. referral to a psychiatrist experienced in working with
patients who have learning disabilities and mental health
. annual documentation of the reasons for continuing a
prescription if the antipsychotic is not reduced in dose or
Side effects of antipsychotic drugs
Side-effects caused by antipsychotic drugs are common and
contribute significantly to non-adherence to therapy.
Extrapyramidal symptoms occur most frequently with the
piperazine phenothiazines (fluphenazine, perphenazine,
prochlorperazine, and trifluoperazine), the butyrophenones
(benperidol and haloperidol), and the first-generation depot
preparations. They are easy to recognise but cannot be
predicted accurately because they depend on the dose, the
type of drug, and on individual susceptibility.
Extrapyramidal symptoms consist of:
. parkinsonian symptoms (including tremor), which may
occur more commonly in adults or the elderly and may
. dystonia (abnormal face and body movements) and
dyskinesia, which occur more commonly in children or
young adults and appear after only a few doses;
. akathisia (restlessness), which characteristically occurs
after large initial doses and may resemble an exacerbation
of the condition being treated;
. tardive dyskinesia (rhythmic, involuntary movements of
short-term treatment with low doses—short-lived tardive
dyskinesia may occur after withdrawal of the drug.
Parkinsonian symptoms remit if the drug is withdrawn and
may be suppressed by the administration of antimuscarinic
drugs. However, routine administration of such drugs is not
justified because not all patients are affected and they may
unmask or worsen tardive dyskinesia.
Tardive dyskinesia is the most serious manifestation of
extrapyramidal symptoms; it is of particular concern because
it may be irreversible on withdrawing therapy and treatment
is usually ineffective. In children, tardive dyskinesia is more
likely to occur when the antipsychotic drug is withdrawn.
However, some manufacturers suggest that drug withdrawal
at the earliest signs of tardive dyskinesia (fine vermicular
movements of the tongue) may halt its full development.
Tardive dyskinesia occurs fairly frequently, especially in the
elderly, and treatment must be carefully and regularly
Most antipsychotic drugs, both first- and second-generation,
increase prolactin concentration to some extent because
dopamine inhibits prolactin release. Aripiprazole reduces
prolactin because it is a dopamine-receptor partial agonist.
Risperidone, amisulpride, and first-generation antipsychotic
drugs are most likely to cause symptomatic
hyperprolactinaemia. The clinical symptoms of
hyperprolactinaemia include sexual dysfunction, reduced
bone mineral density, menstrual disturbances, breast
enlargement, and galactorrhoea.
psychiatric illness, and substance misuse are contributing
factors. Antipsychotic-induced sexual dysfunction is caused
by more than one mechanism. Reduced dopamine
transmission and hyperprolactinaemia decrease libido;
antimuscarinic effects can cause disorders of arousal; and
alpha1-adrenoceptor antagonists are associated with
erection and ejaculation problems in men. Risperidone and
haloperidol commonly cause sexual dysfunction. If sexual
dysfunction is thought to be antipsychotic-induced, dose
reduction or switching medication should be considered.
Antipsychotic drugs have been associated with
cardiovascular side-effects such as tachycardia, arrhythmias,
and hypotension. QT-interval prolongation is a particular
concern with pimozide and haloperidol. There is also a
higher probability of QT-interval prolongation in patients
using any intravenous antipsychotic drug, or any
antipsychotic drug or combination of antipsychotic drugs
with doses exceeding the recommended maximum. Cases of
Hyperglycaemia and weight gain
Hyperglycaemia, and sometimes diabetes, can occur with
antipsychotic drugs, particularly clozapine, olanzapine,
quetiapine, and risperidone. All antipsychotic drugs may
cause weight gain, but the risk and extent varies. Clozapine
and olanzapine commonly cause weight gain.
Hypotension and interference with temperature regulation
Hypotension and interference with temperature regulation
are dose-related side-effects that are liable to cause
dangerous falls and hypothermia or hyperthermia in the
elderly. Clozapine, chlorpromazine, lurasidone, and
quetiapine can cause postural hypotension (especially
during initial dose titration) which may be associated with
syncope or reflex tachycardia in some patients.
