Will Rexulti (brexpiprazole) worsen existing vertigo?

Rexulti and Vertigo: Direct Answer

Rexulti (brexpiprazole) can cause dizziness but does not specifically worsen true vertigo; however, it may increase fall risk and orthostatic symptoms that could be confused with or exacerbate balance problems in patients with existing vestibular disorders.

Understanding the Distinction

The key issue here is distinguishing between true vertigo (a vestibular disorder causing spinning sensation) and dizziness (a broader term that includes lightheadedness, imbalance, and presyncope). According to FDA labeling, Rexulti causes:

• Dizziness: 2-3% incidence across indications 1
• Orthostatic hypotension: 0.1-1% depending on population 1
• Somnolence and motor instability: Leading to fall risk 1

These side effects are not true vertigo (which involves vestibular system dysfunction), but rather cardiovascular and CNS-mediated symptoms that patients may describe as "dizziness."

Clinical Implications for Patients with Existing Vertigo

If Your Patient Has Peripheral Vertigo (BPPV, Vestibular Neuritis)

Rexulti will not directly worsen the underlying vestibular pathology, but it may:

• Complicate symptom assessment by adding orthostatic dizziness on top of vertigo
• Increase fall risk through postural hypotension and motor impairment 1
• Cause somnolence that impairs compensation mechanisms

Key monitoring: Check orthostatic vital signs before starting and during dose titration, especially in elderly patients 1. The risk is highest during initial dosing and dose increases.

If Your Patient Has Central Vertigo (Brainstem/Cerebellar Pathology)

Exercise greater caution. While Rexulti doesn't cause vestibular dysfunction, its effects on:

• Motor coordination
• Postural stability
• Cognitive function 1

...may compound existing CNS-mediated balance problems. Complete fall risk assessments are mandatory when initiating treatment 1.

Practical Management Algorithm

1. Baseline assessment: Document whether symptoms are true vertigo (spinning, nystagmus, positive Dix-Hallpike) versus non-specific dizziness 2

2. If true vertigo is present:

   • Ensure diagnosis is established (peripheral vs central) 2
   • Avoid vestibular suppressants like benzodiazepines that could interact with Rexulti's sedating effects 2
   • Start Rexulti at lowest dose with slow titration

3. Monitor specifically for:

   • Orthostatic blood pressure changes (sitting to standing measurements) 1
   • New-onset imbalance or falls 1
   • Worsening of baseline symptoms versus new medication side effects

4. High-risk populations requiring extra caution 1:

   • Elderly patients
   • Those with dehydration or hypovolemia
   • Patients on antihypertensive medications
   • Known cardiovascular or cerebrovascular disease

Common Pitfalls to Avoid

Don't confuse medication-induced orthostatic dizziness with worsening vertigo. True vertigo involves spinning sensation with nystagmus and is triggered by head movements 2. Rexulti-induced dizziness is typically postural and related to blood pressure changes.

Don't assume all "dizziness" reports mean the same thing. Ask specifically: "Do you feel spinning, lightheadedness when standing, or general imbalance?" This guides whether the issue is vestibular, cardiovascular, or CNS-related.

Don't overlook the cumulative fall risk 1. Even if Rexulti doesn't worsen vertigo per se, the combination of existing balance problems plus medication effects (somnolence, orthostatic hypotension, motor instability) significantly increases injury risk, particularly in older adults 3.

Bottom Line for Clinical Practice

Rexulti does not worsen the vestibular pathology causing true vertigo, but it adds orthostatic and CNS-mediated balance impairment that can complicate existing vertigo symptoms and substantially increase fall risk. The incidence of dizziness with Rexulti is similar to placebo in most trials (2-3%) 1, suggesting it's not a major concern in most patients, but vulnerable populations (elderly, those with cardiovascular disease, patients with existing balance disorders) require careful monitoring and fall prevention strategies 1, 3.