Brexpiprazole

[witzelsucht]

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ER resident here - what is special about this new one? Anything interesting to note as far as indications, bad effects? If it is not on formulary in our ER, what would be an appropriate substitution for psych holds? 5mg aripiprazole to 1mg brex?

 

[Drrrrrr. Celty]

Less akethesia. Possibly less risks of other EPS. FDA approval for depression augmentation?

Can you just let them bring in their med instead of switching or does your hospital have rules against that?

 

[Dharma]

I call a big "maybe" for potential improvements over other atypicals. Let time tell the difference. Reminds one of Ability and "will rarely see weight gain" thing... and then anecdotally having a nice proportion of patients blow up on it.

Stick with the tried and true for now. In the ED, no reason to go outside of what is likely available already unless one is continuing an outpatient medication while holding.

 

[witzelsucht]

Stick with the tried and true for now. In the ED, no reason to go outside of what is likely available already unless one is continuing an outpatient medication while holding.

Can you just let them bring in their med instead of switching or does your hospital have rules against that?

sorry - yes this is the question, like a 48 hour bedsearch thing where I just want them to get a dose of something daily. we dont have a policy against home meds but often times these people are here with police for getting into trouble and by the time family or group home staff can come to bring home meds they may have missed a dose

 

[Candidate2017]

It's not necessary for the ED to tinker with patients' antipsychotics. The ED's job is calm them down enough to be transferred to the psych ward. And medically stabilizing them, of course.

 

[SourceOfDenial]

Brexpiprazole

ER resident here - what is special about this new one? Anything interesting to note as far as indications, bad effects? If it is not on formulary in our ER, what would be an appropriate substitution for psych holds? 5mg aripiprazole to 1mg brex?

Brexpiprazole in my experience benefits froma slow titration to the desired dose. I think the benefit over abilify is really just the thin therapeutic window, there isnt as much 'dose searching' than there is for abilify. I would not use abilify or brexpiprazole in the ED for acute psychosis. My experience with both is that they are more useful in the management of treatment resistant MDD, and stable schizophrenia when a rotation from a typical or atypical anitpsychotic is needed because of side effects. Some limited use in bipolar depression where the patient felt it was helpful, but again this is anecdotal.

Have had some geriatric patients who benefited from it but had to be stopped due to side effects.

Overally, its a tool, but not one I rush to use and consider for specific instances.

 

[witzelsucht]

It's not necessary for the ED to tinker with patients' antipsychotics. The ED's job is calm them down enough to be transferred to the psych ward. And medically stabilizing them, of course.

yes so we frequently have patients who are in our ED for 2-3 days pending bed availability in the psych ward. so we have to order their home meds, both psych and non-psych. so if a patient is on a dose of brexpiprazole, my thought is giving them some abilify for 2 days would be better than either nothing at all or haldol, right? our psychiatrists do not welcome med consult questions at 2300 so its either I order something we have on formulary for 0800 or they get nothing

 

[clausewitz2]

yes so we frequently have patients who are in our ED for 2-3 days pending bed availability in the psych ward. so we have to order their home meds, both psych and non-psych. so if a patient is on a dose of brexpiprazole, my thought is giving them some abilify for 2 days would be better than either nothing at all or haldol, right? our psychiatrists do not welcome med consult questions at 2300 so its either I order something we have on formulary for 0800 or they get nothing

If you can guarantee they are only going to be there for no more than three days, the half-life of brexpiprazole is 91 hours. I am not sure it matters very much what you substitute for it in that time span.

Of course if there is an outside chance that they might board longer that might be a problem. Probably them getting a single dose late, even by a significant number of hours, is unlikely to have much consequence, so trying to get someone to bring the home meds is reasonable even if that means the next day.

 

[Candidate2017]

yes so we frequently have patients who are in our ED for 2-3 days pending bed availability in the psych ward. so we have to order their home meds, both psych and non-psych. so if a patient is on a dose of brexpiprazole, my thought is giving them some abilify for 2 days would be better than either nothing at all or haldol, right? our psychiatrists do not welcome med consult questions at 2300 so its either I order something we have on formulary for 0800 or they get nothing

Zyprexa has a faster onset and faster washout. Get a baseline EKG first. They probably aren't cooperative but at least it's in the chart that you thought about it and tried.

Holding home antipsychotics won't cause any harm since they're in the ED because they're probably non-compliant with it.

2-3 days is pretty good turnaround.

 

[whopper]

What's so special?

A drug rep is pushing it and lots of doctors respond to it.

Seriously, it does have some advantages but each antipsychotic has it's selling point on why it's different than another (E.g. Olanzapine-sedation, high efficacy, Ziprasidone-metabolically neutral). Can it work well? Of course it can. But due to it's price I wouldn't give it first line. It's depression benefits are largely attributed to it working on 5HT1A receptors just like Buspirone does, so why not just give that first?

I do prescribe it but usually as a third-line or later med.

I typically will pull it out with patients with akathisia with other antipsychotics, higher anxiety, or a good response to Aripiprazole except for maybe one or more issues (e.g. akathisia), but even in these cases that's 3rd line or later down the road.

Stick with the tried and true for now. In the ED, no reason to go outside of what is likely available already unless one is continuing an outpatient medication while holding.

Agree. In ER and inpatient settings better to favor the more efficacious meds given that you want quicker results. The outpatient doctor could always change them later.

 

[Amygdarya]

Hey @witzelsucht just wanted to say that I appreciate your concern about continuing meds for your boarding psych patients and your willingness to educate yourself regarding psych issues (as evidenced by your frequenting this subforum).
I wish our ED residents were at least half as concerned about their psychiatric patients or half as willing to follow psych recs regarding meds (even after requesting a consult...) 🙁