Can Rexulti (brexpiprazole) be taken with Cipralex (escitalopram) and Pramipexole?

From the Guidelines

I strongly advise against taking Rexulti with Cipralex and pramipexole without proper medical supervision due to the potential risk of serotonin syndrome and other adverse interactions. These medications can interact with each other in complex ways, and their combination should only be considered under the guidance of a healthcare professional. Rexulti is an atypical antipsychotic, Cipralex is an SSRI antidepressant, and pramipexole is a dopamine agonist used for Parkinson's disease and restless legs syndrome.

Key Considerations

• The combination of Rexulti and Cipralex may increase the risk of serotonin syndrome, a potentially life-threatening condition characterized by symptoms such as confusion, rapid heart rate, and high blood pressure 1.
• Additionally, Rexulti may counteract some effects of pramipexole since they work on dopamine receptors in opposite ways, which could lead to reduced efficacy of pramipexole or increased risk of adverse effects.
• As noted in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders, caution is advised when starting a second non-MAOI serotonergic drug, such as Rexulti, in patients already taking an SSRI like Cipralex, due to the increased risk of serotonin syndrome 1.

Recommendations

• If you're currently taking these medications or considering this combination, consult your healthcare provider immediately to evaluate the potential risks and benefits based on your specific medical conditions.
• Your doctor may need to adjust dosages or monitor you more closely if this combination is deemed necessary for your treatment, and they should be aware of the potential for drug-drug interactions, particularly with regards to the CYP450 isoenzymes 1.
• It's essential to follow a conservative medication trial approach, increasing the dose as tolerated within the therapeutic dosage range, and to systematically assess treatment response using standardized symptom rating scales 1.

From the Research

Drug Interactions

• The provided studies do not directly address the interaction between Rexulti (brexpiprazole), Cipralex (escitalopram), and pramipexole 2, 3, 4, 5, 6.
• However, it is known that brexpiprazole is a partial agonist at dopamine D2 and serotonin 5-HT1A receptors, and as an antagonist at serotonin 5-HT2A and at adrenergic alpha1B and alpha2C receptors 2.
• Escitalopram, on the other hand, is a selective serotonin reuptake inhibitor (SSRI) 5.
• Pramipexole is a dopamine agonist that binds to dopamine D2/D3 receptors 6.
• The combination of these drugs may increase the risk of serotonin syndrome, a potentially life-threatening condition caused by excessive levels of serotonin in the body 4, 6.
• Additionally, the combination of brexpiprazole and escitalopram may increase the risk of adverse effects such as akathisia, weight gain, and increased risk of seizures 3, 5.

Pharmacokinetic Interactions

• The studies do not provide information on the pharmacokinetic interactions between Rexulti, Cipralex, and pramipexole 2, 3, 4, 5, 6.
• However, it is known that drug interactions can occur through alterations in drug metabolism, absorption, distribution, and excretion 4, 6.
• The use of electronic prescribing systems and collaboration with pharmacists can help prevent adverse drug interactions 4, 6.

Clinical Consequences

• The combination of Rexulti, Cipralex, and pramipexole may increase the risk of adverse effects and drug interactions 3, 4, 5, 6.
• It is essential to monitor patients closely for signs of serotonin syndrome, akathisia, and other adverse effects when using this combination of drugs 4, 6.
• Healthcare professionals should use clinical judgment and consider the risks and benefits of certain drugs on a patient-specific basis 4, 6.