Rexulti

Brexpiprazole.

Brexpiprazole (Rexulti) tablets are available in 5 strengths (see Table 1).

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Brexpiprazole, an atypical antipsychotic, is available as Brexpiprazole (Rexulti) tablets. Brexpiprazole is 7-{4-[4-(1-Benzothiophen-4-yl)piperazin-1-yl]butoxy}quinolin-2(1H)-one. The empirical formula is C₂₅H₂₇N₃O₂S and its molecular weight is 433.57.
Brexpiprazole (Rexulti) tablets are for oral administration and are available in 500 mcg, 1 mg, 2 mg, 3 mg and 4 mg strengths. Inactive ingredients include lactose monohydrate, corn starch, microcrystalline cellulose, hydroxypropyl cellulose, low-substituted hydroxypropyl cellulose, magnesium stearate, hypromellose, and talc. Colorants include titanium dioxide, iron oxide and ferrosferric oxide.

Pharmacology: Mechanism of Action: The mechanism of action of brexpiprazole in the treatment of major depressive disorder or schizophrenia is unknown. However, the efficacy of brexpiprazole may be mediated through a combination of partial agonist activity at serotonin 5-HT_1A and dopamine D₂ receptors, and antagonist activity at serotonin 5-HT_2A receptors.
Pharmacodynamics: Brexpiprazole has affinity (expressed as K_i) for multiple monoaminergic receptors including serotonin 5HT_1A (0.12 nM), 5HT_2A (0.47 nM), 5HT_2B (1.9 nM), 5HT₇ (3.7 nM), dopamine D₂ (0.30 nM), D₃ (1.1 nM), and noradrenergic α_1A (3.8 nM), α_1B (0.17 nM), α_1D (2.6 nM), and α_2C (0.59 nM) receptors. Brexpiprazole acts as a partial agonist at the 5-HT_1A, D₂, and D₃ receptors and as an antagonist at 5HT_2A, 5HT_2B, 5HT₇, α_1A, α_1B, α_1D, and α_2C receptors. Brexpiprazole also exhibits affinity for histamine H₁ receptor (19 nM) and for muscarinic M₁ receptor (67% inhibition at 10 μM).
Cardiac Electrophysiology: At a dose 3-times the MRHD for the treatment of schizophrenia and 4-times the MRHD for adjunctive therapy to antidepressants for the treatment of MDD, Brexpiprazole (Rexulti) does not prolong the QTc interval to any clinically relevant extent.
Clinical Studies: Adjunctive Treatment of Major Depressive Disorder: The efficacy of Brexpiprazole (Rexulti) in the adjunctive treatment of major depressive disorder (MDD) was evaluated in two 6-week, double-blind, placebo-controlled, fixed-dose trials of adult patients meeting DSM-IV-TR criteria for MDD, with or without symptoms of anxiety, who had an inadequate response to prior antidepressant therapy (1 to 3 courses) in the current episode and who had also demonstrated an inadequate response throughout the 8 weeks of prospective antidepressant treatment (with escitalopram, fluoxetine, paroxetine controlled-release, sertraline, duloxetine delayed release, or venlafaxine extended-release). Inadequate response during the prospective antidepressant treatment phase was defined as having persistent symptoms without substantial improvement throughout the course of treatment.
Patients in Study 228 (hereafter "Study 1") were randomized to Brexpiprazole (Rexulti) 2 mg once a day or placebo. Patients in Study 227 (hereafter "Study 2") were randomized to Brexpiprazole (Rexulti) 1 or 3 mg once a day or placebo. For patients randomized to Brexpiprazole (Rexulti), all patients initiated treatment at 500 mcg once daily during Week 1. At Week 2, the Brexpiprazole (Rexulti) dosage was increased to 1 mg in all treatment groups, and either maintained at 1 mg or increased to 2 mg or 3 mg once daily, based on treatment assignment, from Week 3 onwards. The dosages were then maintained for the 4 remaining weeks.
The primary endpoint was change from baseline to Week 6 in the Montgomery-Asberg Depression Rating Scale (MADRS), a 10-item clinician-related scale used to assess the degree of depressive symptomatology, with 0 representing no symptoms, and 60 representing worst symptoms.
At randomization, the mean MADRS total score was 27. In Studies 1 and 2, Brexpiprazole (Rexulti) (+ antidepressant (ADT)) 2 mg/day and 3 mg/day were superior to placebo + ADT in reducing mean MADRS total scores. Results from the primary efficacy parameters for both fixed dose trials are shown as follows in Table 2. Figure 1 as follows shows the time course of response based on the primary efficacy measure (MADRS) in Study 1. (See Table 2.)

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An examination of population subgroups did not suggest differential response based on age, gender, race or choice of prospective antidepressant. (See Figure 1.)

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Schizophrenia: The efficacy of Brexpiprazole (Rexulti) in the treatment of adults with schizophrenia was demonstrated in two 6-week, randomized, double-blind, placebo-controlled, fixed-dose clinical trials in patients who met DSM-IV-TR criteria for schizophrenia.
In both studies, Study 231 (hereafter "Study 3") and Study 230 (hereafter "Study 4"), patients were randomized to Brexpiprazole (Rexulti) 2 or 4 mg once per day or placebo. Patients in the Brexpiprazole (Rexulti) groups initiated treatment at 1 mg once daily on Days 1 to 4. The Brexpiprazole (Rexulti) dosage was increased to 2 mg on Days 5 to 7. The dosage was then either maintained at 2 mg once daily or increased to 4 mg once daily, depending on treatment assignment, for the 5 remaining weeks.
The primary efficacy endpoint of both trials was the change from baseline to Week 6 in the Positive and Negative Syndrome Scale (PANSS) total score. The PANSS is a 30-item scale that measures positive symptoms of schizophrenia (7 items), negative symptoms of schizophrenia (7 items), and general psychopathology (16 items), each rated on a scale of 1 (absent) to 7 (extreme); the total PANSS scores range from 30 (best) to 210 (worst).
In Study 3, Brexpiprazole (Rexulti) at both 2 mg/day and 4 mg/day was superior to placebo on the PANSS total score. In Study 4, Brexpiprazole (Rexulti) 4 mg/day was superior to placebo on the PANSS total score (Table 3). Figure 2 shows the time course of response based on the primary efficacy measure (change from baseline in PANSS total score) in Study 3.
Examination of population subgroups based on age, gender and race did not suggest differential responsiveness. (See Table 3 and Figure 2.)

