Initial Dosing and Clinical Titration of Antipsychotic Drugs in Schizophrenia Conventional antipsychotics Dosing Optimal dosing with conventional antipsychotic agents

Conventional antipsychotics Dosing Optimal dosing with conventional antipsychotic agents involves the selection of a moderate initial dose (Table), followed by careful clinical titration to maximize antipsychotic efficacy while minimizing extrapyramidal symptoms (EPS). (If EPS develop on a typical drug, consider decreasing dose or adding an anticholinergic drug or switching to an atypical, if possible). Sedation also may be dose-limiting with lower-potency conventional antipsychotics. Agitation during acute phase is best treated with co-administration of a benzodiazepine, such as oral or intramuscular lorazepam as needed. 1 Because compliance with conventional antipsychotics is often poor, clinicians must first determine that the unresponsive or partially-responsive patient is taking the medication as prescribed before making adjustments to the dose onset of action. While sedation occurs within hours, Starting Dose (mg/day) Antipsychotic a. Typical dose in mg/day b. (Usual Dosage Range) Medically Uncomplicated First Episode Elderly Comments Aripiprazole a. 15 b. (10-30) 15 10 10 72 hour half-life; no evidence of improved efficacy > 20 mg/day Clozapine b. (200-500) 25 N/A 12.5 Response associated with plasma level >350 ng/ml Haloperidol a. 5-8(2-3 for 1 st episode) b. (5-20) 10 5 2 Monitor for EPS, blood levels may be helpful Olanzapine a. 15 b. (10-25) 15 10 5 30-40 mg/day may be more effective in refractory patients Quetiapine a. 400 b. (300-850) 50 50 25 Safety and benefit of high doses (>800 mg/day) not yet established Risperidone a.3-5 b. (2-8) 2 1 0.5 Increased EPS without improved efficacy above 6 mg/day Ziprasidone a. 120 b. (80-160) 40 40 20 Administered with meals; safety and benefits of high doses (>160 mg/day) not yet established