How to switch from Quetiapine (Seroquel) to Brexpiprazole (Rexulti)?

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Switching from Seroquel (quetiapine) to Rexulti (brexpiprazole) should be done gradually under close medical supervision, starting Rexulti at a low dose of 0.5-1 mg daily while continuing the current Seroquel dose, and then gradually increasing the Rexulti dose over 2-4 weeks while tapering down the Seroquel. This approach is supported by the study 1, which found that switching to brexpiprazole is associated with a low long-term risk for metabolic abnormalities, hyperprolactinemia, extrapyramidal symptoms, and QTc changes, and minimal changes in psychiatric symptoms.

Key Considerations

• The cross-titration approach helps minimize withdrawal symptoms and maintains symptom control throughout the transition.
• Monitor for side effects like akathisia (restlessness), insomnia, or changes in mood or psychotic symptoms during the transition.
• The gradual transition is important because these medications work on different receptor systems - Seroquel broadly affects multiple neurotransmitters including dopamine, serotonin, and histamine, while Rexulti is a partial dopamine and serotonin agonist with a more targeted mechanism.
• The study 1 provides the most recent and highest quality evidence, published in 2021, and supports the safety of switching to brexpiprazole in patients with schizophrenia.

Switching Strategy

• Begin by continuing the current Seroquel dose while starting Rexulti at a low dose, typically 0.5-1 mg daily.
• Over 2-4 weeks, gradually increase the Rexulti dose while simultaneously tapering down the Seroquel.
• The doctor may recommend reducing Seroquel by 25-50 mg every 3-7 days while increasing Rexulti by 0.5-1 mg increments until reaching the target Rexulti dose (usually 2-4 mg daily) and completely discontinuing Seroquel.
• This approach is consistent with the recommendations for switching antipsychotic medication, as discussed in the study 2, which emphasizes the importance of individualized switching strategies and dosing.