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Pharmacokinetics: Absorption: After single dose administration of Brexpiprazole (Rexulti) tablets, the peak plasma brexpiprazole concentrations occurred within 4 hours after administration; and the absolute oral bioavailability was 95%. Brexpiprazole steady-state concentrations were attained within 10-12 days of dosing.
Brexpiprazole (Rexulti) can be administered with or without food. Administration of a 4 mg Brexpiprazole (Rexulti) tablet with a standard high fat meal did not significantly affect the C_max or AUC of brexpiprazole. After single and multiple once daily dose administration, brexpiprazole exposure (C_max and AUC) increased in proportion to the dose administered. In vitro studies of brexpiprazole did not indicate that brexpiprazole is a substrate of efflux transporters such as MDRI (P-gp) and BCRP.
Distribution: The volume of distribution of brexpiprazole following intravenous administration is high (1.56±0.42 L/kg), indicating extravascular distribution. Brexpiprazole is highly protein bound in plasma (greater than 99%) to serum albumin and α1-acid glycoprotein, and its protein binding is not affected by renal or hepatic impairment. Based on results of in vitro studies, brexpiprazole protein binding is not affected by warfarin, diazepam, or digitoxin. Elimination: Metabolism: Based on in vitro metabolism studies of brexpiprazole using recombinant human cytochrome P450 (CYP1A1, 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, and 3A4), the metabolism of brexpiprazole was shown to be mainly mediated by CYP3A4 and CYP2D6.
In vivo brexpiprazole is metabolized primarily by CYP3A4 and CYP2D6 enzymes. After single- and multiple-dose administrations, brexpiprazole and its major metabolite, DM-3411, were the predominant drug moieties in the systemic circulation. At steady-state, DM-3411 represented 23% to 48% of brexpiprazole exposure (AUC) in plasma. DM-3411 is considered not to contribute to the therapeutic effects of brexpiprazole.
Based on in vitro data, brexpiprazole showed little to no inhibition of CYP450 isozymes.
Excretion: Following a single oral dose of [¹⁴C]-labeled brexpiprazole, approximately 25% and 46% of the administered radioactivity was recovered in the urine and feces, respectively. Less than 1% of unchanged brexpiprazole was excreted in the urine and approximately 14% of the oral dose was recovered unchanged in the feces. Apparent oral clearance of a brexpiprazole oral tablet after once daily administration is 19.8 (±11.4) mL/h/kg. After multiple once daily administration of Brexpiprazole (Rexulti), the terminal elimination half-lives of brexpiprazole and its major metabolite, DM-3411, were 91 hours and 86 hours, respectively.
Studies In Specific Populations: Exposures of brexpiprazole in specific populations are summarized in Figure 3. Population PK analysis indicated exposure of brexpiprazole in patients with moderate renal impairment was higher compared to patients with normal renal function. (See Figure 3.)

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Drug Interaction Studies: Effects of other drugs on the exposures of brexpiprazole are summarized in Figure 4. Based on simulation, a 5.1-fold increase in AUC values at steady-state is expected when extensive metabolizers of CYP2D6 are administered with both strong CYP2D6 and CYP3A4 inhibitors. A 4.8-fold increase in mean AUC values at steady-state is expected in poor metabolizers of CYP2D6 administered with strong CYP3A4 inhibitors [see Drugs Having Clinically Important Interactions with Brexpiprazole (Rexulti) under Interactions]. (See Figure 4.)

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The effects of Brexpiprazole (Rexulti) on the exposures of other drugs are summarized in Figure 5. (See Figure 5.)

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Toxicology: Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenesis: Lifetime carcinogenicity studies were conducted in ICR mice and SD rats. Brexpiprazole was administered orally for two years to male and female mice at doses of 0.75, 2 and 5 mg/kg/day (0.9 to 6.1 times the oral MRHD of 4 mg/day based on mg/m² body surface area) and to male and female rats at doses of 1, 3, and 10 mg/kg and 3, 10, and 30 mg/kg/day, respectively (2.4 to 24 and 7.3 to 73 times the oral MRHD, males and females). In female mice, the incidence of mammary gland adenocarcinoma was increased at all doses and the incidence of adenosquamous carcinoma was increased at 2.4 and 6.1 times the MRHD. No increase in the incidence of tumors was observed in male mice. In the rat study, brexpiprazole was not carcinogenic in either sex at doses up to 73 times the MRHD.
Proliferative and/or neoplastic changes in the mammary and pituitary glands of rodents have been observed following chronic administration of antipsychotic drugs and are considered to be prolactin mediated. The potential for increasing serum prolactin level of brexpiprazole was shown in both mice and rats. The relevance for human risk of the findings of prolactin-mediated endocrine tumors in rodents is unknown.
Mutagenesis: Brexpiprazole was not mutagenic when tested in the in vitro bacterial reverse mutation assay (Ames test). Brexpiprazole was negative for clastogenic activity in the in vivo micronucleus assay in rats, and was not genotoxic in the in vivo/in vitro unscheduled DNA synthesis assay in rats. In vitro with mammalian cells brexpiprazole was clastogenic but only at doses that induced cytotoxicity. Based on a weight of evidence, brexpiprazole is not considered to present a genotoxic risk to humans.
Impairment of Fertility: Female rats were treated with oral doses of 0.3, 3 or 30 mg/kg/day (0.7, 7.3, and 73 times the oral MRHD on a mg/m² basis) prior to mating with untreated males and continuing through conception and implantation. Estrus cycle irregularities and decreased fertility were observed at 3 and 30 mg/kg/day. Prolonged duration of pairing and increased preimplantation losses were observed at 30 mg/kg/day.
Male rats were treated with oral doses of 3, 10, or 100 mg/kg/day (7.3, 24 and 240 times the oral MRHD on a mg/m² basis) for 63 days prior to mating with untreated females and throughout the 14 days of mating. No differences were observed in the duration of mating or fertility indices in males at any dose of brexpiprazole.

