Class: First Generation Antipsychotic/Butyrophenone FDA Indications: Manifestations Of Psychotic Disorders, Severe Behavior Problems In Children With Combative, Explosive Hyperexcitabile Behaviors, Tourette's Disorder Off-Label Use: OCD, Behavioral Disturbances With Dementia, Delirium (with lorazepam), Chemotherapy-induced Nausea/vomiting, Nausea/vomiting In Terminal Illness, PCP-induced Psychosis, Rapid Tranquilization, Prevention Of PONV
Forms: 0.5, 1, 2, 5, 10, 20mg tablet; 1mg/mL po soln; 5mg/mL IM; LAI: 50 mg/mL, 100 mg/mL Dose Range: 1-40 mg/day Starting: PO: Start 0.5-2 mg bid to or tid; usual max 40mg/day; LAI: initially 10-15x oral dose, given Q month Stopping: Taper 6-8 weeks, rapid d/c can lead to rebound psychosis Monitoring:
Contraindications: Parkinson's disease Serious Side Effects:
Neuroleptic Malignant Syndrome (NMS)
A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with antipsychotic drugs. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status (including catatonic signs) and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmias). Additional signs may include elevated creatine 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 identify 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 (CNS) 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 uncomplicated 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.
Hyperpyrexia and heat stroke, not associated with the above symptom complex, have also been reported with haloperidol.
Antipsychotic Medication and Seizures
All antipsychotics can lower the seizure threshold. They should be used with caution in patients who have a history of seizures and in those with organic brain disorders. Generally, the more sedating the antipsychotic, the more it lowers the seizure threshold. Seizures are most common with low-potency FGAs and clozapine, especially at higher dosages.
A severe extrapyramidal side effect that occurs in 15% to 25% of patients after prolonged neuroleptic treatment, is characterized by stereotyped, involuntary, repetitive, choreiform movements of the face, eyelids, mouth, tongue, extremities, and trunk.
no significant antihistaminic or antimuscarinic actions
lack of anticholinergic activity could, in such a potent dopamine antagonist, account for its poor EPS tolerability
anticholinergics should probably automatically co-prescribed (versus PRN)
Tmax of IM haloperidol takes place after 20 min (faster than PO administration)
APA practice guidelines on the use of antipsychotics to treat agitation & psychosis in patients with dementia recommends against use of haloperidol as a first-line treatment for pts w/ dementia w/o evidence of delirium in nonemergency situations
Category C—Associated with limb malformations in first trimester use. Third-trimester use can result in EPS or withdrawal symptoms in the newborn
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.
2019 BEE℞S Recommendation: Avoid, except in schizophrenia or bipolar disorder. Increased risk of CVA and greater rate of cognitive decline and mortality in persons with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options have failed or are not possible and the older adult is threatening substantial harm to self or others.
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Last updated March 25 2019 15:25:58. Disclaimer: This website does not provide medical advice, nor is it a substitute for clinical judgment.
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