Fluphenazine ROUTE

Prolixin
Oral
PO
1mg
2.5mg
5mg
10mg
5mg/ml soln
HCl
IM
Immediate
Release
2.5mg/ml
Decanoate
Long-Acting
25mg/ml

IM
SC

Haloperidol ROUTE
Haldol
Oral
PO
0.5mg, 1mg,
2mg, 5mg,
10mg, 20mg,
2mg/ml soln

USUAL DOSE (Range)

FREQUENCY
(Range)

2.5-20 mg/dy
(2-60 mg/dy)

QD - QID

CONVERSION RATIO
PO to IM
NA

2.5-10 mg/dy

Q6-8 hr

1/3-1/2 po dose = IM dose

12.5-50mg
(12.5-100mg)

Q2-3 wks
10mg po = 12.5mg IM
(1-4 wks) Round to nearest 12.5mg

USUAL DOSE (Range)

FREQUENCY
(Range)

2-40mg/dy
(1-100mg/dy)

QD-TID

CONVERSION RATIO
PO to IM
NA

OTHER INFORMATION

dose by 2.5mg/dy Q week. After symptoms controlled, slowly dose to 1-5mg/dy (dosed QD)
Onset: 1hr
Caution for doses > 20mg/dy ( risk EPS)
Cmax: 0.5hr
t: 14.7-15.3hr
Elderly: Initial dose = 1 - 2.5mg/dy
Duration of Action: 6-8hr
Oral Soln: Dilute in 2oz water, tomato or fruit juice, milk, or uncaffeinated carbonated drinks
Avoid caffeinated drinks (coffee, cola), tannics (tea), or pectinates (apple juice) 2 possible incompatibilityElimination: Hepatic to inactive metabolites
Hemodialysis: Not dialyzable
Onset: 1hr
Initial dose (usual): 1.25mg
Caution for doses > 10mg/dy
Cmax: 1.5-2hr
t: 14.7-15.3hr
Duration Action: 6-8hr
Elimination: Hepatic to inactive metabolites
Hemodialysis: Not dialyzable
CONVERTING FROM PO TO LONG-ACTING DECANOATE:
Onset: 24-72hr (4-72hr)
Method 1: 1.25 X po daily dose = equiv decanoate dose; admin Q2-3wks. Cont po daily dose X 1st few mths
Cmax: 48-96hr
Method 2: decanoate dose over 4wks & po dose over 4-8wks as follows (accelerate taper for sx of EPS):
t: 6.8-9.6dy (single dose)
15dy (14-100dy chronic administration)
ORAL
DECANOATE (Administer Q 2 weeks)
Steady State: 2mth (1.5-3mth)
ORAL DOSE (mg/dy) DOSE OVER (wks)
INITIAL DOSE (mg) TARGET DOSE (mg)
DOSE OVER (wks)
Duration Action: 2wk (1-6wk)
5
4
6.25
6.25
0
Elimination: Hepatic to inactive metabolites
10
4
6.25
12.5
4
Hemodialysis: Not dialyzable
20
8
6.25
12.5
4
30
8
6.25
25
4
40
8
6.25
25
4
Method 3: Admin equivalent decanoate dose Q2-3wks. Continue po dose X 1 wk
Method 4: Admin equivalent decanoate dose Q2-3wks. For stable pt - d/c po after 1st decanoate inj
If risk relapse/acutely psychotic pt - taper po over 1mth
After 4-6 wks, can decanoate dosing interval to Q 3 wks (drug accumulates), Z-track

OTHER INFORMATION
Elderly: Initial dose: 0.25-2mg QD-TID
dose by 0.25-0.5 mg/day Q4-7dys
Oral Soln: Dilute in 2oz water, juice (orange, apple, tomato) or soda & take immediately after mixing
Avoid skin contact with oral solution and injection - contact dermatitis can occur (rare)

Lactate
Immediate
Release
5mg/ml

IM

10-30mg/dy

Q4-8 hr

2mg po = 1mg lactate

Usual dose: 2-5mg. MR Q1hr (Note: Usually dosed Q4-8hr)

To convert IM haloperidol lactate to po haloperidol (Manufacturer rec does not follow conversion ratio info):
Total daily IM dose total daily po dose. Oral dose can be administered QD
Adjust dose based on efficacy & side effects
Administer first po dose 1224 hours after last IM dose of haloperidol lactate

Decanoate
Long-Acting
50mg/ml
100mg/ml

IM

25-300mg/dose
(Max: 450mg/dose)

Q4 wks
(3-4 wks)