Brexpiprazole (Rexulti) is indicated for: Adjunctive treatment of major depressive disorder (MDD) [see Pharmacology: Pharmacodynamics: Clinical Studies: Adjunctive Treatment of Major Depressive Disorder under Actions].
Treatment of schizophrenia [see Pharmacology: Pharmacodynamics: Clinical Studies: Schizophrenia under Actions].

Adjunctive Treatment of Major Depressive Disorder: The recommended starting dosage for Brexpiprazole (Rexulti) as adjunctive treatment is 500 mcg or 1 mg once daily, taken orally with or without food [see Pharmacology: Pharmacokinetics under Actions].
Titrate to 1 mg once daily, then up to the target dosage of 2 mg once daily. Dosage increases should occur at weekly intervals based on the patient's clinical response and tolerability. The maximum recommended daily dosage is 3 mg. Periodically reassess to determine the continued need and appropriate dosage for treatment.
Treatment of Schizophrenia: The recommended starting dosage for Brexpiprazole (Rexulti) is 1 mg once daily on Days 1 to 4, taken orally with or without food [see Pharmacology: Pharmacokinetics under Actions].
The recommended target Brexpiprazole (Rexulti) dosage is 2 mg to 4 mg once daily. Titrate to 2 mg once daily on Day 5 through Day 7, then to 4 mg on Day 8 based on the patient's clinical response and tolerability. The maximum recommended daily dosage is 4 mg. Periodically reassess to determine the continued need and appropriate dosage for treatment.
Dosage Adjustments for Hepatic Impairment: For patients with moderate to severe hepatic impairment (Child-Pugh score ≥7), the maximum recommended dosage is 2 mg once daily for patients with MDD, and 3 mg once daily for patients with schizophrenia [see Hepatic Impairment under Precautions, Pharmacology: Pharmacokinetics under Actions].
Dosage Adjustments for Renal Impairment: For patients with moderate, severe or end-stage renal impairment (creatinine clearance CL_cr<60 mL/minute), the maximum recommended dosage is 2 mg once daily for patients with MDD and 3 mg once daily for patients with schizophrenia [see Renal Impairment under Precautions, Pharmacology: Pharmacokinetics under Actions].
Dosage Modifications for CYP2D6 Poor Metabolizers and for Concomitant use with CYP Inhibitors or Inducers: Dosage adjustments are recommended in patients who are known cytochrome P450 (CYP) 2D6 poor metabolizers and in patients taking concomitant CYP3A4 inhibitors or CYP2D6 inhibitors or strong CYP3A4 inducers (see Table 4). If the coadministered drug is discontinued, adjust the Brexpiprazole (Rexulti) dosage to its original level. If the coadministered CYP3A4 inducer is discontinued, reduce the Brexpiprazole (Rexulti) dosage to the original level over 1 to 2 weeks [see Drugs Having Clinically Important Interactions with Brexpiprazole (Rexulti) under Interactions, Pharmacology: Pharmacokinetics under Actions]. (See Table 4.)

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Patients with Lactose Intolerance: Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should be aware that brexpiprazole tablets contain lactose.

There is limited clinical trial experience regarding human overdosage with Brexpiprazole (Rexulti).
Management of overdose should concentrate on supportive therapy, maintaining an adequate airway, oxygenation and ventilation, and management of symptoms. Close medical supervision and monitoring should continue until the patient recovers.
Charcoal: Oral activated charcoal and sorbitol (50 g/240 mL), administered one hour after ingesting oral brexpiprazole, decreased brexpiprazole C_max and area under the curve (AUC) by approximately 5% to 23% and 31% to 39% respectively; however, there is insufficient information available on the therapeutic potential of activated charcoal in treating an overdose with Brexpiprazole (Rexulti).
Hemodialysis: There is no information on the effect of hemodialysis in treating an overdose with Brexpiprazole (Rexulti); hemodialysis is unlikely to be useful because brexpiprazole is highly bound to plasma proteins.

Brexpiprazole (Rexulti) is contraindicated in patients with a known hypersensitivity to Brexpiprazole (Rexulti) or any of its components. Reactions have included rash, facial swelling, urticaria, and anaphylaxis.

Increased Mortality in Elderly Patients with Dementia-Related Psychosis; And Suicidal Thoughts and Behaviors.
Increased Mortality in Elderly Patients with Dementia-Related Psychosis: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Brexpiprazole (Rexulti) is not approved for the treatment of patients with dementia-related psychosis [see Increased Mortality in Elderly Patients with Dementia-Related Psychosis under Precautions].
Suicidal Thoughts and Behaviors: Antidepressants increased the risk of suicidal thoughts and behaviors in patients aged 24 years and younger in short-term studies. Monitor closely for clinical worsening and for emergence of suicidal thoughts and behaviors. The safety and efficacy of Brexpiprazole (Rexulti) have not been established in pediatric patients [see Suicidal Thoughts and Behaviors in Children, Adolescents and Young Adults under Precautions, Use in Children under Precautions].

Increased Mortality in Elderly Patients with Dementia-Related Psychosis: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group.
Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Brexpiprazole (Rexulti) is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Cerebrovascular Adverse Reactions Including Stroke in Elderly Patients with Dementia-Related Psychosis as follows].
Suicidal Thoughts and Behaviors in Children, Adolescents and Young Adults: In pooled analyses of placebo-controlled trials of antidepressant drugs (SSRIs and other antidepressant classes) that included approximately 77,000 adult patients, and over 4,400 pediatric patients, the incidence of suicidal thoughts and behaviors in patients age 24 years and younger was greater in antidepressant-treated patients than in placebo-treated patients. The drug-placebo differences in the number of cases of suicidal thoughts and behaviors per 1000 patients treated are provided in Table 5.
No suicides occurred in any of the pediatric studies. There were suicides in the adult studies, but the number was not sufficient to reach any conclusion about antidepressant drug effect on suicide. (See Table 5.)

