (in a therapeutic range of 0.6 mEq/L to 1.0 mEq/L or 50 microgram/mL to 125 microgram/mL, respectively) was superior to lithium or valproate with adjunctive placebo in the reduction of the Y-MRS total score and CGI-BP severity of illness score (mania). Seventy-one percent of the patients coadministered valproate and 62% of the patients coadministered lithium were on 15 mg/day at the 6 week endpoint.
Maintenance of manic and mixed episodes.

Monotherapy maintenance of effect.

Two short-term studies in adult patients with an acute manic or mixed episode included assessment of maintenance of effect to 12 weeks. Patients in the haloperidol active comparator study commenced on placebo, haloperidol (5 mg daily with an option to increase up to 15 mg daily), or aripiprazole (15 mg daily with an option to increase up to 30 mg daily). At week 3 patients initially randomised to placebo were switched to aripiprazole. There were 274 (56.5%) patients completed the 12 week double blind phase of the study, 56.9% given aripiprazole, 57.6% given haloperidol and 54.9% who were initially randomised to placebo and then switched to aripiprazole. The placebo aripiprazole patients were not included in the maintenance of effect analyses. The mean change from baseline in Y-MRS total scores at week 12 for patients given 12 weeks of continuous aripiprazole was -17.16 compared with -17.84 for haloperidol. An increase in the proportion of patients with a reduction in Y-MRS total score of at least 50% from baseline (50% responder rates) for both aripiprazole and haloperidol was apparent between weeks 3 and 12 (from 47.0% to 72.3% for aripiprazole and from 49.7% to 73.9% for haloperidol).
The other 12 week study included lithium as the active comparator. Adult patients in this study commenced on placebo, lithium (900 mg daily with an option to increase up to 1200 mg daily at day 4 and 1500 mg daily at day 7), or aripiprazole (15 mg daily with an option to increase to 30 mg daily). At week 3 patients initially randomised to placebo were switched to aripiprazole. There were 143 (29.8%) patients who completed the 12 week double blind phase of the study: 27.1% given aripiprazole, 33.8% given lithium, and 28.5% who were initially randomised to placebo and then switched blindly to aripiprazole. The placebo aripiprazole patients were not included in the maintenance of effect analyses. The mean change from baseline in Y-MRS total scores at week 12 for patients given 12 weeks of continuous aripiprazole was -14.41 compared with -12.71 for lithium. An increase in the proportion of patients with a reduction in Y-MRS total score of at least 50% from baseline (50% responder rates) for both aripiprazole and lithium was apparent between weeks 3 and 12 (from 46.8% to 56.5% for aripiprazole and from 45.8% to 49.0% for lithium).
A placebo controlled, randomised withdrawal study was conducted in adult patients who had experienced a recent acute manic or mixed episode. This study had an initial stabilisation phase where all patients received aripiprazole for 6 to 18 weeks. Patients continued in this phase until symptoms were stable for at least 6 weeks. They were then randomised to aripiprazole or placebo for a 26 week maintenance phase.
567 patients entered the stabilisation phase, of these 361 (64%) did not proceed further due mostly to adverse events (22%), lack of efficacy (12%) and withdrawal of consent (12%). Of the 206 patients who completed the stabilisation phase 161 were randomised to placebo (n = 83) or aripiprazole (n = 78). 94 (58%) of patients discontinued the maintenance phase, the most frequent reason for discontinuation was lack of efficacy (placebo 43%; aripiprazole 24%). The placebo group relapsed sooner than the aripiprazole group. In the maintenance phase the hazard ratio for recurrence for aripiprazole was 0.523 (95% CI: 0.300; 0.913; p = 0.020).
There are insufficient data to know whether Abilify is effective in delaying the time to occurrence of depression in patients with bipolar I disorder.
An examination of population subgroups did not reveal any clear evidence of differential responsiveness on the basis of age and gender, however, there were insufficient numbers of patients in each of the ethnic groups to adequately assess intergroup differences.

5.2 Pharmacokinetic Properties

Absorption.