Neuroleptic malignant syndrome
Neuroleptic malignant syndrome (hyperthermia, fluctuating
level of consciousness, muscle rigidity, and autonomic
dysfunction with pallor, tachycardia, labile blood pressure,
sweating, and urinary incontinence) is a rare but potentially
fatal side-effect of all antipsychotic drugs. Discontinuation
of the antipsychotic drug is essential because there is no
proven effective treatment, but bromocriptine and
dantrolene have been used. The syndrome, which usually
lasts for 5–7 days after drug discontinuation, may be unduly
prolonged if depot preparations have been used.
Perform blood counts if unexplained infection or fever
There is little meaningful difference in efficacy between each
of the antipsychotic drugs (other than clozapine p. 396), and
response and tolerability to each antipsychotic drug varies.
There is no first-line antipsychotic drug which is suitable for
all patients. Choice of antipsychotic medication is influenced
by the patient’s medication history, the degree of sedation
required (although tolerance to this usually develops), and
consideration of individual patient factors such as risk of
extrapyramidal side-effects, weight gain, impaired glucose
tolerance, QT-interval prolongation, or the presence of
Second generation antipsychotic drugs may be better at
treating the negative symptoms of schizophrenia.
Second-generation antipsychotic drugs should be prescribed
if extrapyramidal side-effects are a particular concern. Of
these, aripiprazole p. 395, clozapine, olanzapine p. 398, and
quetiapine p. 401 are least likely to cause extrapyramidal
common than with the first-generation antipsychotic drugs
because amisulpride selectively blocks mesolimbic dopamine
receptors, and extrapyramidal symptoms are caused by
blockade of the striatal dopamine pathway.
Aripiprazole has negligible effect on the QT interval. Other
antipsychotic drugs with a reduced tendency to prolong QT
interval include amisulpride, clozapine, flupentixol p. 385,
382 Mental health disorders BNF 78
fluphenazine decanoate p. 392, olanzapine, perphenazine,
prochlorperazine p. 389, risperidone p. 402, and sulpiride
Schizophrenia is associated with insulin resistance and
diabetes; the risk of diabetes is increased in patients with
diabetes than second-generation antipsychotic drugs, and of
the first-generation antipsychotic drugs, fluphenazine
decanoate and haloperidol p. 386 are lowest risk.
Amisulpride and aripiprazole have the lowest risk of diabetes
of the second-generation antipsychotic drugs. Amisulpride,
aripiprazole, haloperidol, sulpiride, and trifluoperazine
p. 390 are least likely to cause weight gain.
Sexual dysfunction and prolactin
The antipsychotic drugs with the lowest risk of sexual
dysfunction are aripiprazole and quetiapine. Olanzapine
may be considered if sexual dysfunction is judged to be
secondary to hyperprolactinaemia. Hyperprolactinaemia is
usually not clinically significant with aripiprazole, clozapine,
olanzapine, and quetiapine treatment. When changing from
other antipsychotic drugs, a reduction in prolactin
concentration may increase fertility.
Patients should receive an antipsychotic drug for
4–6 weeks before it is deemed ineffective. Prescribing more
than one antipsychotic drug at a time should be avoided
except in exceptional circumstances (e.g. clozapine
augmentation or when changing medication during
titration) because of the increased risk of adverse effects
such as extrapyramidal symptoms, QT-interval
prolongation, and sudden cardiac death.
Clozapine is licensed for the treatment of schizophrenia in
patients unresponsive to, or intolerant of, other
antipsychotic drugs. Clozapine should be introduced if
schizophrenia is not controlled despite the sequential use of
two or more antipsychotic drugs (one of which should be a
second-generation antipsychotic drug), each for at least
6–8 weeks. If symptoms do not respond adequately to an
optimised dose of clozapine, plasma-clozapine
concentration should be checked before adding a second
antipsychotic drug to augment clozapine; allow 8–10 weeks’
treatment to assess response. Patients must be registered
with a clozapine patient monitoring service.
Full blood count, urea and electrolytes, and liver function
test monitoring is required at the start of therapy with
antipsychotic drugs, and then annually thereafter.
Blood lipids and weight should be measured at baseline, at
3 months (weight should be measured at frequent intervals
during the first 3 months), and then yearly.
Fasting blood glucose should be measured at baseline, at
Before initiating antipsychotic drugs, an ECG may be
required, particularly if physical examination identifies
cardiovascular risk factors, if there is a personal history of
cardiovascular disease, or if the patient is being admitted as
Blood pressure monitoring is advised before starting
therapy and frequently during dose titration of antipsychotic
Some antipsychotic drugs can be used for the treatment of
nausea and vomiting, choreas, and motor tics.
