Can Seroquel (quetiapine) be replaced with Rexulti (brexpiprazole) for anxiety and paranoia, and are there alternative options for nighttime insomnia?

Replacing Seroquel with Rexulti for Anxiety/Paranoia and Alternative Insomnia Options

Replacing Seroquel (quetiapine) with Rexulti (brexpiprazole) for anxiety and paranoia is not recommended, as Rexulti lacks the sedating properties needed for insomnia management and is not indicated for anxiety treatment. Instead, maintain Seroquel for anxiety/paranoia and consider evidence-based alternatives for insomnia if needed.

Comparison of Seroquel vs. Rexulti

Efficacy for Anxiety and Paranoia

• Seroquel (quetiapine) has established use for anxiety symptoms and paranoia, particularly at higher doses
• Rexulti (brexpiprazole) is FDA-approved only for schizophrenia and as adjunctive therapy for major depressive disorder 1, not for anxiety or insomnia

Sleep Properties

• Seroquel has significant sedating properties that make it useful for insomnia management 2
• Rexulti lacks the sedating properties of Seroquel and may actually worsen sleep due to its pharmacological profile 3

Alternative Options for Insomnia Management

If you wish to replace Seroquel for insomnia while maintaining anxiety/paranoia control, consider:

Pharmacological Options

1. Trazodone (25-100mg at bedtime)

   • Preferred alternative to quetiapine for insomnia management 2, 3
   • Lower risk profile in older adults compared to quetiapine 4

2. Mirtazapine (7.5-30mg at bedtime)

   • Especially effective for patients with comorbid depression and insomnia 2, 3
   • May be better tolerated than quetiapine for insomnia in older adults 4

3. Zolpidem (5mg at bedtime)

   • FDA-approved for insomnia with lower recommended doses (5mg immediate-release) 2
   • Caution regarding next-morning impairment

4. Lorazepam (short-acting benzodiazepine)

   • Effective for refractory insomnia 2
   • Should be avoided in older adults and patients with cognitive impairment

Practical Management Approach

Option 1: Maintain Seroquel with Dose Optimization

• If Seroquel is effective for both anxiety/paranoia and insomnia, consider optimizing the dosing schedule:
  • Lower dose (25-50mg) at bedtime for sleep
  • Divided doses during the day for anxiety/paranoia management

Option 2: Split Treatment Approach

• Maintain Seroquel at appropriate dose for anxiety/paranoia
• Add a dedicated sleep agent (trazodone or mirtazapine) for insomnia

Option 3: Complete Medication Change

• Switch to another antipsychotic for anxiety/paranoia (olanzapine has better evidence than Rexulti for this purpose) 2
• Add dedicated sleep agent from options above

Important Considerations and Monitoring

• Quetiapine, even at low doses, has been associated with increased risk of mortality, dementia, and falls in older adults compared to trazodone and mirtazapine 4
• Monitor for metabolic side effects with any antipsychotic medication
• Evaluate effectiveness of insomnia treatment using standardized tools like the Epworth Sleepiness Scale 2
• Consider non-pharmacological approaches for insomnia such as cognitive behavioral therapy, which has strong evidence for effectiveness 2

Conclusion

For optimal management of both anxiety/paranoia and insomnia, maintaining Seroquel for anxiety/paranoia while adding a dedicated sleep agent like trazodone or mirtazapine would be more appropriate than switching to Rexulti, which lacks evidence for both anxiety and insomnia treatment.