Cariprazine
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Martin Nino [2]
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Black Box Warning
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INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS
See full prescribing information for complete Boxed Warning.
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Cariprazine is not approved for the treatment of patients with dementia-related psychosis
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Overview
Cariprazine is an atypical antipsychotic that is FDA approved for the treatment of patients with schizophrenia and acute treatment of manic or mixed episodes associated with bipolar I disorder. There is a Black Box Warning for this drug as shown here. Common adverse reactions include extrapyramidal symptoms and akathisia in Schizophrenia patients and extrapyramidal symptoms, akathisia, dyspepsia, vomiting, somnolence, and restlessness in patients with Bipolar mania (≥5%).
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
Indications
Cariprazine is indicated for the:
- Treatment of schizophrenia
- Acute treatment of manic or mixed episodes associated with bipolar I disorder
Dosage
Cariprazine is given orally once daily and can be taken with or without food.
Because of the long half-life of Cariprazine and its active metabolites, changes in dose will not be fully reflected in plasma for several weeks. Prescribers should monitor patients for adverse reactions and treatment response for several weeks after starting Cariprazine and after each dosage change.
The maximum recommended dose is 6 mg daily. In short-term controlled trials, dosages above 6 mg daily do not confer increased effectiveness sufficient to outweigh dose-related adverse reactions.
The recommended dose range is 1.5 mg to 6 mg once daily. The starting dose of Cariprazine is 1.5 mg. The dosage can be increased to 3 mg on Day 2. Depending upon clinical response and tolerability, further dose adjustments can be made in 1.5 mg or 3 mg increments.
- Manic or Mixed Episodes Associated with Bipolar I Disorder
The recommended dose range is 3 mg to 6 mg once daily. The starting dose of Cariprazine is 1.5 mg and should be increased to 3 mg on Day 2. Depending upon clinical response and tolerability, further dose adjustments can be made in 1.5 mg or 3 mg increments.
- Dosage Adjustments for CYP3A4 Inhibitors and Inducers
CYP3A4 is responsible for the formation and elimination of the major active metabolites of Cariprazine.
- Dosage recommendation for patients initiating a strong CYP3A4 inhibitor while on a stable dose of Cariprazine: If a strong CYP3A4 inhibitor is initiated, reduce the current dosage of Cariprazine by half. For patients taking 4.5 mg daily, the dosage should be reduced to 1.5 mg or 3 mg daily. For patients taking 1.5 mg daily, the dosing regimen should be adjusted to every other day. When the CYP3A4 inhibitor is withdrawn, Cariprazine dosage may need to be increased.
- Dosage recommendation for patients initiating Cariprazine therapy while already on a strong CYP3A4 inhibitor: Patients should be administered 1.5 mg of Cariprazine on Day 1 and on Day 3 with no dose administered on Day 2. From Day 4 onward, the dose should be administered at 1.5 mg daily, then increased to a maximum dose of 3 mg daily. When the CYP3A4 inhibitor is withdrawn, Cariprazine dosage may need to be increased.
- Dosage recommendation for patients concomitantly taking Cariprazine with CYP3A4 inducers:Concomitant use of Cariprazine and a CYP3A4 inducer has not been evaluated and is not recommended because the net effect on active drug and metabolites is unclear.
- Treatment Discontinuation
Following discontinuation of Cariprazine, the decline in plasma concentrations of active drug and metabolites may not be immediately reflected in patients' clinical symptoms; the plasma concentration of Cariprazine and its active metabolites will decline by 50% in ~1 week. There are no systematically collected data to specifically address switching patients from Cariprazine to other antipsychotics or concerning concomitant administration with other antipsychotics.
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Cariprazine in adult patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Cariprazine in adult patients.
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
Safety and effectiveness in pediatric patients have not been established. Pediatric studies of Cariprazine have not been conducted. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery.
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Cariprazine in pediatric patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Cariprazine in pediatric patients.
Contraindications
Cariprazine is contraindicated in patients with history of a hypersensitivity reaction to Cariprazine. Reactions have ranged from rash, pruritus, urticaria, and events suggestive of angioedema (e.g., swollen tongue, lip swelling, face edema, pharyngeal edema, and swelling face).
Warnings
|
INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS
See full prescribing information for complete Boxed Warning.