Aripiprazole is well absorbed after oral administration of Abilify, with peak plasma concentrations occurring within 3 to 5 hours after dosing. The absolute oral bioavailability of the tablet formulation of Abilify is 87%. Abilify can be administered without regard to meals. Following administration of a 15 mg Abilify tablet with a standard high fat meal, the Cmax of aripiprazole and its active metabolite, dehydroaripiprazole, increased by 11%. The AUC of aripiprazole was increased by 18% and that of the active metabolite by 14%. Food delayed Tmax by 3 hours for aripiprazole and 12 hours for the active metabolite. Aripiprazole accumulation is predictable from single dose pharmacokinetics. At steady state, the pharmacokinetics of aripiprazole are dose proportional. There is no diurnal variation in the disposition of aripiprazole and its active metabolite dehydroaripiprazole.

Distribution.

Aripiprazole is widely distributed throughout the body with an apparent volume of distribution of 4.9 L/kg. At therapeutic concentrations, aripiprazole is highly bound (88 to 97% to > 99%, as determined by polydimethylsiloxane glass bead and equilibrium dialysis assays, respectively) to serum proteins, primarily albumin, in vitro. Aripiprazole did not alter the pharmacokinetics and pharmacodynamics of highly protein bound warfarin, suggesting that protein displacement of warfarin did not occur.

Metabolism.

Aripiprazole undergoes minimal presystemic metabolism. Aripiprazole is extensively metabolized by the liver primarily by three biotransformation pathways: dehydrogenation, hydroxylation and N-dealkylation. Based on in vitro studies, CYP3A4 and CYP2D6 enzymes are primarily responsible for dehydrogenation and hydroxylation of aripiprazole, while N-dealkylation is primarily catalysed by CYP3A4. Aripiprazole is the predominant drug moiety in systemic circulation. At steady state dehydroaripiprazole, the active metabolite, represented about 39% of aripiprazole AUC in plasma. Approximately 8% of Caucasians lack the capacity to metabolise CYP2D6 substrates and are classified as poor metabolisers (PM), whereas the rest are extensive metabolisers (EM). PMs have about an 80% increase in aripiprazole exposure and about a 30% decrease in exposure to the active metabolite compared to EMs, resulting in about a 60% higher exposure to the total active moieties from a given dose of aripiprazole compared to EMs. Subjects were entered into clinical studies without knowledge of their metaboliser status and, therefore, the safety profile reflects experience in both EMs and PMs.

Excretion.

Following a single, oral dose of [14C]-labelled aripiprazole, approximately 27% and 60% of the administered radioactivity was recovered in the urine and faeces, respectively. Less than 1% of unchanged aripiprazole was excreted in the urine and approximately 18% of the oral dose was recovered unchanged in the faeces. The total body clearance of aripiprazole is 0.7 mL/min/kg, which is primarily hepatic.
In a bioavailability study comparing fasted and fed subjects at a dose of 15 mg, the elimination half-life of aripiprazole from human plasma was found to be 75 hours mean, range 32 to 146 hours, n = 58, in fasted subjects and 84 hours mean, range 32 to 157 hours, n = 57 in subjects taking a high fat meal immediately before drug administration. Steady-state concentrations are attained within 14 days of dosing. The plasma elimination half-life of the chief metabolite, dehydroaripiprazole, from human plasma was found to be approx. 100 hours.

Elderly.

There were no differences in the pharmacokinetics of aripiprazole between healthy elderly and younger adult subjects nor was there any detectable effect of age in a population pharmacokinetic analysis in schizophrenic patients. In formal single dose pharmacokinetic studies (with aripiprazole given in a single dose of 15 mg), aripiprazole clearance was 20% lower in elderly (≥ 65 years) subjects compared to younger adult subjects (18 to 64 years). There was no detectable age effect, however, in the population pharmacokinetic analysis in schizophrenia patients. Also, the pharmacokinetics of aripiprazole after multiple doses in elderly patients appeared similar to that observed in young healthy subjects. No dosage adjustment is recommended for elderly patients. (See Section 4.4 Special Warnings and Precautions for Use, Increased mortality in elderly patients with dementia related psychosis, Use in the elderly).

Gender.