Chlorpromazine hydrochloride p. 384 and haloperidol p. 386
can be used for intractable hiccup. Benperidol p. 380 is used
in deviant antisocial sexual behaviour but its value is not
Psychomotor agitation should be investigated for an
underlying cause; it can be managed with low doses of
chlorpromazine hydrochloride or haloperidol used for short
periods. Antipsychotic drugs can be used with caution for the
short-term treatment of severe agitation and restlessness in
Equivalent doses of oral antipsychotics
These equivalences are intended only as an approximate
guide; individual dosage instructions should also be
checked; patients should be carefully monitored after any
change in medication. Equivalent daily dose of antipsychotic
Important: These equivalences must not be extrapolated
beyond the maximum dose for the drug. Higher doses require
careful titration in specialist units and the equivalences
shown here may not be appropriate.
After an initial period of stabilisation, in most patients, the
total daily oral dose can be given as a single dose. The Royal
College of Psychiatrists has published advice on doses of
antipsychotic drugs above BNF upper limit.
Antipsychotic depot injections
Long-acting depot injections are used for maintenance
therapy especially when compliance with oral treatment is
unreliable. However, depot injections of conventional
antipsychotics may give rise to a higher incidence of
extrapyramidal reactions than oral preparations;
risperidone p. 402 and olanzapine embonate p. 404.
There is no clear-cut division in the use of the conventional
antipsychotics, but zuclopenthixol p. 391 may be suitable for
the treatment of agitated or aggressive patients whereas
flupentixol decanoate p. 392 can cause over-excitement in
such patients. Zuclopenthixol decanoate p. 394 may be more
effective in preventing relapses than other conventional
antipsychotic depot preparations. The incidence of
extrapyramidal reactions is similar for the conventional
Individual responses to neuroleptic drugs are variable and to
achieve optimum effect, dosage and dosage interval must be
titrated according to the patient’s response.
Equivalent doses of depot antipsychotics
Antipsychotic drug/interval Dosage (mg)
Flupentixol decanoate / 2 weeks 40
Fluphenazine decanoate / 2 weeks 25
Haloperidol (as decanoate) / 4 weeks 100
Zuclopenthixol decanoate / 2 weeks 200
Important: These equivalences must not be extrapolated beyond
These equivalences are intended only as an approximate
guide; individual dosage instructions should also be
checked; patients should be carefully monitored after any
BNF 78 Psychoses and schizophrenia 383
exacerbated)(in adults). photosensitisation (may occur
▶ Cardiovascular disease An ECG may be required, particularly
if physical examination identifies cardiovascular risk
factors, personal history of cardiovascular disease, or if the
patient is being admitted as an inpatient.
▶ Rare or very rare Sudden death . withdrawal syndrome
SIDE-EFFECTS, FURTHER INFORMATION For depot
antipsychotics—side-effects may persist until the drug has
been cleared from its depot site.
Overdose Phenothiazines cause less depression of
consciousness and respiration than other sedatives.
Hypotension, hypothermia, sinus tachycardia, and
arrhythmias may complicate poisoning. For details on the
management of poisoning see Antipsychotics under
Emergency treatment of poisoning p. 1359.
l PREGNANCY Extrapyramidal effects and withdrawal
syndrome have been reported occasionally in the neonate
when antipsychotic drugs are taken during the third
trimester of pregnancy. Following maternal use of
antipsychotic drugs in the third trimester, neonates should
be monitored for symptoms including agitation,
hypertonia, hypotonia, tremor, drowsiness, feeding
problems, and respiratory distress.
l BREAST FEEDING There is limited information available on
the short- and long-term effects of antipsychotic drugs on
the breast-fed infant. Animal studies indicate possible
adverse effects of antipsychotic medicines on the
developing nervous system. Chronic treatment with
antipsychotic drugs whilst breast-feeding should be
avoided unless absolutely necessary. Phenothiazine
derivatives are sometimes used in breast-feeding women
for short-term treatment of nausea and vomiting.
▶ It is advisable to monitor prolactin concentration at the
start of therapy, at 6 months, and then yearly. Patients
taking antipsychotic drugs not normally associated with
symptomatic hyperprolactinaemia should be considered
for prolactin monitoring if they show symptoms of
hyperprolactinaemia (such as breast enlargement and
▶ Patients with schizophrenia should have physical health
monitoring (including cardiovascular disease risk
assessment) at least once per year.
