Medication Titration Assessment for Partial Response with Ongoing Agitation
Continue titrating brexpiprazole upward to the target dose of 2-3 mg daily, as the patient is showing partial response ("doing better") but still experiencing intermittent agitation, indicating they have not yet reached optimal therapeutic benefit. 1, 2
Current Clinical Status Assessment
Your patient demonstrates:
- Partial therapeutic response ("doing better")
- Residual target symptoms (ongoing agitation episodes)
- No concerning adverse effects (AIMS score of 0 indicates no extrapyramidal symptoms or tardive dyskinesia) 3
This clinical picture indicates the patient is tolerating the medication well but has not achieved full symptom control, warranting continued dose optimization. 3
Titration Strategy for Brexpiprazole
Target the 2-3 mg daily range, as this dosing demonstrated statistically significant improvements in agitation in clinical trials, with approximately 5-point greater reduction on agitation scales compared to placebo at week 12. 2
Specific Titration Protocol:
- Increase dose weekly based on clinical response and tolerability 1
- For agitation in dementia: Target 2-3 mg daily (the FDA-approved range for this indication) 2
- Monitor response quantitatively using a standardized agitation scale at each visit 3
- Assess for 4 weeks minimum at each dose level before determining inadequate response 3
Critical Safety Monitoring During Titration
Continue AIMS assessments at each visit, as you're appropriately doing, though brexpiprazole has favorable extrapyramidal symptom profiles compared to typical antipsychotics. 2
Watch specifically for:
- Akathisia (most common adverse effect, though rates are modest) 4, 5
- Dizziness and somnolence (common in dementia populations) 2
- Orthostatic hypotension (particularly if elderly or frail) 6
When to Stop Titrating
Stop increasing the dose when:
- Agitation episodes resolve or become minimal 3
- Intolerable side effects emerge (then reduce to previous tolerated dose) 3
- Maximum dose of 3 mg daily is reached without response (then reassess diagnosis and consider alternative approaches) 1, 2
Critical Pitfall to Avoid
Do not use brexpiprazole as a PRN medication for breakthrough agitation episodes—it is a maintenance medication requiring daily dosing to achieve steady-state therapeutic levels (takes approximately 14 days to reach steady state). 1, 2 For acute breakthrough agitation, consider PRN lorazepam 0.5-1 mg instead. 6
Reassessment Timeline
If no clinically significant response after 4 weeks at an adequate dose (2-3 mg daily), the medication should be tapered and discontinued, and alternative treatments considered. 3 However, given your patient is showing partial response, continue optimizing the dose before making this determination.