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It is unknown whether the risk of suicidal thoughts and behaviors in children, adolescents, and young adults extends to longer-term use, i.e., beyond four months. However, there is substantial evidence from placebo-controlled maintenance studies in adults with MDD that antidepressants delay the recurrence of depression.
Monitor all antidepressant-treated patients for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy and at times of dosage changes. Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider. Consider changing the therapeutic regimen, including possibly discontinuing Brexpiprazole (Rexulti), in patients whose depression is persistently worse, or who are experiencing emergent suicidal thoughts or behaviors.
Cerebrovascular Adverse Reactions Including Stroke in Elderly Patients with Dementia-Related Psychosis: In placebo-controlled trials with risperidone, aripiprazole, and olanzapine in elderly patients with dementia, there was a higher incidence of cerebrovascular adverse reactions (cerebrovascular accidents and transient ischemic attacks), including fatalities, compared to placebo-treated subjects. Brexpiprazole (Rexulti) is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Increased Mortality in Elderly Patients with Dementia-Related Psychosis previously].
Neuroleptic Malignant Syndrome (NMS): A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with administration of antipsychotic drugs.
Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardiac dysrhythmia). Additional signs may include elevated creatinine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure.
The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is important to exclude cases where the clinical presentation includes both serious medical illness (e.g., pneumonia, systemic infection, etc.) and untreated or inadequately treated extrapyramidal signs and symptoms (EPS). Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, drug fever, and primary central nervous system pathology.
The management of NMS should include: 1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy; 2) intensive symptomatic treatment and medical monitoring; and 3) treatment of any concomitant serious medical problems for which specific treatments are available. There is no general agreement about specific pharmacological treatment regimens for NMS.
If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported.
Tardive Dyskinesia: A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs. Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to rely upon prevalence estimates to predict, at the inception of antipsychotic treatment, which patients are likely to develop the syndrome. Whether antipsychotic drugs differ in their potential to cause tardive dyskinesia is unknown.
The risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase. However, the syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses or may even arise after discontinuation of treatment.
There is no known treatment for established cases of tardive dyskinesia, although the syndrome may remit, partially or completely, if antipsychotic treatment is withdrawn. Antipsychotic treatment, itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome and thereby may possibly mask the underlying process. The effect that symptomatic suppression has upon the long-term course of the syndrome is unknown.
Given these considerations, Brexpiprazole (Rexulti) should be prescribed in a manner that is most likely to minimize the occurrence of tardive dyskinesia. Chronic antipsychotic treatment should generally be reserved for patients who appear to suffer from a chronic illness that (1) is known to respond to antipsychotic drugs, and (2) for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate. In patients who do require chronic treatment, the smallest dose and the shortest duration of treatment producing a satisfactory clinical response should be sought. The need for continued treatment should be reassessed periodically.
If signs and symptoms of tardive dyskinesia appear in a patient on Brexpiprazole (Rexulti), drug discontinuation should be considered. However, some patients may require treatment with Brexpiprazole (Rexulti) despite the presence of the syndrome.
Metabolic Changes: Atypical antipsychotic drugs have been associated with metabolic changes that include hyperglycemia/diabetes mellitus, dyslipidemia, and body weight gain. While all of the drugs in the class have been shown to produce some metabolic changes, each drug has its own specific risk profile.
Hyperglycemia and Diabetes Mellitus: Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics. There have been reports of hyperglycemia in patients treated with Brexpiprazole (Rexulti) [see Clinical Trials Experience under Adverse Reactions]. Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders, the relationship between atypical antipsychotic use and hyperglycemia-related adverse reactions is not completely understood. However, epidemiological studies suggest an increased risk of hyperglycemia-related adverse reactions in patients treated with the atypical antipsychotics.
Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the atypical antipsychotic drug.
Major Depressive Disorder: In the 6 week, placebo-controlled, fixed-dose clinical trials in patients with MDD, the proportions of patients with shifts in fasting glucose from normal (<100 mg/dL) to high (≥126 mg/dL) and borderline (≥100 and <126 mg/dL) to high were similar in patients treated with Brexpiprazole (Rexulti) and placebo.
In the long-term, open-label depression studies, 5% of patients with normal baseline fasting glucose experienced a shift to high while taking Brexpiprazole (Rexulti)+Antidepressant (ADT); 25% of subjects with borderline fasting glucose experienced shifts to high. Combined, 9% of subjects with normal or borderline fasting glucose experienced shifts to high fasting glucose during the long-term depression studies.
Schizophrenia: In the 6-week, placebo-controlled, fixed-dose clinical trials in patients with schizophrenia, the proportions of patients with shifts in fasting glucose from normal (<100 mg/dL) to high (≥126 mg/dL) or borderline (≥100 and <126 mg/dL) to high were similar in patients treated with Brexpiprazole (Rexulti) and placebo.
In the long-term, open-label schizophrenia studies, 8% of patients with normal baseline fasting glucose experienced a shift from normal to high while taking Brexpiprazole (Rexulti), 17% of subjects with borderline fasting glucose experienced shifts from borderline to high. Combined, 10% of subjects with normal or borderline fasting glucose experienced shifts to high fasting glucose during the long-term schizophrenia studies.
Dyslipidemia: Undesirable alterations in lipids have been observed in patients treated with atypical antipsychotics.
Major Depressive Disorder: In the 6-week, placebo-controlled, fixed-dose clinical trials in patients with MDD, changes in fasting total cholesterol, LDL cholesterol, and HDL cholesterol were similar in Brexpiprazole (Rexulti)- and placebo-treated patients. Table 6 shows the proportions of patients with changes in fasting triglycerides. (See Table 6.)