▶ In children Regular clinical monitoring of endocrine
function should be considered when children are taking an
antipsychotic drug known to increase prolactin levels; this
includes measuring weight and height, assessing sexual
maturation, and monitoring menstrual function.
l TREATMENT CESSATION There is a high risk of relapse if
medication is stopped after 1–2 years. Withdrawal of
antipsychotic drugs after long-term therapy should always
be gradual and closely monitored to avoid the risk of acute
withdrawal syndromes or rapid relapse. Patients should be
monitored for 2 years after withdrawal of antipsychotic
medication for signs and symptoms of relapse.
l PATIENT AND CARER ADVICE As photosensitisation may
occur with higher dosages, patients should avoid direct
Driving and skilled tasks Drowsiness may affect
performance of skilled tasks (e.g. driving or operating
machinery), especially at start of treatment; effects of
ANTIPSYCHOTICS › FIRST-GENERATION
Chlorpromazine hydrochloride 09-Jul-2018
Schizophrenia and other psychoses | Mania | Short-term
adjunctive management of severe anxiety | Psychomotor
agitation, excitement, and violent or dangerously
▶ Adult: Initially 25 mg 3 times a day, adjusted according
to response, alternatively initially 75 mg once daily,
adjusted according to response, dose to be taken at
night; maintenance 75–300 mg daily, increased if
necessary up to 1 g daily, this dose may be required in
psychoses; use a third to half adult dose in the elderly
▶ Adult: 100 mg every 6–8 hours, dose expressed as
▶ Adult: 25–50 mg 3–4 times a day
Relief of acute symptoms of psychoses (under expert
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: 25–50 mg every 6–8 hours
Nausea and vomiting in palliative care (where other drugs
have failed or are not available)
▶ Child 1–5 years: 500 micrograms/kg every 4–6 hours;
▶ Child 6–11 years: 500 micrograms/kg every 4–6 hours;
▶ Child 12–17 years: 10–25 mg every 4–6 hours
▶ Adult: 10–25 mg every 4–6 hours
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Child 1–5 years: 500 micrograms/kg every 6–8 hours;
▶ Child 6–11 years: 500 micrograms/kg every 6–8 hours;
▶ Child 12–17 years: Initially 25 mg, then 25–50 mg every
3–4 hours until vomiting stops
▶ Adult: Initially 25 mg, then 25–50 mg every 3–4 hours
▶ Adult: 100 mg every 6–8 hours
DOSE EQUIVALENCE AND CONVERSION
▶ For equivalent therapeutic effect 100 mg
chlorpromazine base given rectally as a suppository :
20–25 mg chlorpromazine hydrochloride by
intramuscular injection: 40–50 mg of chlorpromazine
base or hydrochloride given by mouth.
384 Mental health disorders BNF 78
l UNLICENSED USE Rectal route is not licensed.
l CONTRA-INDICATIONS CNS depression . comatose states . hypothyroidism . phaeochromocytoma
l INTERACTIONS → Appendix 1: phenothiazines
▶ Common or very common Anxiety . glucose tolerance
impaired . mood altered . muscle tone increased
deposit. eye disorders . gastrointestinal disorders . hepatic
▶ With intramuscular use Muscle rigidity . nasal congestion
SIDE-EFFECTS, FURTHER INFORMATION Acute dystonic
reactions may occur; children are particularly susceptible.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe hepatic failure (increased risk of accumulation).
Dose adjustments Start with small doses in severe renal
impairment because of increased cerebral sensitivity.