There were no differences in the pharmacokinetics of aripiprazole between healthy male and female subjects nor was there any detectable effect of gender in a population pharmacokinetic analysis in schizophrenic patients. Cmax and AUC of aripiprazole and its active metabolite, dehydroaripiprazole, are 30 to 40% higher in women than in men, and correspondingly, the apparent oral clearance of aripiprazole is lower in women. These differences, however, are largely explained by differences in bodyweight (25%) between men and women. No dosage adjustment is recommended based on gender.

Race.

Population pharmacokinetic evaluation has revealed no evidence of clinically significant race related differences in the pharmacokinetics of aripiprazole.

Smoking.

Population pharmacokinetic evaluation has revealed no evidence of clinically significant effects of smoking on the pharmacokinetics of aripiprazole. Based on studies utilising human liver enzymes in vitro, aripiprazole is not a substrate for CYP1A2 and also does not undergo direct glucuronidation. Smoking should, therefore, not have an effect on the pharmacokinetics of aripiprazole. Consistent with these in vitro results, population pharmacokinetic evaluation did not reveal any significant pharmacokinetic differences between smokers and nonsmokers. No dosage adjustment is recommended based on smoking status.

Renal impairment.

The pharmacokinetic characteristics of aripiprazole and dehydroaripiprazole were found to be similar in patients with severe renal disease compared to young healthy subjects. In patients with severe renal impairment (creatinine clearance < 30 mL/min), Cmax of aripiprazole (given in a single dose of 15 mg) and dehydroaripiprazole increased by 36% and 53%, respectively, but AUC was 15% lower for aripiprazole and 7% higher for dehydroaripiprazole. Renal excretion of both unchanged aripiprazole and dehydroaripiprazole is less than 1% of the dose. No dosage adjustment is required in subjects with renal impairment.

Hepatic impairment.

A study in subjects with varying degrees of liver cirrhosis (Child-Pugh classes A, B and C) did not reveal a significant effect of hepatic impairment on the pharmacokinetics of aripiprazole and dehydroaripiprazole. In a single dose study (15 mg of aripiprazole) in subjects with varying degrees of liver cirrhosis (Child-Pugh classes A, B and C), the AUC of aripiprazole, compared to healthy subjects, increased 31% in mild HI, increased 8% in moderate HI, and decreased 20% in severe HI. None of these differences would require dose adjustment.

5.3 Preclinical Safety Data

Genotoxicity.

Aripiprazole was tested in a standard range of assays for gene mutation, chromosomal damage, and DNA damage and repair. Aripiprazole was nongenotoxic in the in vitro bacterial reverse mutation assay, the in vitro forward gene mutation assay in mouse lymphoma cells, in vitro bacterial DNA repair assay, and the unscheduled DNA synthesis assay in rat hepatocytes. However, aripiprazole and its minor metabolite 2,3-DCPP were clastogenic in the in vitro chromosomal aberration assay in Chinese hamster lung (CHL) cells in both the presence and absence of metabolic activation. A positive response for aripiprazole in 1 of 6 in vivo mouse micronucleus tests was attributed to drug induced hypothermia.

Carcinogenicity.