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In the long-term, open-label depression studies, shifts in baseline fasting cholesterol from normal to high were reported in 9% (total cholesterol), 3% (LDL cholesterol), and shifts in baseline from normal to low were reported in 14% (HDL cholesterol) of patients taking Brexpiprazole (Rexulti). Of patients with normal baseline triglycerides, 17% experienced shifts to high, and 0.2% experienced shifts to very high. Combined, 0.6% of subjects with normal or borderline fasting triglycerides experienced shifts to very high fasting triglycerides during the long-term depression studies.
Schizophrenia: In the 6-week, placebo-controlled, fixed-dose clinical trials in patients with schizophrenia, changes in fasting total cholesterol, LDL cholesterol, and HDL cholesterol were similar in Brexpiprazole (Rexulti)- and placebo-treated patients. Table 7 shows the proportions of patients with changes in fasting triglycerides. (See Table 7.)

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In the long-term, open-label schizophrenia studies, shifts in baseline fasting cholesterol from normal to high were reported in 6% (total cholesterol), 2% (LDL cholesterol), and shifts in baseline from normal to low were reported in 17% (HDL cholesterol) of patients taking Brexpiprazole (Rexulti). Of patients with normal baseline triglycerides, 13% experienced shifts to high, and 0.4% experienced shifts to very high triglycerides. Combined, 0.6% of subjects with normal or borderline fasting triglycerides experienced shifts to very high fasting triglycerides during the long-term schizophrenia studies.
Weight Gain: Weight gain has been observed in patients treated with atypical antipsychotics. Clinical monitoring of weight is recommended.
Major Depressive Disorder: Table 8 shows weight gain data at last visit and percentage of adult patients with ≥7% increase in body weight at endpoint from the 6-week, placebo-controlled, fixed-dose clinical studies in patients with MDD. (See Table 8.)

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In the long-term, open-label depression studies, 4% of patients discontinued due to weight increase. Brexpiprazole (Rexulti) was associated with mean change from baseline in weight of 2.9 kg at week 26 and 3.1 kg at week 52. In the long-term, open label depression studies, 30% of patients demonstrated a ≥7% increase in body weight and 4% demonstrated a ≥7% decrease in body weight.
Schizophrenia: Table 9 shows weight gain data at last visit and percentage of adult patients with ≥7% increase in body weight at endpoint from the 6-week, placebo-controlled, fixed-dose clinical studies in patients with schizophrenia. (See Table 9.)