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Cariprazine is not approved for the treatment of patients with dementia-related psychosis
|
Increased Mortality in Elderly Patients with Dementia-Related Psychosis
Antipsychotic drugs increase the all-cause risk of death in elderly patients with dementia-related psychosis. Analyses of 17 dementia-related psychosis placebo-controlled trials (modal duration of 10 weeks and largely in patients taking atypical antipsychotic drugs) revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that 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 placebo-treated patients.
Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Cariprazine is not approved for the treatment of patients with dementia-related psychosis.
Cerebrovascular Adverse Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis
In placebo-controlled trials in elderly subjects with dementia, patients randomized to risperidone, aripiprazole, and olanzapine had a higher incidence of stroke and transient ischemic attack, including fatal stroke. Cariprazine is not approved for the treatment of patients with dementia-related psychosis.
Neuroleptic Malignant Syndrome (NMS)
Neuroleptic Malignant Syndrome (NMS), a potentially fatal symptom complex, has been reported in association with administration of antipsychotic drugs. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, delirium, and autonomic instability. Additional signs may include elevated creatine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure.
If NMS is suspected, immediately discontinue Cariprazine and provide intensive symptomatic treatment and monitoring.
Falls
Cariprazine may cause somnolence, postural hypotension, motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries. For patients with diseases, conditions, or medications that could exacerbate these effects, complete fall risk assessments when initiating antipsychotic treatment and recurrently for patients on long-term antipsychotic therapy.
Tardive Dyskinesia
Tardive dyskinesia, a syndrome consisting of potentially irreversible, involuntary, dyskinetic movements, may develop in patients treated with antipsychotic drugs, including Cariprazine. The risk appears to be highest among the elderly, especially elderly women, but it is not possible to predict which patients are likely to develop the syndrome. Whether antipsychotic drug products differ in their potential to cause tardive dyskinesia is unknown.
The risk of tardive dyskinesia and the likelihood that it will become irreversible increase with the duration of treatment and the cumulative dose. The syndrome can develop after a relatively brief treatment period, even at low doses. It may also occur after discontinuation of treatment.
There is no known treatment for tardive dyskinesia, although the syndrome may remit, partially or completely, if antipsychotic treatment is discontinued. Antipsychotic treatment itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome, possibly masking the underlying process. The effect that symptomatic suppression has upon the long-term course of tardive dyskinesia is unknown.
Given these considerations, Cariprazine should be prescribed in a manner most likely to reduce the risk of tardive dyskinesia. Chronic antipsychotic treatment should generally be reserved for patients: 1) who suffer from a chronic illness that is known to respond to antipsychotic drugs; and 2) for whom alternative, effective, but potentially less harmful treatments are not available or appropriate. In patients who do require chronic treatment, use the lowest dose and the shortest duration of treatment producing a satisfactory clinical response should be sought. Periodically reassess the need for continued treatment.
If signs and symptoms of tardive dyskinesia appear in a patient on Cariprazine, drug discontinuation should be considered. However, some patients may require treatment with Cariprazine despite the presence of the syndrome.
Late-Occurring Adverse Reactions
Adverse events may first appear several weeks after the initiation of Cariprazine treatment, probably because plasma levels of Cariprazine and its major metabolites accumulate over time. As a result, the incidence of adverse reactions in short-term trials may not reflect the rates after longer term exposures.
Monitor for adverse reactions, including EPS or akathisia, and patient response for several weeks after a patient has begun Cariprazine and after each dosage increase. Consider reducing the dose or discontinuing the drug.
Metabolic Changes
Atypical antipsychotic drugs, including Cariprazine, have caused metabolic changes, including hyperglycemia, diabetes mellitus, dyslipidemia, and weight gain. Although all of the drugs in the class to date have been shown to produce some metabolic changes, each drug has its own specific risk profile.
Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics. Assess fasting plasma glucose before or soon after initiation of antipsychotic medication, and monitor periodically during long-term treatment.
In the 6-week, placebo-controlled trials of adult patients with schizophrenia, the proportion of patients with shifts in fasting glucose from normal (<100 mg/dL) to high (≥126 mg/dL) and borderline (≥100 and <126 mg/dL) to high were similar in patients treated with Cariprazine and placebo. In the long-term, open-label schizophrenia studies, 4% patients with normal hemoglobin A1c baseline values developed elevated levels ( ≥6.5%).
