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For Pregnant Women, Suggest:

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ATC Code (read only) Comments/Instructions 1. For first episode, positive symptoms (delusions, hallucinations), use high-potency conventional antipsychotic trifluoperazine 4-30 mg/day, divided bid $0.01-0.05/day or fluphenazine 2.5-15 mg/day, divided tid to qid; or single dose hs $0.08-0.49/day or haloperidol 3-15 mg/day, divided bid to tid $0.37-0.60/day 2. For first episode, negative symptoms (withdrawal, flattening of affect, poverty of speech), or acute exacerbation off medication i. High-potency conventional antipsychotic trifluoperazine 4-30 mg/day, divided bid $0.01-0.05/day or fluphenazine 2.5-15 mg/day, divided tid to qid or single dose hs $0.08-0.49/day or haloperidol 3-15 mg/day, divided bid to tid $0.37-0.60/day or ii. risperidone 1 mg, bid; increase by 2 mg/day to 4 mg, bid $1.92-7.67/day or iii. olanzaprine 5-10 mg, once daily initially; increase to 10-15 mg, once daily after a few days $3.38-10.13/day 3. For severe anxiety, irritability or agitaiton as an adjunct to the antipsychotics add benzodiazepines i. Long-acting diazepam 5-40 mg/day, in divided doses tid to qid $0.01-0.05/day OR ii. Intermediate-acting lorazepam 0.5-2.0 mg, tid $0.14-0.23/day or 0.5-2.0 mg sublingual, tid $0.23-0.51/day Second-line therapies: 1. For first episode, positive symptoms i. risperidone 1 mg, bid; increase by 2 mg/day to 4 mg, bid $1.92-7.67/day or ii. olanzaprine 5-10 mg, once daily initially; increase to 10-15 mg, once daily after a few days $3.38-10.13/day OR iii. Low-potency conventional antipsychotics chlorpromazine 50-400 mg/day, divided bid to qid $0.03-0.35/day or 50-400 mg, hs $0.02-0.09/day or thioridazine 50-400 mg/day, divided bid to qid $0.05-0.39/day or methotrimeprazine 50-300 mg/day, divided bid to tid $0.17-1.03/day OR iv. Intermediate-potency conventional antipsychotics perphenazine 8-24 mg/day, divided tid $0.02-0.06/day or prochlorperazine 20-60 mg/day, divided bid to qid $0.26-0.77/day or loxapine 10-60 mg/day, divided bid to qid $0.36-2.14/day 2. For first episode, negative symptoms or acute exacerbation off medication i. Low-potency conventional antipsychotics chlorpromazine 50-400 mg/day, divided bid to qid $0.03-0.05/day or 50-400 mg, hs $0.02-0.09/day or thioridazine 50-400 mg/day, divided bid to qid $0.05-0.39/day or methotrimeprazine 50-300 mg/day, divided bid to tid $0.17-1.03/day OR ii. Intermediate-potency conventional antipsychotics perphenazine 8-24 mg/day ,divided tid $0.02-0.06/day or prochlorperazine 20-60 mg/day, divided bid to qid $0.26-0.77/day or loxapine 10-60 mg/day, divided bid to qid $0.36-2.14/day 3. For patients with predominantly positive or negative symptoms unresponsive to other agents clozapine 200-400 mg/day, divided tid $8.10-16.20/day 4. Where compliance is a problem, depot formulations fluphenazine decanoate 12.5-37.5 mg IM, every 3 weeks $3.48-10.45/3 weeks or fluphenazine enanthate 12.5-25 mg IM, every 2 weeks $4.36-8.71/2 weeks or flupenthixol decanoate 20-40 mg IM, every 2 weeks $6.75-13.50/2 weeks 5. For extrapyramidal or Parkinsonian effects, add anticholinergics trihexyphenidyl 2-5 mg, up to tid $0.01-0.03/day or benztropine mesylate 1-2 mg, up to tid $0.03-0.05/day or procyclidine 2.5-5 mg, up to tid $0.03-0.08/day Additional instructions and notes -Antipsychotic drugs are classified as "low" and "high" potency. Low-potency drugs tend to be considerably more sedating and cause more postural hypotension, whereas high-potency drugs have more extrapyramidal effects. -Many clinicians think that agitated patients respond best to the more-sedating drugs and that withdrawn patients respond better to less-sedating drugs. -If patients do not improve on the first antipsychotic drug after 2-3 weeks of therapy, check compliance. If compliance is good, then switch to a different class of antipsychotic drug. -In general, drugs produce much less improvement in negative symptoms (e.g., withdrawal, flattening of affect, poverty of speech) than in positive symptoms (e.g., delusions, hallucinations). -The risk of tardive dyskinesia is low with clozapine, olanzapine and possibly risperidone. -Patients taking clozapine need a white blood cell count weekly for 6 months and then every 2 weeks until 4 weeks after the therapy is discontinued. -After an acute episode, patients relapse at a rate of about 8-12% per month without medication and at half that rate with medication. -Adding a benzodiazepine, where appropriate, often allows a reduction in the dose of antipsychotic medication. Duration of action of benzodiazepines, including the effect of active metabolites: long acting >24 h, intermediate acting 12-24 h, short acting <12 h. -Benzodiazepines are variously indicated for anxiety, panic attacks, seizures and insomnia, but there is no evidence to suggest superior efficacy of one or more benzodiazepines for any of these conditions. Choice should be based on pharmacokinetics, side-effect profiles and knowledge of the individual patient (e.g., expected compliance, potential for abuse, etc.). Reference

