A patient with schizophrenia develops markedly elevated serum prolactin, galactorrhea, and amenorrhea after starting an antipsychotic. The treating physician wishes to switch to an agent with the least prolactin-elevating effect while maintaining D2 receptor blockade. Which antipsychotic is most appropriate?

• A Risperidone
• B Haloperidol
• C Amisulpride
• D Aripiprazole ✓

Explanation

Aripiprazole is a partial D2 agonist (functional D2 antagonist in hyperdopaminergic states) and a partial 5-HT1A agonist. Its partial D2 agonism in the tuberoinfundibular pathway produces minimal or even reduced prolactin elevation compared to baseline; it can actually normalise prolactin elevated by other antipsychotics. Risperidone and amisulpride cause the most pronounced hyperprolactinaemia among second-generation agents, and haloperidol causes marked elevation as a first-generation agent.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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