Alternative Medications to Brexpiprazole

Primary Alternatives Based on Indication

The American Academy of Family Physicians recommends risperidone starting at 0.25 mg daily at bedtime, maximum 2-3 mg daily in divided doses, for psychotic symptoms with lower risk of extrapyramidal symptoms than typical antipsychotics 2
The American Academy of Family Physicians suggests olanzapine starting at 2.5 mg daily at bedtime, maximum 10 mg daily, which is generally well tolerated but carries higher metabolic risk 2, 3, 4
The American Academy of Family Physicians recommends quetiapine starting at 12.5 mg twice daily, maximum 200 mg twice daily, which provides more sedation and requires monitoring for orthostatic hypotension 2

When minimizing metabolic effects, the American Heart Association and the American College of Cardiology recommend choosing aripiprazole, ziprasidone, or cariprazine over olanzapine or quetiapine 3, 4, 5
The Lancet Psychiatry guidelines recommend switching to antipsychotics with more benign metabolic profiles when weight gain or metabolic syndrome develops 5

The American College of Cardiology recommends aripiprazole when QTc prolongation is a concern, as it has not been associated with significant QT prolongation 1
The Lancet Psychiatry guidelines recommend monitoring requirements before starting any alternative antipsychotic, including BMI, waist circumference, blood pressure, HbA1c, glucose, lipids, prolactin, liver function tests, electrolytes, full blood count, and ECG 5
The American College of Cardiology and The Lancet Psychiatry suggest that aripiprazole or other D2 partial agonists are preferred for hyperprolactinemia management, as they typically lower prolactin levels 1, 5