How to Safely Discontinue Rexulti (Brexpiprazole)
When discontinuing Rexulti (brexpiprazole), a gradual taper is recommended with dose reduction of 25% every 1-2 weeks to minimize withdrawal symptoms and ensure patient safety. 1
Recommended Tapering Protocol
- Begin with patient education about the risks of abrupt discontinuation and benefits of gradual tapering 1
- Implement a structured tapering schedule reducing the total daily dose by approximately 25% every 1-2 weeks 1
- For patients on standard doses (2-4 mg/day for schizophrenia or 2 mg/day for depression), consider this sample schedule:
- Weeks 1-2: Reduce dose by 25% of original dose
- Weeks 3-4: Reduce to 50% of original dose
- Weeks 5-6: Reduce to 25% of original dose
- Weeks 7-8: Complete discontinuation 1
Monitoring During Tapering
- Assess for withdrawal symptoms at each follow-up visit 1
- Watch for both acute withdrawal symptoms (anxiety, insomnia, restlessness) and protracted withdrawal symptoms 1
- Monitor for potential return of underlying symptoms, as brexpiprazole is used for schizophrenia and as adjunctive therapy for major depressive disorder 2, 3
Special Considerations
- Patients with schizophrenia require particularly careful monitoring during discontinuation as relapse risk is significant (38.5% relapse rate observed in clinical trials when medication is stopped) 4
- For patients taking brexpiprazole as adjunctive therapy for depression, consider whether the antidepressant therapy should be adjusted during the taper 3, 5
- Patients earlier in their disease course may respond differently to medication changes than those with longer-standing illness 5
Adjunctive Strategies During Discontinuation
- Consider non-pharmacological interventions to manage symptoms during taper, such as cognitive-behavioral therapy and relaxation techniques 1
- Avoid concurrent use of other CNS depressants during the taper period to minimize complications 1
- Address underlying reasons for discontinuation and provide appropriate alternative treatments if needed 1
Common Pitfalls to Avoid
- Avoid abrupt discontinuation due to risk of withdrawal symptoms 1
- Don't overlook the need for continued monitoring after complete discontinuation, as delayed withdrawal effects can occur 1
- Remember that brexpiprazole has a unique receptor binding profile with effects on multiple neurotransmitter systems (dopamine D2, serotonin 5-HT1A, 5-HT2A), so withdrawal may manifest in various ways 2, 6
When to Seek Additional Help
- If severe withdrawal symptoms occur despite gradual tapering, consider slowing the taper further 1
- If symptoms of the underlying condition (schizophrenia or depression) worsen significantly during tapering, consult with a psychiatrist to reassess the treatment plan 2, 3
- For patients with complex comorbidities or on multiple psychotropic medications, consider referral to a specialist for medication management during discontinuation 1