Lifetime carcinogenicity studies were conducted in ICR mice and in Sprague-Dawley (SD) and Fischer (F344) rats. Aripiprazole was administered for 2 years in the diet at doses of 1, 3, 10, and 30 mg/kg/day to ICR mice and 1, 3, and 10 mg/kg/day to F344 rats (0.2 to 5 and 0.3 to 3 times the maximum recommended human dose [MRHD] based on mg/m2, respectively). SD rats were dosed orally by gavage for 2 years at 10, 20, 40, and 60 mg/kg/day (3 to 18 times the MRHD based on mg/m2). There was no evidence of tumorigenesis in male mice or rats. In female mice, the incidences of pituitary gland adenomas and mammary gland adenocarcinomas and adenoacanthomas were increased at dietary doses of 3 to 30 mg/kg/day (0.1 to 0.9 times MRHD based on AUC and 0.5 to 5 times the MRHD based on mg/m2). In female rats, the incidence of mammary gland fibroadenomas was increased at a dietary dose of 10 mg/kg/day (< 0.1 times MRHD based on AUC and 3 times the MRHD based on mg/m2); and the incidences of adrenocortical carcinomas and combined adrenocortical adenomas/ carcinomas were increased at an oral gavage dose of 60 mg/kg/day (10 times the MRHD based on AUC and 18 times MRHD based on mg/m2). In male rats, the incidence of benign and combined benign/ malignant phaeochromocytomas were also increased at an oral gavage dose of 60 mg/kg/day (10 times the MRHD based on AUC and 18 times the MRHD based on mg/m2).
Proliferative changes in the pituitary and mammary gland of rodents have been observed following chronic administration of other antipsychotic agents and are considered prolactin mediated. Serum prolactin was not measured in the aripiprazole carcinogenicity studies. Hyperprolactinaemia was observed in female mice in a 13 week dietary study at doses associated with mammary gland and pituitary tumours, but not in female rats in 4 and 13 week dietary studies at doses associated with mammary gland tumours. Hyperprolactinaemia was observed in female rats after 5 and 13 weeks of oral administration at doses up to that associated with adrenocortical tumours, but serum prolactin was decreased at this dose in male rats. The relationship between tumourigenic findings with aripiprazole and prolactin is unclear and the relevance for human risk of prolactin mediated endocrine tumours is unknown. The adrenocortical response in female rats is considered a consequence of increased adrenocortical cell proliferation secondary to chronic drug related adrenocortical cytotoxicity; the no effect exposure (plasma AUC) was about 7-fold clinical exposure at the MRHD.

Animal toxicology.

Choleliths (gallsand and/or gallstones) were observed in the bile of monkeys given aripiprazole orally for 4 to 52 weeks at doses of 25 to 125 mg/kg/day (1 to 3 times the MRHD based on plasma AUC and 15 to 76 times the MRHD based on mg/m2) and were attributed to precipitation of sulfate conjugates of hydroxy metabolites, which exceeded their solubility limits in bile. Human biliary concentrations of these sulfate conjugates after repeated daily administration of the MRHD are substantially lower (0.2 to 14% of their in vitro solubility limits).
Bilateral retinal degeneration was observed in albino rats given oral aripiprazole for 6 months or two years at exposures of 6 to 13 times the clinical exposure at the MRHD (based on plasma AUC). The exposure at the NOEL dose was 3 times that at the MRHD. A subsequent 18 month study reported this finding in albino but not pigmented rats, possibly due to lack of photoprotective ocular melanin in the albino rats, although it is unknown whether pigmentation prevented or merely delayed retinal degeneration in the pigmented rats. The clinical relevance of this finding is uncertain.

6 Pharmaceutical Particulars

6.1 List of Excipients

The inactive ingredients in the tablets are: lactose monohydrate, maize starch, microcrystalline cellulose, hyprolose, and magnesium stearate. The following colorants are also contained in the tablets: 2 mg tablets - indigo carmine aluminium lake and iron oxide yellow; 5 mg tablets - indigo carmine aluminium lake; 10 mg tablets - iron oxide red; 15 mg tablets - iron oxide yellow; 20 mg tablets - nil; 30 mg tablets - iron oxide red.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 30°C.

6.5 Nature and Contents of Container

Abilify tablets are packed in aluminium blisters in cartons.
Not all pack sizes may be available in Australia.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

Aripiprazole is a novel antipsychotic agent with a chemical structure that differs from current antipsychotic. Aripiprazole is insoluble in water with its equilibrium solubility being about 0.00001% w/v, its pKa was established in 20% aqueous ethanol; pKa = 7.6 (20% ethanol, at 25°C). The partition coefficients (Po/w) of aripiprazole range from 3.4 at pH 2.0 to > 1000 at pH 6.0.

Chemical structure.

Aripiprazole is 7-[4-[4-(2,3-dichlorophenyl)-1-piperazinyl]butoxy]-3,4-dihydrocarbostyril.
The empirical formula is C23H27Cl2N3O2 and its molecular weight is 448.39. The chemical structure is:

CAS number.

129722-12-9.

7 Medicine Schedule (Poisons Standard)

S4 Prescription Medicine.

Summary Table of Changes