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In the long-term, open-label schizophrenia studies, 0.6% of patients discontinued due to weight increase. Brexpiprazole (Rexulti) was associated with mean change from baseline in weight of 1.3 kg at week 26 and 2.0 kg at week 52. In the long-term, open label schizophrenia studies, 20% of patients demonstrated a ≥7% increase in body weight and 10% demonstrated a ≥7% decrease in body weight.
Leukopenia, Neutropenia, and Agranulocytosis: In clinical trial and/or post-marketing experience, leukopenia and neutropenia have been reported temporally related to atypical antipsychotic agents. Agranulocytosis has also been reported.
Possible risk factors for leukopenia/neutropenia include pre-existing low white blood cell count (WBC)/absolute neutrophil count (ANC) and history of drug-induced leukopenia/neutropenia. In patients with a history of a clinically significant low WBC/ANC or drug-induced leukopenia/neutropenia, perform a complete blood count (CBC) frequently during the first few months of therapy. In such patients, consider discontinuation of Brexpiprazole (Rexulti) at the first sign of a clinically significant decline in WBC in the absence of other causative factors.
Monitor patients with clinically significant neutropenia for fever or other symptoms or signs of infection and treat promptly if such symptoms or signs occur. Discontinue Brexpiprazole (Rexulti) in patients with severe neutropenia (absolute neutrophil count <1000/mm³) and follow their WBC until recovery.
Orthostatic Hypotension and Syncope: In the short-term, placebo-controlled clinical studies of Brexpiprazole (Rexulti)+ADT in patients with MDD, the incidence of orthostatic hypotension-related adverse reactions in Brexpiprazole (Rexulti)+ADT-treated patients compared to placebo+ADT patients included: dizziness (2% vs. 2%) and orthostatic hypotension (0.1% vs. 0%). In the short-term, placebo-controlled clinical studies of Brexpiprazole (Rexulti) in patients with schizophrenia, the incidence of orthostatic hypotension-related adverse reactions in Brexpiprazole (Rexulti)-treated patients compared to placebo patients included: dizziness (2% versus 2%), orthostatic hypotension (0.4% versus 0.2%), and syncope (0.1% versus 0%).
Adverse reactions associated with orthostatic hypotension can include dizziness, lightheadedness and tachycardia. Generally, these risks are greatest at the beginning of treatment and during dose escalation. Patients at increased risk of these adverse reactions or at increased risk of developing complications from hypotension include those with dehydration, hypovolemia, treatment with antihypertensive medication, history of cardiovascular disease (e.g., heart failure, myocardial infarction, ischemia, or conduction abnormalities), history of cerebrovascular disease, as well as patients who are antipsychotic-naïve. In such patients, consider using a lower starting dosage and slower titration, and monitor orthostatic vital signs.
Seizures: As with other antipsychotic drugs, Brexpiprazole (Rexulti) should be used cautiously in patients with a history of seizures or with conditions that potentially lower the seizure threshold. Conditions that lower the seizure threshold may be more prevalent in patients 65 years or older.
Body Temperature Dysregulation: Disruption of the body's ability to reduce core body temperature has been attributed to antipsychotic agents. Appropriate care is advised when prescribing Brexpiprazole (Rexulti) for patients who will be experiencing conditions that may contribute to an elevation in core body temperature, e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity, or being subject to dehydration.
Dysphagia: Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Antipsychotic drugs, including Brexpiprazole (Rexulti), should be used cautiously in patients at risk for aspiration pneumonia.
Potential for Cognitive and Motor Impairment: In the short-term, placebo-controlled clinical trials in patients with MDD, somnolence (including sedation and hypersomnia) was reported in 4% for Brexpiprazole (Rexulti)+ADT-treated patients compared to 1% of placebo+ADT patients.
In the short-term, placebo-controlled clinical trials in patients with schizophrenia, somnolence (including sedation and hypersomnia) was reported in 5% of Brexpiprazole (Rexulti)-treated patients compared to 3% of placebo-treated patients.
As with other antipsychotics that have the potential to impair judgment, thinking or motor skills, patients should be cautioned about operating hazardous machinery including motor vehicles until they are certain that Brexpiprazole (Rexulti) therapy does not affect them adversely.
Impulse-Control Disorders/Compulsive Behaviors: Post-marketing reports of impulse-control disorders including gambling have been reported very rarely in patients treated with brexpiprazole and other antipsychotics with partial agonist activity at dopamine receptors. Patients with a prior history of impulse-control disorders may be at increased risk and should be monitored carefully. Because patients may not recognize these behaviors as abnormal, it is important for prescribers to ask patients or their caregivers specifically about the development of new or increased impulse-control disorders or other compulsive behaviors while being treated with brexpiprazole. It should be noted that impulse-control symptoms can be associated with the underlying disorder. Compulsive behaviors may result in harm to the patient and others if not recognized.
CYP2D6 Poor Metabolizers: Dosage adjustment is recommended in known CYP2D6 poor metabolizers, because these patients have higher brexpiprazole concentrations than normal metabolizers of CYP2D6. Approximately 8% of Caucasians and 3-8% of Black/African Americans cannot metabolize CYP2D6 substrates and are classified as poor metabolizers (PM) [see Dosage Modifications for CYP2D6 Poor Metabolizers and for Concomitant use with CYP Inhibitors or Inducers under Dosage & Administration, Pharmacology: Pharmacokinetics under Actions].
Hepatic Impairment: Reduce the maximum recommended dosage in patients with moderate to severe hepatic impairment (Child-Pugh score ≥7). Patients with moderate to severe hepatic impairment (Child-Pugh score ≥7) generally had higher exposure to brexpiprazole than patients with normal hepatic function [see Pharmacology: Pharmacokinetics under Actions]. Greater exposure may increase the risk of Brexpiprazole (Rexulti)-associated adverse reactions [see Dosage Adjustments for Hepatic Impairment under Dosage & Administration].
Renal Impairment: Reduce the maximum recommended dosage in patients with moderate, severe, or end-stage renal impairment (CLcr<60 mL/minute). Patients with impaired renal function (CLcr<60 mL/minute) had higher exposure to brexpiprazole than patients with normal renal function [see Pharmacology: Pharmacokinetics under Actions]. Greater exposure may increase the risk of Brexpiprazole (Rexulti)-associated adverse reactions [see Dosage Adjustments for Renal Impairment under Dosage & Administration].
Other Specific Populations: No dosage adjustment for Brexpiprazole (Rexulti) is required on the basis of a patient's sex, race, or smoking status [see Pharmacology: Pharmacokinetics under Actions].
Drug Abuse and Dependence: Controlled Substance: Brexpiprazole (Rexulti) is not a controlled substance.
Abuse: Animals given access to Brexpiprazole (Rexulti) did not self-administer the drug, suggesting that Brexpiprazole (Rexulti) does not have rewarding properties.
Dependence: Humans and animals that received chronic Brexpiprazole (Rexulti) administration did not demonstrate any withdrawal signs upon drug discontinuation. This suggests that Brexpiprazole (Rexulti) does not produce physical dependence.
Use in Children: Safety and effectiveness in pediatric patients have not been established. Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric patients [see Warnings and Suicidal Thoughts and Behaviors in Children, Adolescents and Young Adults previously].
Use in Elderly: Clinical studies of the efficacy of Brexpiprazole (Rexulti) did not include any patients aged 65 or older to determine whether they respond differently from younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, and cardiac function, concomitant diseases, and other drug therapy.
Based on the results of a safety, tolerability and pharmacokinetics trial, the pharmacokinetics of once daily oral administration of brexpiprazole (up to 3 mg/day for 14 days) as an adjunct therapy in the treatment of elderly subjects (70 to 85 years old, N=11) with MDD were comparable to those observed in adults subjects with MDD.
Antipsychotic drugs increase the risk of death in elderly patients with dementia-related psychosis. Brexpiprazole (Rexulti) is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Increased Mortality in Elderly Patients with Dementia-Related Psychosis previously].

