Cariprazine for hyperactive delirium in a medically complex ICU Patient: A case report

Background

Hyperactive delirium is a dangerous and under-studied complication in critically ill patients. Management is often complicated by QTc (corrected QT interval) prolongation associated with standard antipsychotics. Cariprazine, a dopamine D₂/D₃ partial agonist with minimal cardiac risk, may offer an alternative, though its role in delirium remains unexplored. Emerging real-world evidence supports cariprazine’s use in treatment-resistant psychiatric conditions, providing indirect support for its consideration in medically complex patients (Martiadis et al., 2024)

Case Presentation

A 33-year-old male with end-stage renal disease, sepsis, and prolonged QTc developed severe hyperactive delirium during an ICU admission. Despite trials of olanzapine (Zyprexa), lorazepam (2 mg IV q6h), and haloperidol (5 mg IV q6h), his agitation persisted. He required intubation for safety and sedation. Supportive care included dialysis, broad-spectrum antibiotics, oxygen supplementation (nasal cannula, high-flow, then intubation), IV fluids, and enteral feeding. Psychiatry was re-consulted on June 3 and confirmed hyperactive delirium. On June 4, cariprazine 1.5 mg was administered via NG tube (capsule powder dissolved in 30 mL water). Within 48–72 h, his behavior improved, coinciding with correction of metabolic derangements, resolution of sepsis, and stabilization of renal function. He was successfully extubated and discharged psychiatrically and medically stable.

Conclusion

This case suggests that cariprazine may be a potential alternative in ICU patients with hyperactive delirium and QTc concerns. However, clinical improvement was multifactorial, reflecting both psychiatric pharmacotherapy and comprehensive ICU management. This single case highlights the importance of multidisciplinary care and should be considered hypothesis-generating.