In the 3-week, placebo-controlled trials of adult patients with bipolar disorder, the proportion of patients with shifts in fasting glucose from normal (<100 mg/dL) to high (≥126 mg/dL) and borderline (≥100 and <126 mg/dL) to high were similar in patients treated with Cariprazine and placebo. In the long-term, open-label bipolar disorder studies, 4% patients with normal hemoglobin A1c baseline values developed elevated levels (≥6.5%).
Atypical antipsychotics cause adverse alterations in lipids. Before or soon after initiation of antipsychotic medication, obtain a fasting lipid profile at baseline and monitor periodically during treatment.
In the 6-week, placebo-controlled trials of adult patients with schizophrenia, the proportion of patients with shifts in fasting total cholesterol, LDL, HDL and triglycerides were similar in patients treated with Cariprazine and placebo.
In the 3-week, placebo-controlled trials of adult patients with bipolar disorder, the proportion of patients with shifts in fasting total cholesterol, LDL, HDL and triglycerides were similar in patients treated with Cariprazine and placebo.
- Weight Gain
Weight gain has been observed with use of atypical antipsychotics, including Cariprazine. Monitor weight at baseline and frequently thereafter. TABLES 1 and 2 show the change in body weight occurring from baseline to endpoint in 6-week schizophrenia and 3-week bipolar mania trials.
- Table 1. Change in Body Weight (kg) in 6-Week Schizophrenia Trials
VRAYLAR: Cariprazine's Brand name
- Table 2. Change in Body Weight (kg) in 3-Week Bipolar Mania Trials
VRAYLAR: Cariprazine's Brand name
In long-term, uncontrolled trials with Cariprazine in schizophrenia, the mean changes from baseline in weight at 12, 24, and 48 weeks were 1.2 kg, 1.7 kg, and 2.5 kg, respectively.
Leukopenia, Neutropenia, and Agranulocytosis
Leukopenia and neutropenia have been reported during treatment with antipsychotic agents, including Cariprazine. Agranulocytosis (including fatal cases) has been reported with other agents in the class.
Possible risk factors for leukopenia and neutropenia include pre-existing low white blood cell count (WBC) or absolute neutrophil count (ANC) and history of drug-induced leukopenia or neutropenia. In patients with a pre-existing low WBC or ANC or a history of drug-induced leukopenia or neutropenia, perform a complete blood count (CBC) frequently during the first few months of therapy. In such patients, consider discontinuation of Cariprazine at the first sign of a clinically significant decline in WBC in the absence of other causative factors.
Monitor patients with clinically significant neutropenia for fever or other symptoms or signs of infection and treat promptly if such symptoms or signs occur. Discontinue Cariprazine in patients with absolute neutrophil count < 1000/mm3 and follow their WBC until recovery.
Orthostatic Hypotension and Syncope
Atypical antipsychotics cause orthostatic hypotension and syncope. Generally, the risk is greatest during initial dose titration and when increasing the dose. Symptomatic orthostatic hypotension was infrequent in trials of Cariprazine and was not more frequent on Cariprazine than placebo. Syncope was not observed.
Orthostatic vital signs should be monitored in patients who are vulnerable to hypotension (e.g., elderly patients, patients with dehydration, hypovolemia, and concomitant treatment with antihypertensive medications), patients with known cardiovascular disease (history of myocardial infarction, ischemic heart disease, heart failure, or conduction abnormalities), and patients with cerebrovascular disease. Cariprazine has not been evaluated in patients with a recent history of myocardial infarction or unstable cardiovascular disease. Such patients were excluded from pre-marketing clinical trials.
Seizures
Like other antipsychotic drugs, Cariprazine may cause seizures. This risk is greatest in patients with a history of seizures or with conditions that lower the seizure threshold. Conditions that lower the seizure threshold may be more prevalent in older patients.
Potential for Cognitive and Motor Impairment
Cariprazine, like other antipsychotics, has the potential to impair judgment, thinking, or motor skills.
In 6-week schizophrenia trials, somnolence (hypersomnia, sedation, and somnolence) was reported in 7% of Cariprazine-treated patients compared to 6% of placebo-treated patients. In 3-week bipolar mania trials, somnolence was reported in 8% of Cariprazine-treated patients compared to 4% of placebo-treated patients.