Pregnancy: Risk Summary: Adequate and well-controlled studies have not been conducted with Brexpiprazole (Rexulti) in pregnant women to inform drug-associated risks. However, neonates whose mothers are exposed to antipsychotic drugs, like Brexpiprazole (Rexulti), during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms. In animal reproduction studies, no teratogenicity was observed with oral administration of brexpiprazole to pregnant rats and rabbits during organogenesis at doses up to 73 and 146 times, respectively, of maximum recommended human dose (MRHD) of 4 mg/day on a mg/m² basis. However, when pregnant rats were administered brexpiprazole during the period of organogenesis through lactation, the number of perinatal deaths of pups was increased at 73 times the MRHD [see Data as follows]. The background risk of major birth defects and miscarriage for the indicated population(s) is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Clinical Considerations: Fetal/Neonatal Adverse Reactions: Extrapyramidal and/or withdrawal symptoms, including agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress and feeding disorder have been reported in neonates whose mothers were exposed to antipsychotic drugs during the third trimester of pregnancy. These symptoms have varied in severity. Some neonates recovered within hours or days without specific treatment; others required prolonged hospitalization. Monitor neonates for extrapyramidal and/or withdrawal symptoms and manage symptoms appropriately.
Data: Animal Data: Pregnant rats were treated with oral doses of 3, 10, and 30 mg/kg/day (7.3, 24, and 73 times the MRHD on a mg/m² basis) of brexpiprazole during the period of organogenesis. Brexpiprazole was not teratogenic and did not cause adverse developmental effects at doses up to 73 times the MRHD.
Pregnant rabbits were treated with oral doses of 10, 30, and 150 mg/kg/day (49, 146, and 730 times the MRHD) of brexpiprazole during the period of organogenesis. Brexpiprazole was not teratogenic and did not cause adverse developmental effects at doses up to 146 times the MRHD. Findings of decreased body weight, retarded ossification, and increased incidences of visceral and skeletal variations were observed in fetuses at 730 times the MRHD, a dose that induced maternal toxicity.
In a study in which pregnant rats were administered oral doses of 3, 10, and 30 mg/kg/day (7.3, 24, and 73 times the MRHD) during the period of organogenesis and through lactation, the number of live-born pups was decreased and early postnatal deaths increased at a dose 73 times the MRHD. Impaired nursing by dams, and low birth weight and decreased body weight gain in pups were observed at 73 times, but not at 24 times, the MRHD.
Lactation: Risk Summary: Lactation studies have not been conducted to assess the presence of brexpiprazole in human milk, the effects of brexpiprazole on the breastfed infant, or the effects of brexpiprazole on milk production. Brexpiprazole is present in rat milk. The development and health benefits of breastfeeding should be considered along with the mother's clinical need for Brexpiprazole (Rexulti) and any potential adverse effects on the breastfed infant from Brexpiprazole (Rexulti) or from the underlying maternal condition.

The following adverse reactions are discussed in more detail in other sections of the monograph: Increased Mortality in Elderly Patients with Dementia-Related Psychosis [see Warnings and Precautions].
Suicidal Thoughts and Behaviors in Adolescents and Young Adults [see Warnings and Precautions].
Cerebrovascular Adverse Reactions Including Stroke in Elderly Patients with Dementia-Related Psychosis [see Precautions].
Neuroleptic Malignant Syndrome (NMS) [see Precautions].
Tardive Dyskinesia [see Precautions].
Metabolic Changes [see Precautions].
Leukopenia, Neutropenia, and Agranulocytosis [see Precautions].
Orthostatic Hypotension and Syncope [see Precautions].
Seizures [see Precautions].
Body Temperature Dysregulation [see Precautions].
Dysphagia [see Precautions].
Potential for Cognitive and Motor Impairment [see Precautions].
Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
Major Depressive Disorder: The safety of Brexpiprazole (Rexulti) was evaluated 1,054 patients (18 to 65 years of age) diagnosed with MDD who participated in two 6-week, placebo-controlled, fixed-dose clinical trials in patients with major depressive disorder in which Brexpiprazole (Rexulti) was administered at doses of 1 mg to 3 mg daily as adjunctive treatment to continued antidepressant therapy; patients in the placebo group continued to receive antidepressant therapy [see Pharmacology: Pharmacodynamics: Clinical Studies: Adjunctive Treatment of Major Depressive Disorder under Actions].
Adverse Reactions Reported as Reasons for Discontinuation of Treatment: A total of 3% (17/643) of Brexpiprazole (Rexulti)-treated patients and 1% (3/411) of placebo-treated patients discontinued due to adverse reactions.
Common Adverse Reactions: Adverse reactions associated with the adjunctive use of Brexpiprazole (Rexulti) (incidence of 2% or greater and adjunctive Brexpiprazole (Rexulti) incidence greater than adjunctive placebo) that occurred during acute therapy (up to 6-weeks in patients with MDD) are shown in Table 10. (See Table 10.)

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Dose-Related Adverse Reactions in the MDD trials: In Studies 1 and 2, among the adverse reactions that occurred at ≥2% incidence in the patients treated with Brexpiprazole (Rexulti)+ADT, the incidences of akathisia and restlessness increased with increases in dose.
Schizophrenia: The safety of Brexpiprazole (Rexulti) was evaluated 852 patients (18 to 65 years of age) diagnosed with schizophrenia who participated in two 6-week, placebo-controlled, fixed-dose clinical trials in which Brexpiprazole (Rexulti) was administered at daily doses of 1 mg, 2 mg and 4 mg [see Pharmacology: Pharmacodynamics: Clinical Studies: Schizophrenia under Actions].
Common Adverse Reactions: Adverse reactions associated with Brexpiprazole (Rexulti) (incidence of 2% or greater and Brexpiprazole (Rexulti) incidence greater than placebo) during short-term (up to 6 weeks) trials in patients with schizophrenia are shown in Table 11. (See Table 11.)

