Brexpiprazole for the Treatment of Brain Injury Agitation

Case Diagnosis: Brain injury agitation treated with a new antipsychotic medication brexpiprazole.

Case Description or Program Description: A 45-year-old-male presented to an acute care hospital with anoxic brain injury after a cardiac arrest. During his hospitalization, the patient presented with episodes combativeness, restlessness, and insomnia. The patient was placed on restraints with 1:1 supervision. Multiple medications including quetiapine, propranolol, valproic acid, melatonin, and olanzapine were administered to the patient and found to be ineffective for his behavior.

Setting: Acute Care Hospital

Assessment/Results: A new second generation antipsychotic, brexpiprazole, was trialed for the patient’s agitation. Quetiapine was discontinued and 1 mg of brexpiprazole was started. Within 24 hours the patient’s behavior improved, and he was able to participate in therapy and socialize. The dose was then increased to 2 mg daily and the patient’s 1:1 supervision was discontinued. The patient was ultimately transferred to an inpatient brain injury rehabilitation without restraints and 1:1 supervision.

Discussion (relevance): Brexpiprazole is currently an approved treatment for Alzheimer dementia-associated agitation, along with schizophrenia and depression. Second generation antipsychotics and behavioral modification are commonly used in deescalating brain injury agitation, however, the adverse effects of these neuropsychiatric medications can lead to sedation, cognitive impairment, and QT prolongation and delaying rehabilitation progression. This newer second generation antipsychotic have shown to have lower incidence of side effects and has been effective in the Alzheimer dementia population for agitation. The patient in this case showed behavioral improvement after receiving brexpiprazole.

Conclusions: This is the first reported case, to our knowledge, of administrating brexpiprazole for the treatment of brain injury agitation.