Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 29: Psychopharmacological Treatment

Table 29.29-1 Comparison of Usual Dosing a for Some Available Second-generation Antipsychotics in Schizophrenia

Maximum Recommended Dosage

Typical Starting Dosage 10–15 mg tablets once a day 5 mg twice a day 12.5 mg tablets once or twice a day

Maintenance Therapy Dose Range Titration

Antipsychotic

Aripiprazole (Abilify) Asenapine (Saphris) Clozapine (Clozaril)

10–30 mg/day 10 mg twice a day 150–300 mg/day in divided doses or 200 mg as a single dose in the evening

Dosage increases should not be made before 2 weeks Titration not necessary The dosage should be increased to 25–50 mg on the second day. Further increases may be made in daily increments of 25–50 mg to a target dosage of 300–450 mg/day. Subsequent dosage increases should be made no more than once or twice weekly in increments of no more than 100 mg. Start at 1 mg twice a day than move to 2, 4, 6, 8 and 12 mg twice a day. Do this over the course of 7 days

30 mg/day 20 mg/day 900 mg/day

Iloperidone (Fanapt)

1 mg twice a day

12–24 mg a day in divided dose

24 mg/day

Lurasidone (Latuda) Olanzapine (Zyprexa)

40 mg/day

40–80 mg/day

Titration not necessary

120 mg/day

5–10 mg/day

10–20 mg/day

Dosage increments of 5 mg once a day are recommended when required at intervals of not less than 1 week.

20 mg/day

tablets or orally disintegrating tablets 3–9 mg extended- release tablets once a day 25 mg tablets twice a day

Paliperidone (Invega)

3–6 mg/day

Plasma concentration rises to a peak approximately 24 hr after dosing

12 mg/day

Quetiapine

Lowest dose needed to maintain remission

Increase in increments of 25–50 mg two or three times a day on the second and the third day, as tolerated, to a target dosage of 500 mg daily by the fourth day (given in two or three doses/day). Further dosage adjustments, if required, should be of 25–50 mg twice a day and occur at intervals of not fewer than 2 days. Increase to 2 mg once a day on the second day and 4 mg once a day on the third day. In some patients, a slower titration may be appropriate. When dosage adjustments are necessary, further dosage increments of 1–2 mg/day at intervals of not less than 1 week are recommended. Dosage adjustments based on individual clinical status may be made at intervals of not fewer than 2 days. For acute agitation: Doses of 10 mg may be administered every 2 hours, and doses of 20 mg may be administered every 4 hours up to a maximum of 40 mg/day.

800 mg/day

(Seroquel)

Risperidone (Risperdal)

1 mg tablet and oral solution once a day 25–50 mg IM

2–6 mg once a day Starting dose: 25 mg every 2 weeks

50 mg for 2 weeks

Risperidone IM long-acting (Consta)

Start with oral

1–6 mg/day

injection every 2 weeks

risperidone for 3 weeks

Ziprasidone (Geodon)

20 mg capsules twice a day with food For acute agitation: 10–20 mg, as

20–80 mg twice a day

80 mg twice a day

Ziprasidone (IM)

Not applicable

For acute agitation: 40 mg/day, for not more than 3 consecutive days

required, up to a maximum of 40 mg/day

Note: Information taken from U.S. Prescribing Information for individual agents. a Dosage adjustments may be required in special populations. IM, intramuscular.

then regressing on monotherapy with the newer drug. Little is known about the effectiveness and safety of a strategy of com- bining one SDA with another SDA or with a DRA. Persons receiving regular injections of depot formulations of a DRA who are to switch to SDA use are given the first dose of the SDA on the day the next injection is due. Persons who developed agranulocytosis while taking clozap- ine can safely switch to olanzapine use, although initiation of

sive salivation, nausea, vomiting, and diarrhea. The risk of cholinergic rebound can be mitigated by initially augmenting risperidone, quetiapine, or ziprasidone with an anticholinergic drug, which is then tapered off slowly. Any initiation and termi- nation of SDA use should be accomplished gradually. It is wise to overlap administration of the new drug with the old drug. Of interest, some people have a more robust clinical response while taking the two agents during the transition and