10-15 X QD po dose = IM
dose
Round to nearest 50mg

Max initial dose=100mg. If > 100 mg needed, give balance in 3-7 dys if no EPS.
CONVERTING FROM PO TO LONG-ACTING DECANOATE:
Method 1: 10-15 X po daily dose = equiv decanoate dose; admin Q4wks. Cont po daily dose X 1st few mths
Method 2: Admin equivalent decanoate dose Q4wks. po dose over 3 months. Accelerate taper if SE occur
Method 3: Admin equivalent decanoate dose Q4wks. Continue po X 1 mth (or d/c w/in 7 dys of 2nd injection)
Note: decanoate dose Q3-4 months by 25% until minimum effective dose achieved (drug accumulates).
Z-track, 21G 2 needle

Chlorpromazine
ROUTE
Thorazine

USUAL DOSE (Range)

FREQUENCY
(Range)

HCl (Oral) PO
10mg, 25mg,
50mg, 100mg,
200mg,
100mg/ml Soln
HCl (Inj)
IM
25mg/ml

25-800mg/dy
(25-2000mg/dy)

BID-QID
(QD-QID)

Avoid skin contact with haloperidol lactate injection - contact dermatitis can occur (rare)

CONVERSION RATIO
PO to IM
NA

KINETICS

OTHER INFORMATION
Elderly: dose by 10-25mg/dy Q4-7dys

KINETICS
Onset: 2hr
Cmax: 3hr (2-6hr)
t: 12-38hr
Duration: 8-12hr
Elimination: Hepatic to inactive metabolites
Hemodialysis: Not dialyzable
Onset: 20-30min (10-60min)
Cmax: 30-45min (20-60min)
t: 21hr
Duration: 4-8hr
Elimination: Hepatic to inactive metabolites
Hemodialysis: Not dialyzable
Onset: 48-72hr
Cmax: 6-7dys (1-9dy)
t: 3 wk (8-21dy) Chronic administration
Steady State: 3 months (4-12 wk)
Duration of Action: 4 wk (3-4wk)
Elimination: Hepatic to inactive metabolites
Hemodialysis: Not dialyzable

KINETICS
Onset: 30-60min
Cmax: 2-4hr (1.5-8hr)
t: 16-30hr (3-40hr) Chronic administration
Elimination: Hepatic to active/ inactive metab

300-800mg/dy

Q4-6hr

1/4 po dose = IM dose

Initial dose: 25mg -50mg. MR Q1-4hr

Gradually dose until symptoms controlled (up to 400mg q4-6hr) then change to po

Hemodialysis: Not dialyzable

Onset: 15min
Cmax: 2-3hr
t: 16-30hr (3-40hr) Chronic administration
Elimination: Hepatic to active/ inactive metab

Hemodialysis: Not dialyzable

Risperidone
Risperdal

ROUTE

USUAL DOSE (Range)

FREQUENCY

CONVERSION RATIO
PO to IM

2-8mg
(0.5-16mg/dy)

QD-BID

NA

Severe renal (Cr Cl < 30ml/min) and/or hepatic impairment: 0.25-0.5mg BID
Elderly: 0.25-1mg/dy, admin QD-BID. After 2-3dys, may change to QD dosing
dose by 1-2 mg/dy Q24hr

25-50mg
(12.5-75mg)

Q2 wks

NA

Initial dose = 25mg (Liver/renal impairment or elderly: 12.5mg)

Continue po dose X 3 wks then d/c (manufacturer rec.) - Continue po dose X 4 wks then d/c (Sac County rec.)
Adjust dose: Q month (manufacturer rec.)
to 37.5mg after 4 doses of 25mg; to 50mg after 2 doses of 37.5mg (Sac County rec.)
Deep IM deltoid (1 needle-incl-alternate arms) or gluteal (2 needle-incl-alternate buttocks), Z-track not reqd
To convert patient from a different antipsychotic to Risperdal Consta
1. Administer test dose of po risperidone (to check for tolerance/hypersensitivity)
2. Titrate as above
3. Continue original po atypical antipsychotic X 3 wks then dc (manufacturer rec) -orContinue original po atypical antipsychotic X 4 wks then dc (Sac County rec)
To convert from haloperidol decanoate or fluphenazine decanoate to Risperdal Consta (Sac County rec):
1. Administer test dose of po risperidone
2. Begin Risperdal Consta when the next dose of decanoate is due
Initial dose = 25mg Risperdal Consta (no po supplementation required)
If pt stablized on high dose depot formulation, can administer > 25mg Risperdal Consta
3. If patient remains symptomatic, add po meds X 2 weeks

