Ak-ak-ak-ak-akathesia . . .the trouble with Abilify

 Now . . . don’t get me wrong . . . I am a big fan of Abilify.  Even if their over the top marketing binge is so financially disgusting to me that I want to reflexively run screaming into the night.  I mean, really, how many prime time advertisements for this product do they need???  Then my patients come in talking about how expensive the medicine is . . . like $1000 for a month’s supply . . . ridiculous.  

But anyway . . . I digress . . .

As many of you know, Abilify is the newest addition to the genera of medication I affectionately refer to as “mood stabilizing antipsychotic tranquilizers”.  This usually gets a patient’s or a parent’s attention as I talk about all the horrible things that can go wrong when someone takes these medicines.  And make no mistake, you have to know that these medicines are not without their issues.  But, overall, they are GREAT medicines.  They are reliable in what they do and they work quickly.  OK, so they can contribute to weight gain . . . diabetes . . . hypercholesterolemia . . . affective flattening . . . irreversible movement disorders . . . I mean . . . no medicine is perfect . . . right? . . . RIGHT??? . . .

Where the rubber hits the road (that is where my office is) Abilify is a great medicine.  It covers mood instability, irritability, manic symptoms, and can boost the effectiveness of antidepressants.  It’s tendency to cause weight gain, and the other above mentioned bug-a-boos is less than most of the other members of this class.  People rarely get sedated and dopey on it.  But more frequently than with the other medicines, it seems to induce akathesia.

Akathesia is one of my favorite words.  The definition of akathesia is “the subjective feeling of wanting to jump out of your skin”.  ISN’T THAT A GREAT DEFINITION???  And that is exactly what someone will say if they develop akathesia.  They will call or come into the office and will be trying to describe this vague internal uncomfortableness that leaves them jumpy and restless and out of sorts and I will ask . . . “so . . . do you feel like you want to jump out of your skin?” and they will invariably respond “YES!!!” like I understand them better than anyone else in the universe.  Cool feeling for me.  Lousy feeling for them.

This is one of those states of being that is just horrible.  If you every have had the displeasure of watching old video shorts of patients in state mental hospitals that are rocking and rocking furiously in their seats . . . that is extreme akathesia.  It is caused by the action of the medicines at the dopamine receptors and is rarely treatable by anything but getting off the medicine.  Cogentin and benzos typically just don’t touch it.  The best solution is to get the patient off the medicine as quickly and safely as possible and to try something else.  Since moving to the second generation of neuroleptics, I have seen less and less akathesia in my patients.  The older second generation agents seemed to cause this less.  So patients on Risperdal, Zyprexa, and Seroquel only presented back with akathesia rarely.  Ever since I became an Abilify convert, however, I have seen a steady stream of patients complaining about this.  So much so that I routinely tell people that they might feel agitated on the medicine and that they need to call me if they do.  And I have gotten my fair share of calls.

So why am I still using Abilify?  Well, the frequency of the development of akathesia is not that high (no, I have not done the statistics).  And many people get great benefit from it.  If they do develop akatheisa, I lower the dose and, if that is not successful, take them off and try something else.  The potential benefits that the medicine brings far outweighs the low risk of a temporary level of discomfort. As long as they know that it can happen, and that they don’t have to live with it.  

That would be intolerable.

–Dan Hartman, MD 


2 comments to Ak-ak-ak-ak-akathesia . . .the trouble with Abilify

  • An adult in our family had a terrible reaction to crossing over to Abilify, in 2004 — STILL HAS ONLY PARTIALLY RECOVERED. This, despite fact that, at the outset on Abilify, the first few weeks were better by far than on olanzapine. Then the symptoms that set in looked like dementia, serious and so sweeping, The M.D. FEARED EITHER A SUDDEN STROKE, OR SUDDEN SYMPTOMS OF A BRAIN TUMOR AND SENT THE PATIENT FOR TESTS. A neurologist diagnosed reaction as a toxic encephalopathy.

    By the way, there was not akathesia, altho the individual had had severe akathesia on “regular” older neuroleptic. YOu did not mention nearly uncontrollable pacing?

    If memory serves, it was propanolol that, alone, helped..how would you feel about trying that ?

    Several others who crossed from either clozapine, or olanzapine in the same period, when Abilify was quite new on the market, (also) had prolonged, awful effects from crossing over to Abilify and had to be hospitalized. My information is from first hand knowledge, from close participation in a local human rights group at a state hospital here in Virginia.

    By coincidence, I am doing some pieces on some ethical aspects of these atypicals, particularly the testing process for FDA approval. If you would be interested in some cites to review, please let me know. The ads you refer to, are they on Cable TV?

    Did you see the Sunday Times June 8 on some colleagues at Harvard Med?

    Would you mind saying whether you are in Philadelphia? Thank you, e.n.

    P.S. Just to show you I am as careful an editor as a writer, “its” – when used as a possessive — does NOT HAVE AN APOSTROPHE !! OOps…Do not allow your secretary to type your messages next time.

  • e.n.–

    1. Sorry to hear about your family member. For some, the only thing worse then the illness is the “cure”. I don’t know the statistics of such an awful reaction to Abilify but it must be a low frequency event. – – – – saying this might get me in trouble – – – – maybe it wasn’t caused by the Abilify. Could the toxic encephalopathy have been caused by something else? Who knows. We do know that these medicines are potent and not to be used lightly.

    2. Pacing is a big part of akathesia (even patients with mental illness get tired of sitting).

    3. Propranolol can work but I have rarely seen it work well enough to bother using it. Switching to a different med or lowering the dose is usually a better solution.

    4. The Abilify advertisements are everywhere. I have direct TV so everything is beemed in. They are certainly ubiquitous on the “big 4” stations (I am now including FOX in that grouping).

    5. I did not see the Sunday Times article

    6. I am in the Philadelphia area

    7. You got to be kidding me . . . a secretary that types this stuff???? This is “stream of consciousness stuff” . . . straight from my brain to the page!!! I am my own editor . . . and I am periodically reminded by my wife that I need to hire a new one!!! For some reason, the women in my family have perfect grammatical and spelling ability. The men are just strong and handsome (joke). I do my best with the spelling but, honestly, I have come to grips with the fact that it is not my strong suit. When I get big and famous, I’ll hire a proof-reader. In the meantime, please forgive . . .