▶ With intramuscular use Patients should remain supine, with
blood pressure monitoring for 30 minutes after
l PRESCRIBING AND DISPENSING INFORMATION
Palliative care For further information on the use of
chlorpromazine hydrochloride in palliative care, see
www.medicinescomplete.com/#/content/palliative/
l HANDLING AND STORAGE Owing to the risk of contact
sensitisation, pharmacists, nurses, and other health
workers should avoid direct contact with chlorpromazine;
tablets should not be crushed and solutions should be
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet, capsule, oral
suspension, oral solution, suppository
CAUTIONARY AND ADVISORY LABELS 2, 11
▶ Chlorpromazine hydrochloride (Non-proprietary)
Chlorpromazine hydrochloride 25 mg Chlorpromazine 25mg
tablets | 28 tablet P £44.78 DT = £41.72
Chlorpromazine hydrochloride 50 mg Chlorpromazine 50mg
tablets | 28 tablet P £48.00 DT = £41.81
Chlorpromazine hydrochloride 100 mg Chlorpromazine 100mg
tablets | 28 tablet P £46.25 DT = £41.56
Chlorpromazine hydrochloride 25 mg per 1 ml Largactil 50mg/2ml
solution for injection ampoules | 10 ampoule P £7.51
CAUTIONARY AND ADVISORY LABELS 2, 11
▶ Chlorpromazine hydrochloride (Non-proprietary)
Chlorpromazine hydrochloride 5 mg per 1 ml Chlorpromazine
25mg/5ml syrup | 150 ml P £2.35 DT = £2.35
Chlorpromazine 25mg/5ml oral solution sugar free sugar-free |
Chlorpromazine 25mg/5ml oral solution | 150 ml P £2.35 DT =
Chlorpromazine hydrochloride 20 mg per 1 ml Chlorpromazine
100mg/5ml oral solution | 150 ml P £5.50 DT = £5.50
Schizophrenia and other psychoses, particularly with
apathy and withdrawal but not mania or psychomotor
▶ Adult: Initially 3–9 mg twice daily, adjusted according
to response, for debilitated patients, use elderly dose;
▶ Elderly: Initially 0.75–4.5 mg twice daily, adjusted
▶ Adult: Initially 1 mg once daily, dose to be taken in the
morning, increased if necessary to 2 mg after 1 week,
doses above 2 mg to be given in divided doses, last dose
to be taken before 4 pm; discontinue if no response
after 1 week at maximum dosage; maximum 3 mg per
▶ Elderly: Initially 500 micrograms daily, dose to be taken
in the morning, then increased if necessary to 1 mg
after 1 week, doses above 1 mg to be given in divided
doses, last dose to be taken before 4 pm; discontinue if
no response after 1 week at maximum dosage;
l CONTRA-INDICATIONS Circulatory collapse . CNS
depression . comatose states . excitable patients . impaired
consciousness . overactive patients . phaeochromocytoma
l INTERACTIONS → Appendix 1: flupentixol
▶ Rare or very rare Glucose tolerance impaired . hyperglycaemia . jaundice .thrombocytopenia
▶ Frequency not known Suicidal tendencies
l PREGNANCY Avoid unless potential benefit outweighs risk.
l BREAST FEEDING Present in breast milk—avoid.
l HEPATIC IMPAIRMENT Manufacturer advises caution—
monitor serum drug concentration.
l RENAL IMPAIRMENT Manufacturer advises caution in renal
Dose adjustments Start with small doses of antipsychotic
drugs in severe renal impairment because of increased
l PATIENT AND CARER ADVICE Although drowsiness may
occur, can also have an alerting effect so should not be
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
Flupentixol (as Flupentixol dihydrochloride) 3 mg Depixol 3mg
tablets | 100 tablet P £13.92 DT = £13.92
BNF 78 Psychoses and schizophrenia 385
Flupentixol (as Flupentixol dihydrochloride)
500 microgram Fluanxol 500microgram tablets | 60 tablet P £2.88 DT = £2.88
Flupentixol (as Flupentixol dihydrochloride) 1 mg Fluanxol 1mg
tablets | 60 tablet P £4.86 DT = £4.86
Prophylaxis of postoperative nausea and vomiting [in
patients at moderate to high risk and when alternatives
▶ Adult: 1–2 mg, to be given at induction or 30 minutes
▶ Elderly: 500 micrograms, to be given at induction or
30 minutes before the end of anaesthesia
Combination treatment of postoperative nausea and
vomiting [when alternatives ineffective or not tolerated]
Nausea and vomiting in palliative care
▶ Adult: Initially 1.5 mg 1–2 times a day, increased if
necessary to 5–10 mg daily in divided doses
Schizophrenia and schizoaffective disorder
▶ Adult: 2–10 mg daily in 1–2 divided doses; usual dose
2–4 mg daily, in first-episode schizophrenia, up to
10 mg daily, in multiple-episode schizophrenia, dose
adjusted according to response at intervals of 1–7 days.
