What is the preferred choice between Abilify (aripiprazole) and Rexulti (brexpiprazole) for a patient with hypotension?

Rexulti (Brexpiprazole) is Preferred Over Abilify (Aripiprazole) for Patients with Hypotension

For patients with hypotension, Rexulti (brexpiprazole) is the preferred choice over Abilify (aripiprazole) due to its lower risk of worsening orthostatic hypotension and more favorable cardiovascular profile.

Comparison of Cardiovascular Effects

Orthostatic Hypotension Risk

• Aripiprazole (Abilify): Has a higher incidence of orthostatic hypotension due to its α1-adrenergic receptor antagonism. FDA labeling reports orthostatic hypotension in 1% of adult patients (vs 0.3% with placebo), postural dizziness in 0.5%, and syncope in 0.5% 1.
• Brexpiprazole (Rexulti): Shows lower rates of orthostatic hypotension with only 0.1% incidence (vs 0% with placebo) and similar dizziness rates (2%) as placebo 2.

Blood Pressure Effects

• Aripiprazole: Has been associated with cases of worsened hypertension control 3, 4, suggesting it may have unpredictable effects on blood pressure regulation.
• Brexpiprazole: Has not been associated with similar reports of hypertension and demonstrates more predictable cardiovascular effects.

Clinical Decision-Making Algorithm

1. Assess baseline cardiovascular status:

   • Measure orthostatic vital signs (supine and standing BP)
   • Evaluate for dehydration or hypovolemia
   • Review concomitant medications that may affect BP

2. Select antipsychotic based on hypotension risk:

   • For patients with hypotension: Choose brexpiprazole
   • For patients with hypertension: Either agent may be appropriate with monitoring

3. Initiate treatment:

   • Start with lowest effective dose
   • Titrate slowly, especially in elderly or frail patients
   • Monitor orthostatic vital signs before each dose increase

Dosing Considerations

For Brexpiprazole (Rexulti):

• Start at lower doses (0.5-1 mg) for patients with hypotension
• Increase gradually based on response and tolerability
• Monitor orthostatic vital signs regularly during dose adjustments

For Aripiprazole (Abilify) if used despite concerns:

• Use with caution in patients with known cardiovascular disease
• Start with lower doses (2.5-5 mg)
• Consider once-daily dosing at bedtime to minimize orthostatic effects

Monitoring Recommendations

• Test for orthostatic hypotension before starting treatment and with each dose increase by measuring BP after 5 minutes lying down and then 1 and 3 minutes after standing 5
• Monitor more frequently in elderly patients or those with cardiovascular comorbidities
• Watch for symptoms of orthostatic hypotension: dizziness, lightheadedness, syncope

Special Considerations

Elderly Patients

• Use lower starting doses of either medication
• Titrate more gradually
• Consider non-pharmacological approaches for orthostatic hypotension management 5

Patients with Cardiovascular Disease

• Brexpiprazole is preferred due to lower cardiovascular risk profile
• Both medications should be used with caution in patients with known cardiovascular disease, cerebrovascular disease, or conditions predisposing to hypotension 1, 2

Risk Mitigation Strategies

• Ensure adequate hydration
• Recommend slow position changes (sitting before standing)
• Consider compression stockings for patients with severe orthostatic hypotension
• Schedule medication administration to minimize orthostatic effects (e.g., bedtime dosing)

Conclusion

When choosing between Abilify and Rexulti for a patient with hypotension, Rexulti (brexpiprazole) is the preferred option due to its lower risk of orthostatic hypotension and more favorable cardiovascular profile. The decision should be based on careful assessment of the patient's cardiovascular status and implemented with appropriate monitoring to ensure safety and efficacy.