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Extrapyramidal Symptoms: Major Depressive Disorder: The incidence of reported EPS-related adverse reactions, excluding akathisia, was 6% for Brexpiprazole (Rexulti)+ADT-treated patients versus 3% for placebo+ADT-treated patients. The incidence of akathisia events for Brexpiprazole (Rexulti)+ADT-treated patients was 9% versus 2% for placebo+ADT-treated patients.
In the 6-week, placebo-controlled MDD studies, data was objectively collected on the Simpson Angus Rating Scale (SAS) for extrapyramidal symptoms (EPS), the Barnes Akathisia Rating Scale (BARS) for akathisia and the Abnormal Involuntary Movement Score (AIMS) for dyskinesia. The mean change from baseline at last visit for Brexpiprazole (Rexulti)+ADT-treated patients for the SAS, BARS and AIMS was comparable to placebo treated patients. The percentage of patients who shifted from normal to abnormal was greater in Brexpiprazole (Rexulti)+ADT-treated patients versus placebo+ADT for the BARS (4% versus 0.6%) and the SAS (4% versus 3%).
Schizophrenia: The incidence of reported EPS-related adverse reactions, excluding akathisia, was 5% for Brexpiprazole (Rexulti)-treated patients versus 4% for placebo-treated patients. The incidence of akathisia events for Brexpiprazole (Rexulti)-treated patients was 6% versus 5% for placebo treated patients.
In the 6-week, placebo-controlled, fixed-dose schizophrenia studies, data was objectively collected on the Simpson Angus Rating Scale (SAS) for extrapyramidal symptoms (EPS), the Barnes Akathisia Rating Scale (BARS) for akathisia and the Abnormal Involuntary Movement Scale (AIMS) for dyskinesia. The mean change from baseline at last visit for Brexpiprazole (Rexulti)-treated patients for the SAS, BARS and AIMS was comparable to placebo-treated patients. The percentage of patients who shifted from normal to abnormal was greater in Brexpiprazole (Rexulti)-treated patients versus placebo for the BARS (2% versus 1%) and the SAS (7% versus 5%).
Dystonia: Symptoms of dystonia may occur in susceptible individuals during the first few days of treatment. Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups.
Other Adverse Reactions Observed During the Premarketing Evaluation of Brexpiprazole (Rexulti): Other adverse reactions (≥1% frequency and greater than placebo) within the short-term, placebo-controlled trials in patients with MDD and schizophrenia are shown below. The following listing does not include adverse reactions: 1) already listed in previous tables or elsewhere in the labeling, 2) for which a drug cause was remote, 3) which were so general as to be uninformative, 4) which were not considered to have clinically significant implications, or 5) which occurred at a rate equal to or less than placebo.
Eye Disorders: Vision Blurred.
Gastrointestinal Disorders: Nausea, Dry Mouth, Salivary Hypersecretion, Abdominal Pain, Flatulence.
Infections and Infestations: Urinary Tract Infection.
Investigations: Blood Prolactin Increased.
Musculoskeletal and Connective Tissue Disorders: Myalgia.
Psychiatric Disorders: Abnormal Dreams, Insomnia.
Skin and Subcutaneous Tissue Disorders: Hyperhidrosis.
Postmarketing Experience: The following adverse reaction has been identified during post-approval use of Brexpiprazole (Rexulti). Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Nervous System disorders: Neuroleptic Malignant Syndrome.

Drugs Having Clinically Important Interactions with Brexpiprazole (Rexulti): See Table 12.

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Drugs Having No Clinically Important Interactions with Brexpiprazole (Rexulti): Based on pharmacokinetic studies, no dosage adjustment of Brexpiprazole (Rexulti) is required when administered concomitantly with CYP2B6 inhibitors (e.g., ticlopidine) or gastric pH modifiers (e.g., omeprazole). Additionally, no dosage adjustment for substrates of CYP2D6 (e.g., dextromethorphan), CYP3A4 (e.g., lovastatin), CYP2B6 (e.g., bupropion), BCRP (e.g., rosuvastatin), or P-gp (e.g., fexofenadine) is required when administered concomitantly with Brexpiprazole (Rexulti).

Store at temperatures not exceeding 30°C.

Advise the patient or caregiver to read the FDA-approved patient labeling (Medication Guide).
Suicidal Thoughts and Behaviors: Advise patients and caregivers to look for the emergence of suicidality, especially early during treatment and when the dosage is adjusted up or down and instruct them to report such symptoms to the healthcare provider [see Warnings and Suicidal Thoughts and Behaviors in Children, Adolescents and Young Adults under Precautions].
Dosage and Administration: Advise patients that Brexpiprazole (Rexulti) can be taken with or without food. Advise patients regarding importance of following dosage escalation instructions [see Adjunctive Treatment of Major Depressive Disorder and Treatment of Schizophrenia under Dosage & Administration].
Neuroleptic Malignant Syndrome (NMS): Counsel patients about a potentially fatal adverse reaction - Neuroleptic Malignant Syndrome (NMS) that has been reported in association with administration of antipsychotic drugs. Advise patients to contact a health care provider or report to the emergency room if they experience signs or symptoms of NMS [see Neuroleptic Malignant Syndrome (NMS) under Precautions].
Tardive Dyskinesia: Counsel patients on the signs and symptoms of tardive dyskinesia and to contact their health care provider if these abnormal movements occur [see Tardive Dyskinesia under Precautions].
Metabolic Changes: Educate patients about the risk of metabolic changes, how to recognize symptoms of hyperglycemia and diabetes mellitus, and the need for specific monitoring, including blood glucose, lipids, and weight [see Metabolic Changes under Precautions].
Leukopenia, Neutropenia and Agranulocytosis: Advise patients with a pre-existing low WBC or a history of drug induced leukopenia/neutropenia that they should have their CBC monitored while taking Brexpiprazole (Rexulti) [see Leukopenia, Neutropenia and Agranulocytosis under Precautions].
Orthostatic Hypotension and Syncope: Educate patients about the risk of orthostatic hypotension and syncope especially early in treatment, and also at times of re-initiating treatment or increases in dosage [see Orthostatic Hypotension and Syncope under Precautions].
Heat Exposure and Dehydration: Counsel patients regarding appropriate care in avoiding overheating and dehydration [see Body Temperature Dysregulation under Precautions].
Interference with Cognitive and Motor Performance: Caution patients about performing activities requiring mental alertness, such as operating hazardous machinery or operating a motor vehicle, until they are reasonably certain that Brexpiprazole (Rexulti) therapy does not adversely affect their ability to engage in such activities [see Potential for Cognitive and Motor Impairment under Precautions].
Concomitant Medications: Advise patients to inform their health care providers of any changes to their current prescription or over-the-counter medications because there is a potential for clinically significant interactions [see Drugs Having Clinically Important Interactions with Brexpiprazole (Rexulti) under Interactions].
Pregnancy: Advise patients that third trimester use of Brexpiprazole (Rexulti) may cause extrapyramidal and/or withdrawal symptoms in a neonate and to notify their healthcare provider with a known or suspected pregnancy. Advise patients that there is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to Brexpiprazole (Rexulti) during pregnancy [see Pregnancy under Use in Pregnancy & Lactation].

Antipsychotics

N05AX16 - brexpiprazole ; Belongs to the class of other antipsychotics.

Rx