Individual benefit-risk should be assessed when
considering doses above 10 mg daily; maximum 20 mg
▶ Elderly: Initially, use half the lowest adult dose, then
adjust gradually according to response up to maximum
5 mg daily, doses above 5 mg daily should only be
considered in patients who have tolerated higher doses
and after reassessment of the individual benefit-risk
Acute delirium [when non-pharmacological treatments
▶ Adult: 1–10 mg daily in 1–3 divided doses, treatment
should be started at the lowest possible dose and
adjusted in increments at 2–4 hourly intervals if
required; maximum 10 mg per day
▶ Elderly: Initially, use half the lowest adult dose, then
adjust gradually according to response up to maximum
5 mg daily, doses above 5 mg daily should only be
considered in patients who have tolerated higher doses
and after reassessment of the individual benefit-risk
▶ Adult: 1–10 mg, treatment should be started at the
lowest possible dose and adjusted in increments at
2–4 hourly intervals if required; maximum 10 mg per
▶ Elderly: Initially 500 micrograms, dose adjusted
gradually according to response up to maximum 5 mg
daily, doses above 5 mg daily should only be considered
in patients who have tolerated higher doses and after
reassessment of the individual benefit-risk
Moderate to severe manic episodes associated with
▶ Adult: 2–10 mg daily in 1–2 divided doses, dose
adjusted according to response at intervals of 1–3 days.
Individual benefit-risk should be assessed when
considering doses above 10 mg daily; continued use
should be evaluated early in treatment; maximum
▶ Elderly: Initially, use half the lowest adult dose, then
adjust gradually according to response up to maximum
5 mg daily, doses above 5 mg daily should only be
considered in patients who have tolerated higher doses
and after reassessment of the individual benefit-risk;
continued use should be evaluated early in treatment
Acute psychomotor agitation associated with psychotic
disorder or manic episodes of bipolar I disorder
▶ Adult: 5–10 mg, dose may be repeated after 12 hours if
necessary; continued use should be evaluated early in
treatment; maximum 20 mg per day
▶ Elderly: Initially 2.5 mg, dose may be repeated after
12 hours if necessary up to maximum 5 mg daily, doses
above 5 mg daily should only be considered in patients
who have tolerated higher doses and after
reassessment of the individual benefit-risk; continued
use should be evaluated early in treatment
Rapid control of severe acute psychomotor agitation
associated with psychotic disorder or manic episodes of
bipolar I disorder [when oral therapy is not appropriate]
▶ Adult: 5 mg, dose may be repeated hourly if required—
up to 15 mg daily is usually sufficient; continued use
should be evaluated early in treatment; maximum
▶ Elderly: 2.5 mg, dose may be repeated hourly if
required up to maximum 5 mg daily, doses above 5 mg
daily should only be considered in patients who have
tolerated higher doses and after reassessment of the
individual benefit-risk; continued use should be
Persistent aggression and psychotic symptoms in
moderate to severe Alzheimer’s dementia and vascular
dementia [when non-pharmacological treatments
ineffective and there is a risk of harm to self or others]
▶ Adult: 0.5–5 mg daily in 1–2 divided doses, dose
adjusted according to response at intervals of 1–3 days.
Reassess treatment after no more than 6 weeks
▶ Elderly: 500 micrograms daily, reassess treatment after
Severe tic disorders, including Tourette’s syndrome [when
educational, psychological and other pharmacological
▶ Adult: 0.5–5 mg daily in 1–2 divided doses, dose
adjusted according to response at intervals of 1–7 days.
Reassess treatment every 6–12 months
▶ Elderly: Initially, use half the lowest adult dose, then
adjust gradually according to response up to maximum
5 mg daily. Reassess treatment every 6–12 months
Mild to moderate chorea in Huntington’s disease [when
alternatives ineffective or not tolerated]
▶ Adult: 2–10 mg daily in 1–2 divided doses, dose
adjusted according to response at intervals of 1–3 days
▶ Elderly: Initially, use half the lowest adult dose, then
adjust gradually according to response up to maximum
5 mg daily, doses above 5 mg daily should only be
considered in patients who have tolerated higher doses
and after reassessment of the individual benefit-risk
386 Mental health disorders BNF 78
Mild to moderate chorea in Huntington’s disease [when
alternatives ineffective or not tolerated and oral therapy
▶ Adult: 2–5 mg, dose may be repeated hourly if
required; maximum 10 mg per day
▶ Elderly: Initially 1 mg, dose may be repeated hourly if
required up to maximum 5 mg daily, doses above 5 mg
daily should only be considered in patients who have
tolerated higher doses and after reassessment of the
Restlessness and confusion in palliative care
▶ Adult: 2 mg, then 2 mg every 2 hours if required
▶ Adult: 2.5 mg, then 2.5 mg every 2 hours if required
l UNLICENSED USE Not licensed for use in palliative care.