Patients should be cautioned about operating hazardous machinery, including motor vehicles, until they are reasonably certain that therapy with Cariprazine does not affect them adversely.
Body Temperature Dysregulation
Atypical antipsychotics may disrupt the body's ability to reduce core body temperature. Strenuous exercise, exposure to extreme heat, dehydration, and anticholinergic medications may contribute to an elevation in core body temperature; use Cariprazine with caution in patient who may experience these conditions.
Dysphagia
Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Dysphagia has been reported with Cariprazine. Cariprazine and other antipsychotic drugs should be used cautiously in patients at risk for aspiration.
Adverse Reactions
Clinical Trials Experience
The following adverse reactions are discussed in more detail in other sections of the labeling:
- Increased Mortality in Elderly Patients with Dementia-Related Psychosis
- Cerebrovascular Adverse Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis
- Neuroleptic Malignant Syndrome
- Tardive Dyskinesia
- Late Occurring Adverse Reactions
- Metabolic Changes
- Leukopenia, Neutropenia, and Agranulocytosis
- Orthostatic Hypotension and Syncope
- Seizures
- Potential for Cognitive and Motor Impairment
- Body Temperature Dysregulation
- Dysphagia
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The information below is derived from the clinical trial database for Cariprazine, consisting of 1733 patients with schizophrenia (aged 18 to 65) and 1025 patients with manic or mixed episodes associated with bipolar I disorder (aged 18 to 65) exposed to one or more doses with a total experience of 566.5 patient-years. Of these patients, 1317 participated in placebo-controlled, 6-week schizophrenia trials with doses ranging from 1.5 mg to 12 mg/day and 623 participated in placebo-controlled, 3-week bipolar mania trials with doses ranging from 3 mg to 12 mg/day. A total of 364 Cariprazine-treated patients had at least 24 weeks of exposure and 239 Cariprazine-treated patients had at least 48 weeks of exposure.
Patients with Schizophrenia
The following findings are based on four placebo-controlled, 6-week schizophrenia trials with Cariprazine doses ranging from 1.5 to 12 mg once daily.
- Adverse Reactions Associated with Discontinuation of Treatment: There was no single adverse reaction leading to discontinuation that occurred at a rate of ≥ 2% in Cariprazine-treated patients and at least twice the rate of placebo.
- Common Adverse Reactions (≥ 5% and at least twice the rate of placebo): extrapyramidal symptoms and akathisia.
Adverse Reactions with an incidence of ≥ 2% and greater than placebo, at any dose are shown in TABLE 3.
- Table 3. Adverse Reactions Occurring in ≥ 2% of Cariprazine-treated Patients and > Placebo-treated Adult Patients in 6-Week Schizophrenia Trials
VRAYLAR: Cariprazine's Brand name
Patients with Bipolar Mania
The following findings are based on three placebo-controlled, 3-week bipolar mania trials with Cariprazine doses ranging from 3 to 12 mg once daily.
- Adverse Reactions Associated with Discontinuation of Treatment: The only adverse reaction leading to discontinuation that occurred at a rate of ≥ 2% in Cariprazine-treated patients and at least twice the rate of placebo was akathisia (2%). Overall, 12% of the patients who received Cariprazine discontinued treatment due to an adverse reaction, compared with 7% of placebo-treated patients in these trials.
- Common Adverse Reactions (≥ 5% and at least twice the rate of placebo): extrapyramidal symptoms, akathisia, dyspepsia, vomiting, somnolence, and restlessness.
Adverse Reactions with an incidence of ≥ 2% and greater than placebo at any dose are shown in TABLE 4.
- Table 4. Adverse Reactions Occurring in ≥ 2% of Cariprazine-treated Patients and > Placebo-treated Adult Patients in 3-Week Bipolar Mania Trials
VRAYLAR: Cariprazine's Brand name
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. Although these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and higher doses of first-generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups.
Extrapyramidal Symptoms (EPS) and Akathisia
In schizophrenia and bipolar mania trials, data were objectively collected using the Simpson Angus Rating Scale (SAS) for treatment-emergent EPS (parkinsonism) (SAS total score ≤ 3 at baseline and > 3 post-baseline) and the Barnes Akathisia Scale (BARS) for treatment-emergent akathisia (BARS total score ≤ 2 at baseline and > 2 post-baseline).