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1. For first episode, positive symptoms (delusions, hallucinations), use high-potency conventional antipsychotic

trifluoperazine
4-30 mg/day, divided bid
$0.01-0.05/day

or fluphenazine
2.5-15 mg/day, divided tid to qid; or single dose hs
$0.08-0.49/day

or haloperidol
3-15 mg/day, divided bid to tid
$0.37-0.60/day

2. For first episode, negative symptoms (withdrawal, flattening of affect, poverty of speech), or acute exacerbation off medication

i. High-potency conventional antipsychotic

trifluoperazine
4-30 mg/day, divided bid
$0.01-0.05/day

or fluphenazine
2.5-15 mg/day, divided tid to qid or single dose hs
$0.08-0.49/day

or haloperidol
3-15 mg/day, divided bid to tid
$0.37-0.60/day

or ii. risperidone
1 mg, bid; increase by 2 mg/day to 4 mg, bid
$1.92-7.67/day

or iii. olanzaprine
5-10 mg, once daily initially; increase to 10-15 mg, once daily after a few days
$3.38-10.13/day

3. For severe anxiety, irritability or agitaiton as an adjunct to the antipsychotics add benzodiazepines

i. Long-acting

diazepam
5-40 mg/day, in divided doses tid to qid
$0.01-0.05/day

OR

ii. Intermediate-acting

lorazepam
0.5-2.0 mg, tid
$0.14-0.23/day

or
0.5-2.0 mg sublingual, tid
$0.23-0.51/day

Second-line therapies:

1. For first episode, positive symptoms

i. risperidone
1 mg, bid; increase by 2 mg/day to 4 mg, bid
$1.92-7.67/day

or ii. olanzaprine
5-10 mg, once daily initially; increase to 10-15 mg, once daily after a few days
$3.38-10.13/day

OR

iii. Low-potency conventional antipsychotics

chlorpromazine
50-400 mg/day, divided bid to qid
$0.03-0.35/day

or
50-400 mg, hs
$0.02-0.09/day

or thioridazine
50-400 mg/day, divided bid to qid
$0.05-0.39/day

or methotrimeprazine
50-300 mg/day, divided bid to tid
$0.17-1.03/day

OR

iv. Intermediate-potency conventional antipsychotics

perphenazine
8-24 mg/day, divided tid
$0.02-0.06/day

or prochlorperazine
20-60 mg/day, divided bid to qid
$0.26-0.77/day

or loxapine
10-60 mg/day, divided bid to qid
$0.36-2.14/day

2. For first episode, negative symptoms or acute exacerbation off medication

i. Low-potency conventional antipsychotics

chlorpromazine
50-400 mg/day, divided bid to qid
$0.03-0.05/day

or
50-400 mg, hs
$0.02-0.09/day

or thioridazine
50-400 mg/day, divided bid to qid
$0.05-0.39/day

or methotrimeprazine
50-300 mg/day, divided bid to tid
$0.17-1.03/day

OR

ii. Intermediate-potency conventional antipsychotics

perphenazine
8-24 mg/day ,divided tid
$0.02-0.06/day

or prochlorperazine
20-60 mg/day, divided bid to qid
$0.26-0.77/day

or loxapine
10-60 mg/day, divided bid to qid
$0.36-2.14/day

3. For patients with predominantly positive or negative symptoms unresponsive to other agents

clozapine
200-400 mg/day, divided tid
$8.10-16.20/day

4. Where compliance is a problem, depot formulations

fluphenazine decanoate
12.5-37.5 mg IM, every 3 weeks
$3.48-10.45/3 weeks

or fluphenazine enanthate
12.5-25 mg IM, every 2 weeks
$4.36-8.71/2 weeks

or flupenthixol decanoate
20-40 mg IM, every 2 weeks
$6.75-13.50/2 weeks

5. For extrapyramidal or Parkinsonian effects, add anticholinergics

trihexyphenidyl
2-5 mg, up to tid
$0.01-0.03/day

or benztropine mesylate
1-2 mg, up to tid
$0.03-0.05/day

or procyclidine
2.5-5 mg, up to tid
$0.03-0.08/day

Additional instructions and notes

-Antipsychotic drugs are classified as "low" and "high" potency. Low-potency drugs tend to be considerably more sedating and cause more postural hypotension, whereas high-potency drugs have more extrapyramidal effects.

-Many clinicians think that agitated patients respond best to the more-sedating drugs and that withdrawn patients respond better to less-sedating drugs.

-If patients do not improve on the first antipsychotic drug after 2-3 weeks of therapy, check compliance. If compliance is good, then switch to a different class of antipsychotic drug.

-In general, drugs produce much less improvement in negative symptoms (e.g., withdrawal, flattening of affect, poverty of speech) than in positive symptoms (e.g., delusions, hallucinations).

-The risk of tardive dyskinesia is low with clozapine, olanzapine and possibly risperidone.

-Patients taking clozapine need a white blood cell count weekly for 6 months and then every 2 weeks until 4 weeks after the therapy is discontinued.

-After an acute episode, patients relapse at a rate of about 8-12% per month without medication and at half that rate with medication.

-Adding a benzodiazepine, where appropriate, often allows a reduction in the dose of antipsychotic medication. Duration of action of benzodiazepines, including the effect of active metabolites: long acting >24 h, intermediate acting 12-24 h, short acting <12 h.

-Benzodiazepines are variously indicated for anxiety, panic attacks, seizures and insomnia, but there is no evidence to suggest superior efficacy of one or more benzodiazepines for any of these conditions. Choice should be based on pharmacokinetics, side-effect profiles and knowledge of the individual patient (e.g., expected compliance, potential for abuse, etc.).

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