Rexulti (brexpiprazole) is an atypical antipsychotic sometimes used off-label to manage Behavioral and Psychological Symptoms of Dementia (BPSD)—such as agitation, aggression, delusions, or hallucinations. However, its use in elderly patients with dementia-related psychosis carries a black box warning: increased risk of death.
1.
Key Warnings Before Use
- Not FDA-approved for BPSD (only for schizophrenia and major depressive disorder)
- Should be used only when symptoms are severe, distressing, or dangerous, and non-pharmacologic interventions have failed
- Requires informed consent and close monitoring for cerebrovascular events and sedation
2.
Suggested Off-Label Titration Strategy in BPSD (Low and Slow)
Due to sensitivity in elderly patients, start with a very low dose and increase gradually, if needed:
Initial Dose
- 0.25 mg once daily, usually in the evening
- Monitor closely for sedation, hypotension, EPS, or falls
Titration Schedule
- After 4–7 days, if tolerated and needed, increase to:
- 0.5 mg once daily
- If still needed after another week:
- Consider 1 mg once daily, which is often the upper end for frail elderly in BPSD
Note: In contrast, the starting dose for schizophrenia is 1 mg/day and target 2–4 mg/day — which is too high for elderly patients with dementia.
3.
Monitoring Parameters
- Vital signs, especially orthostatic blood pressure
- Fall risk and sedation
- Metabolic profile (glucose, lipids, weight)
- EPS symptoms, including parkinsonism and akathisia
- Neuroleptic malignant syndrome (NMS) (rare but serious)
4.
Duration and Review
- Evaluate benefits within 2–4 weeks
- Attempt dose reduction or discontinuation if stabilized
- Regularly reassess risk-benefit ratio
5.
Alternatives to Consider
- Non-pharmacologic interventions first (e.g., structured routine, caregiver support, environmental modification)
- Other agents sometimes used (also off-label):
- Quetiapine (low dose)
- Risperidone (only for short-term, limited to 6–12 weeks in many guidelines)
- Citalopram (may help with agitation in some cases)
Would you like a visual titration chart or a comparison table of antipsychotics used off-label in BPSD?