In 6-week schizophrenia trials, the incidence of reported events related to extrapyramidal symptoms (EPS), excluding akathisia and restlessness was 17% for Cariprazine-treated patients versus 8% for placebo-treated patients. These events led to discontinuation in 0.3% of Cariprazine-treated patients versus 0.2% of placebo-treated patients. The incidence of akathisia was 11% for Cariprazine-treated patients versus 4% for placebo-treated patients. These events led to discontinuation in 0.5% of Cariprazine-treated patients versus 0.2% of placebo-treated patients. The incidence of EPS is shown in TABLE 5.
- Table 5. Incidence of EPS Compared to Placebo in 6-Week Schizophrenia Studies
VRAYLAR: Cariprazine's Brand name
In 3-week bipolar mania trials, the incidence of reported events related to extrapyramidal symptoms (EPS), excluding akathisia and restlessness, was 28% for Cariprazine-treated patients versus 12% for placebo-treated patients. These events led to a discontinuation in 1% of Cariprazine-treated patients versus 0.2% of placebo-treated patients. The incidence of akathisia was 20% for Cariprazine-treated patients versus 5% for placebo-treated patients. These events led to discontinuation in 2% of Cariprazine-treated patients versus 0% of placebo-treated patients. The incidence of EPS is provided in TABLE 6.
- Table 6. Incidence of EPS Compared to Placebo in 3-Week Bipolar Mania Trials
VRAYLAR: Cariprazine's Brand name
In the long-term uncontrolled schizophrenia (48-week) and bipolar mania (16-week) trials, the incidence of cataracts was 0.1% and 0.2%, respectively. The development of cataracts was observed in nonclinical studies. The possibility of lenticular changes or cataracts cannot be excluded at this time.
Vital Signs Changes
There were no clinically meaningful differences between Cariprazine-treated patients and placebo-treated patients in mean change from baseline to endpoint in supine blood pressure parameters except for an increase in supine diastolic blood pressure in the 9 - 12 mg/day Cariprazine-treated schizophrenia patients.
Pooled data from 6-week schizophrenia and 3-week bipolar mania trials are shown in TABLES 7 and 8.
- Table 7. Mean Change in Blood Pressure at Endpoint in 6-Week Schizophrenia Trials
VRAYLAR: Cariprazine's Brand name
- Table 8. Mean Change in Blood Pressure at Endpoint in 3-Week Bipolar Mania Trials
VRAYLAR: Cariprazine's Brand name
Changes in Laboratory Tests
The proportions of patients with transaminase elevations of ≥3 times the upper limits of the normal reference range in 6-week schizophrenia trials ranged between 1% and 2% for Cariprazine-treated patients, increasing with dose, and was 1% for placebo-treated patients. The proportions of patients with transaminase elevations of ≥3 times the upper limits of the normal reference range in 3-week bipolar mania trials ranged between 2% and 4% for Cariprazine-treated patients depending on dose group administered and 2% for placebo-treated patients.
The proportions of patients with elevations of creatine phosphokinase (CPK) greater than 1000 U/L in 6-week schizophrenia trials ranged between 4% and 6% for Cariprazine-treated patients, increasing with dose, and was 4% for placebo-treated patients. The proportions of patients with elevations of CPK greater than 1000 U/L in 3-week bipolar mania trials was about 4% in Cariprazine and placebo-treated patients.
Other Adverse Reactions Observed During the Pre-marketing Evaluation of Cariprazine
Adverse reactions listed below were reported by patients treated with Cariprazine at doses of ≥ 1.5 mg once daily within the database of 2758 Cariprazine-treated patients. The reactions listed are those that could be of clinical importance, as well as reactions that are plausibly drug-related on pharmacologic or other grounds. Reactions that appear elsewhere in the Cariprazine label are not included.
Reactions are further categorized by organ class and listed in order of decreasing frequency, according to the following definition: those occurring in at least 1/100 patients (frequent) [only those not already listed in the tabulated results from placebo-controlled studies appear in this listing]; those occurring in 1/100 to 1/1000 patients (infrequent); and those occurring in fewer than 1/1000 patients (rare).
