What is the best course of action for a patient experiencing dystonia after being switched from Vyvanse (lisdexamfetamine) to Rexulti (brexpiprazole) while taking Cymbalta (duloxetine), Wellbutrin XL (bupropion), and Propranolol (propranolol) for severe depression and anxiety?

From the Guidelines

The patient should immediately contact their healthcare provider to address the dystonia, and the provider may recommend temporarily stopping Rexulti, as it is the most likely cause of the dystonia, and consider increasing the propranolol dose or prescribing an anticholinergic medication like benztropine (Cogentin) for symptom relief. This is a medical emergency that requires prompt evaluation, as dystonia can be a severe and potentially debilitating side effect. The healthcare provider will need to reassess the entire medication regimen to determine the best course of action, taking into account the patient's severe depression and anxiety, and the potential interactions between Cymbalta, Wellbutrin XL, and Propranolol 1.

Some key considerations in managing this patient's care include:

• The potential for extrapyramidal side effects from Rexulti, an atypical antipsychotic that affects dopamine receptors, which may be increased by the combination with Cymbalta and Wellbutrin XL 1
• The importance of monitoring for adverse events, particularly in the first 1-2 weeks after initiation of therapy, as recommended by the American College of Physicians 1
• The need to reassess the medication regimen and consider alternative treatments, such as switching to a different antidepressant or augmenting with a different medication, if the patient does not have an adequate response to pharmacotherapy or experiences significant adverse effects 1
• The potential benefits of cognitive therapy or other non-pharmacologic interventions, which may be considered as an alternative or adjunct to pharmacologic treatment, particularly in patients who do not respond to or cannot tolerate medication 1

The patient's healthcare provider should prioritize their safety and well-being, and work closely with them to develop a treatment plan that balances the need to manage their depression and anxiety with the risk of adverse effects from their medications.

From the Research

Patient's Current Situation

The patient is experiencing dystonia after being switched from Vyvanse (lisdexamfetamine) to Rexulti (brexpiprazole) while taking Cymbalta (duloxetine), Wellbutrin XL (bupropion), and Propranolol (propranolol) for severe depression and anxiety.

Potential Causes of Dystonia

• The introduction of Rexulti (brexpiprazole) may be the cause of dystonia, as it is a serotonin-dopamine activity modulator with a unique receptor binding profile 2.
• Although brexpiprazole has a lower potential to cause activation-like adverse effects, such as akathisia, compared to aripiprazole, it may still contribute to dystonia in some patients.

Management of Dystonia

• The patient's treatment plan should be reassessed to determine the best course of action for managing dystonia while also addressing their severe depression and anxiety.
• Consideration should be given to adjusting the dosage of Rexulti (brexpiprazole) or exploring alternative treatment options that may be more effective in managing the patient's symptoms with fewer side effects.

Treatment of Depression and Anxiety

• Cymbalta (duloxetine) has been shown to be effective in treating anxiety symptoms associated with depression, with rapid relief of anxiety symptoms observed in clinical trials 3.
• The use of brexpiprazole as an adjunctive therapy to antidepressant treatment has been found to be effective in improving depressive symptoms in adults with major depressive disorder (MDD) who have demonstrated an incomplete response to previous treatment with antidepressant therapy 2, 4.
• Brexpiprazole has also been found to have anxiolytic effects in patients with MDD and anxiety symptoms, with improvements observed in anxiety symptoms and depressive symptoms 5.

Next Steps

• The patient's treatment plan should be closely monitored, and adjustments made as necessary to manage their dystonia and depressive symptoms.
• Consideration should be given to consulting with a specialist, such as a psychiatrist or neurologist, to determine the best course of action for managing the patient's complex treatment needs.
• The patient's response to treatment should be regularly assessed, and adjustments made to their treatment plan as necessary to ensure optimal management of their symptoms 6.