When prescribing, dispensing or administering, check
that this injection is the correct preparation—this
preparation is usually used in hospital for the rapid
control of an acute episode and should not be confused
with depot preparations which are usually used in the
community or clinics for maintenance treatment.
arrhythmia . Parkinson’s disease . progressive supranuclear
palsy . QTc-interval prolongation .recent acute myocardial
infarction . uncompensated heart failure . uncorrected
l CAUTIONS Bradycardia . electrolyte disturbances (correct
hypotension). prolactin-dependent tumours . prolactinaemia .risk factors for stroke
l INTERACTIONS → Appendix 1: haloperidol
dysfunction . psychotic disorder. vision disorders . weight
reaction .restlessness . sexual dysfunction . skin reactions . temperature regulation disorders
▶ Rare or very rare Hypoglycaemia .respiratory disorders . SIADH .trismus
▶ Frequency not known Hypersensitivity vasculitis . pancytopenia .rhabdomyolysis .thrombocytopenia
▶ With parenteral use Hypertension . severe cutaneous
SIDE-EFFECTS, FURTHER INFORMATION Haloperiol is a less
l PREGNANCY Manufacturer advises it is preferable to
avoid—moderate amount of data indicate no malformative
or fetal/neonatal toxicity, however there are isolated case
reports of birth defects following fetal exposure, mostly in
combination with other drugs; reproductive toxicity
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Manufacturer advises halve initial dose
and then adjust if necessary with smaller increments and
l RENAL IMPAIRMENT Manufacturer advises use with
Dose adjustments Manufacturer advises consider lower
initial dose in severe impairment and then adjust if
necessary with smaller increments and at longer intervals.
▶ Manufacturer advises monitor electrolytes before
treatment initiation and periodically during treatment.
▶ Manufacturer advises perform ECG before treatment
initiation and assess need for further ECGs during
treatment on an individual basis; continuous ECG
monitoring is recommended for repeated intramuscular
doses, and for up to 6 hours after administration of
intramuscular doses for prophylaxis or treatment of
postoperative nausea and vomiting.
l PRESCRIBING AND DISPENSING INFORMATION
Palliative care For further information on the use of
haloperidol in palliative care, see www.medicinescomplete.
com/#/content/palliative/haloperidol.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Haloperidol (Non-proprietary)
Haloperidol 500 microgram Haloperidol 500microgram tablets | 28 tablet P £22.05–£30.00 DT = £29.59
Haloperidol 1.5 mg Haloperidol 1.5mg tablets | 28 tablet P £15.10 DT = £15.10
Haloperidol 5 mg Haloperidol 5mg tablets | 28 tablet P £16.58
Haloperidol 10 mg Haloperidol 10mg tablets | 28 tablet P £19.85 DT = £19.36
▶ Haloperidol (Non-proprietary)
Haloperidol 5 mg per 1 ml Haloperidol 5mg/1ml solution for
injection ampoules | 10 ampoule P £35.00 DT = £35.00
CAUTIONARY AND ADVISORY LABELS 2
▶ Haloperidol (Non-proprietary)
Haloperidol 1 mg per 1 ml Haloperidol 5mg/5ml oral solution sugar
free sugar-free | 100 ml P £35.99 DT = £6.47 sugar-free | 500 ml P £32.35
Haloperidol 2 mg per 1 ml Haloperidol 10mg/5ml oral solution
sugar free sugar-free | 100 ml P £46.75 DT = £7.10 sugar-free | 500 ml P £35.50
Haloperidol 2 mg per 1 ml Haldol 2mg/ml oral solution sugar-free |
▶ Halkid (Thame Laboratories Ltd)
Haloperidol 200 microgram per 1 ml Halkid 200micrograms/ml
oral solution sugar-free | 100 ml P £89.90
CAUTIONARY AND ADVISORY LABELS 2
Haloperidol 500 microgram Serenace 500microgram capsules |
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