- Gastrointestinal Disorders: Infrequent: gastroesophageal reflux disease, gastritis
- Hepatobiliary Disorders: Rare: hepatitis
- Metabolism and Nutrition Disorders: Frequent: decreased appetite; Infrequent: hyponatremia
- Musculoskeletal and Connective Tissue Disorders: Rare: rhabdomyolysis
- Nervous System Disorders: Rare: ischemic stroke
- Psychiatric Disorders: Infrequent: suicide attempts, suicide ideation; Rare: completed suicide
- Renal and Urinary Disorders: Infrequent: pollakiuria
- Skin and Subcutaneous Tissue Disorders: Infrequent: hyperhidrosis
Postmarketing Experience
There is limited information regarding Cariprazine Postmarketing Experience in the drug label.
Drug Interactions
Drugs Having Clinically Important Interactions with Cariprazine
- Table 9: Clinically Important Drug Interactions with Cariprazine
VRAYLAR: Cariprazine's Brand name
Drugs Having No Clinically Important Interactions with Cariprazine Based on in vitro studies, Cariprazine is unlikely to cause clinically significant pharmacokinetic drug interactions with substrates of CYP1A2, CYP2A6, CYP2C9, CYP2C19, CYP2D6, CYP2E, and CYP3A4, or OATP1B1, OATP1B3, BCRP, OCT2, OAT1 and OAT3.
Use in Specific Populations
Pregnancy
- Pregnancy Exposure Registry
There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to Cariprazine during pregnancy. For more information, contact the National Pregnancy Registry for Atypical Antipsychotics at 1-866-961-2388 or visit http://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/.
- Risk Summary
Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. There are no available data on Cariprazine use in pregnant women to inform any drug-associated risks for birth defects or miscarriage. Based on animal data Cariprazine may cause fetal harm. Administration of Cariprazine to rats during the period of organogenesis caused malformations, lower pup survival, and developmental delays at drug exposures less than the human exposure at the maximum recommended human dose (MRHD) of 6 mg/day. However, Cariprazine was not teratogenic in rabbits at doses up to 4.6 times the MRHD of 6 mg/day. The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Advise pregnant women of the potential risk to a fetus.
- Clinical Considerations
- Fetal/Neonatal Adverse Reactions
Extrapyramidal and/or withdrawal symptoms, including agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress and feeding disorder have been reported in neonates whose mothers were exposed to antipsychotic drugs during the third trimester of pregnancy. These symptoms have varied in severity. Some neonates recovered within hours or days without specific treatment; others required prolonged hospitalization. Monitor neonates for extrapyramidal and/or withdrawal symptoms and manage symptoms appropriately.
- Data
- Animal Data
Administration of Cariprazine to pregnant rats during the period of organogenesis at oral doses of 0.5, 2.5, and 7.5 mg/kg/day which are 0.2 to 3.5 times the maximum recommended human dose (MRHD) of 6 mg/day based on AUC of total Cariprazine (i.e. sum of Cariprazine, DCAR, and DDCAR) caused fetal developmental toxicity at all doses which included reduced body weight, decreased male anogenital distance and skeletal malformations of bent limb bones, scapula and humerus. These effects occurred in the absence or presence of maternal toxicity. Maternal toxicity, observed as a reduction in body weight and food consumption, occurred at doses 1.2 and 3.5-times the MRHD of 6 mg/kg/day based on AUC of total Cariprazine. At these doses, Cariprazine caused fetal external malformations (localized fetal thoracic edema), visceral variations (undeveloped/underdeveloped renal papillae and/or distended urethrae), and skeletal developmental variations (bent ribs, unossified sternebrae). Cariprazine had no effect on fetal survival.
Administration of Cariprazine to pregnant rats during pregnancy and lactation at oral doses of 0.1, 0.3, and 1 mg/kg/day which are 0.03 to 0.4 times the MRHD of 6 mg/day based on AUC of total Cariprazine caused a decrease in postnatal survival, birth weight, and post-weaning body weight of first generation pups at the dose that is 0.4 times the MRHD of 6 mg/day based on AUC of total Cariprazine in absence of maternal toxicity. First generation pups also had pale, cold bodies and developmental delays (renal papillae not developed or underdeveloped and decreased auditory startle response in males). Reproductive performance of the first generation pups was unaffected; however, the second generation pups had clinical signs and lower body weight similar to these of the first generation pups.
