What is the recommended administration method for Vraylar (cariprazine) in a critically ill adult patient with a psychiatric condition who requires ongoing antipsychotic therapy and is currently intubated?

Administration of Vraylar (Cariprazine) in Intubated ICU Patients

Vraylar cannot be administered to an intubated patient because it is only available as oral capsules and orodispersible tablets—there is no intravenous, intramuscular, or liquid formulation available. 1, 2, 3

Critical Formulation Limitations

• Cariprazine is manufactured exclusively as hard gelatin capsules (1.5-6 mg) and orodispersible tablets for oral administration 1, 2, 3
• The orodispersible tablet formulation was developed specifically for situations where capsules cannot be swallowed, but this still requires an intact oral route and ability to manage oral secretions 1
• No parenteral (IV/IM) or liquid suspension formulations exist for cariprazine 1, 2, 3
• The medication cannot be crushed or dissolved from capsules for enteral tube administration, as this would alter the pharmacokinetic profile and is not an FDA-approved route 2, 3

Alternative Management Strategy for Intubated Patients

For a critically ill intubated patient requiring ongoing antipsychotic therapy, you must transition to an alternative antipsychotic agent that has parenteral formulations available.

Immediate Considerations

• Haloperidol IV/IM remains an option for short-term management if the patient has significant distress from hallucinations, delusions with fearfulness, or agitation posing physical harm, though guidelines emphasize this should not be routine 4, 5, 6
• Avoid haloperidol in patients with baseline QT prolongation, history of torsades de pointes, or concurrent QT-prolonging medications 4, 5
• Atypical antipsychotics with parenteral formulations (such as olanzapine IM, ziprasidone IM, or aripiprazole IM) may be considered for short-term use until distressing symptoms resolve 4, 5, 6

Sedation-Focused Approach

• Dexmedetomidine infusion is the preferred agent for mechanically ventilated ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, and is specifically indicated when agitation is precluding weaning/extubation 4, 5, 7
• Dexmedetomidine reduces delirium duration compared to benzodiazepine infusions and was associated with increased ventilator-free hours 4, 7
• Avoid benzodiazepines as they are a risk factor for developing delirium in ICU patients 4, 5

Non-Pharmacological Interventions (First-Line)

• Implement multicomponent interventions immediately: early mobilization (even in intubated patients), sleep optimization through light/noise control, cognitive stimulation with reorientation, and sensory optimization 4, 5, 6
• The ABCDEF bundle (Assessment of pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobility, Family engagement) reduces mortality and ICU days with delirium 5

Critical Pitfall to Avoid

Do not attempt to administer cariprazine capsules via nasogastric or orogastric tube in intubated patients. This is not an FDA-approved route, would compromise the medication's integrity, and could result in unpredictable pharmacokinetics given cariprazine's complex metabolism and long-acting metabolites (didesmethyl-cariprazine has a 2-3 week half-life) 2, 8, 9

Plan for Extubation

• Once the patient is extubated and can safely swallow, cariprazine can be restarted at the previously effective dose (1.5-6 mg daily) 2, 3, 9
• Account for the extremely long half-life of cariprazine's active metabolites when timing the restart—if the patient was recently on cariprazine before intubation, significant drug levels may still be present for weeks 2, 8, 9
• The recommended starting dose is 1.5 mg daily, which is potentially therapeutic, with titration as needed 2, 9