Administration of Cariprazine to pregnant rabbits during the period of organogenesis at oral doses of 0.1, 1, and 5 mg/kg/day, which are 0.02 to 4.6 times the MRHD of 6 mg/day based on AUC of total Cariprazine was not teratogenic. Maternal body weight and food consumption were decreased at 4.6 times the MRHD of 6 mg/day based on AUC of total Cariprazine; however, no adverse effects were observed on pregnancy parameters or reproductive organs.
Pregnancy Category (AUS):
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Cariprazine in women who are pregnant.
Labor and Delivery
There is no FDA guidance on use of Cariprazine during labor and delivery.
Nursing Mothers
Lactation studies have not been conducted to assess the presence of Cariprazine in human milk, the effects on the breastfed infant, or the effects on milk production. Cariprazine is present in rat milk. The development and health benefits of breastfeeding should be considered along with the mother's clinical need for Cariprazine and any potential adverse effects on the breastfed infant from Cariprazine or from the underlying maternal condition.
Pediatric Use
Safety and effectiveness in pediatric patients have not been established. Pediatric studies of Cariprazine have not been conducted. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery.
Geriatic Use
Clinical trials of Cariprazine in the treatment of schizophrenia and bipolar mania did not include sufficient numbers of patients aged 65 and older to determine whether or not they respond differently from younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
Elderly patients with dementia-related psychosis treated with Cariprazine are at an increased risk of death compared to placebo. Cariprazine is not approved for the treatment of patients with dementia-related psychosis.
Gender
There is no FDA guidance on the use of Cariprazine with respect to specific gender populations.
Race
There is no FDA guidance on the use of Cariprazine with respect to specific racial populations.
Renal Impairment
No dosage adjustment for Cariprazine is required in patients with mild to moderate (CrCL ≥ 30 mL/minute) renal impairment.
Usage of Cariprazine is not recommended in patients with severe renal impairment (CrCL < 30 mL/minute). Cariprazine has not been evaluated in this patient population.
Hepatic Impairment
No dosage adjustment for Cariprazine is required in patients with mild to moderate hepatic impairment (Child-Pugh score between 5 and 9). Usage of Cariprazine is not recommended in patients with severe hepatic impairment (Child-Pugh score between 10 and 15). Cariprazine has not been evaluated in this patient population.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Cariprazine in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Cariprazine in patients who are immunocompromised.
Administration and Monitoring
Administration
There is limited information regarding Cariprazine Administration in the drug label.
Monitoring
There is limited information regarding Cariprazine Monitoring in the drug label.
IV Compatibility
There is limited information regarding the compatibility of Cariprazine and IV administrations.
Overdosage
There is limited information regarding Cariprazine overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.
Pharmacology
Cariprazine
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| Bioavailability | ? |
| Metabolism | ? |
| Half life | ? |
| Excretion | ? |
| Therapeutic considerations | |
| Pregnancy cat. |
? |
| Legal status | |
| Routes | ? |
Mechanism of Action
There is limited information regarding Cariprazine Mechanism of Action in the drug label.
Structure
There is limited information regarding Cariprazine Structure in the drug label.
Pharmacodynamics
There is limited information regarding Cariprazine Pharmacodynamics in the drug label.
Pharmacokinetics
There is limited information regarding Cariprazine Pharmacokinetics in the drug label.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment of Fertility
Clinical Studies
There is limited information regarding Cariprazine Clinical Studies in the drug label.
How Supplied
VRAYLAR (cariprazine) capsules are available in four strengths.
1.5 mg capsules: White cap and body imprinted with “FL 1.5” 3 mg capsules: Green to blue-green cap and white body imprinted with “FL 3” 4.5 mg capsules: Green to blue-green cap and body imprinted with “FL 4.5” 6 mg capsules: Purple cap and white body imprinted with “FL 6”
Storage
There is limited information regarding Cariprazine Storage in the drug label.
Images
Drug Images
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Package and Label Display Panel
{{#ask: Label Page::Cariprazine |?Label Name |format=template |template=DrugLabelImages |mainlabel=- |sort=Label Page }}
Patient Counseling Information
There is limited information regarding Cariprazine Patient Counseling Information in the drug label.
Precautions with Alcohol
Alcohol-Cariprazine interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication.
Brand Names
VRAYLAR™
Look-Alike Drug Names
There is limited information regarding Cariprazine Look-Alike Drug Names in the drug label.
Drug Shortage Status
Price
References
The contents of this FDA label are provided by the National Library of Medicine.