USUAL DOSE (Range)

FREQUENCY

6mg/dy
(3-12mg/dy)

QD

Oral
PO
0.25mg,0.5mg*
1mg*,2mg*,
3mg*, 4mg*,

OTHER INFORMATION

2mg/ml Soln
(*=avail as M-Tab)

Risperdal
Consta
12.5mg
25mg
37.5mg
50mg

IM

Paliperidone
ROUTE
Invega
InvegaSustenna

Invega
PO
Extended
Release Tablet

Risperdal
Invega
Consta Sustenna
IM
IM
(mg/2 wks) (mg/mth)
12.5
39
25
78
37.5
117
50
156
75
234

CONVERSION RATIO
PO to IM
NA
Risperdal
Tablets
(mg/dy)
2mg
4mg
6mg

Invega
Tablets
(mg/dy)
3mg
6mg
9-12mg

Per mfr: Doses not necessarily

equivalent

Invega
Sustenna
Long-Acting
39mg
78mg
117mg
156mg
234mg

IM

Initiation
(Loading Doses)
Dy 1: 234mg - deltoid
Dy 8 ( 4 dy): 156mg deltoid
2nd Initiation Dose Missed:
Time Since
Day 1 Initiation
Dose

Dosing
Schedule

2 Injections:
1st -156mg ASAP, deltoid
2nd-117mg 5 wks after Dy 1
<4 weeks
dose, deltoid or gluteal
Then maint dose (39-234mg)
IM Q4wk, deltoid or gluteal
2 Injections:
1st -156mg ASAP, deltoid
4 - 7 weeks 2nd-156mg in 1 week, deltoid
Then maint. dose (39-234mg)
IM Q4wk, deltoid or gluteal
Re-initiate w/ recommended
>7 weeks initiation regimen

Maintenance
Qmth(7dy):117 mg (39-234mg)
Deltoid or gluteal muscle

Q mth

Invega ER
Tablets PO
(mg/dy)

Invega
Sustenna IM
(mg/mth)

3
6
9
12

39 - 78
117
156
234

Risperdal
Consta IM
(mg/q2 wks)

Invega
Sustenna IM
(mg/mth)

12.5
25
37.5
50
75

39
78
117
156
234

OTHER INFORMATION
Major active metabolite of risperidone
Usual initial dose = 6mg QAM. dose by 3mg/dy at intervals of greater than 5 days. Maximum dose = 12mg/dy
Renal impairment:
Mild (50ml/min Cr Cl < 80ml/min): Initial dose = 3 mg/day. Max = 6mg/dy
Moderate to severe (10 ml/min Cr Cl <50ml/min): Initial dose = 1.5 mg/day. Max = 3mg/day
Cr Cl < 10ml/min: Not recommended
Hepatic Impairment: Mild to moderate: No dose adjustment
Severe: Not studied
Elderly: Adjust dose based on renal function
Administer paliperidone (po) or risperidone (po or IM) prior to initiating tx to assess tolerance/hypersensitivity
Discontinue po antipsychotic when Sustenna tx initiated - no oral supplementation required
Adjust maintenance dose Q month
Missed Maintenance Dose
4-6 Weeks since last dose: Admin same dose pt previously stabilized on. Resume Q monthly inj
>6 Weeks to 6 Months since last dose:
1) Administer same dose patient previously stabilized on via deltoid injection
2) Administer same dose 1 week later via deltoid injection
3) Resume monthly injections. Administer in either deltoid or gluteal muscle
NOTE: If patient stabilized on 234 mg, first two injections should be 156 mg
>6 Months since last dose: Treat as new start Invega Sustenna
Renal Impairment: Mild (50 ml/min Cr Cl < 80ml/min): Day 1: 156 mg; Day 8: 117mg (both admin in deltoid muscle)
Maintenance: 78 mg IM Qmth in deltoid or gluteal muscle
Moderate to severe (Cr Cl < 50ml/min): Not recommended
Hepatic Impairment: Mild to moderate: No dose adjustment
Severe: Not studied
Elderly: Adjust dose based on renal function
To switch pt currently @ steady state on different long-acting inj antipsychotic to SUSTENNA:
Give test dose po paliperidone or risperidone. Then start Invega Sustenna @ desired maint. dose at next
scheduled inj date (no initiation dosing regimen or po supplementation reqd). Continue SUSTENNA Q mth.
Z-track NOT reqd

TRIAL OF PO ANTIPSYCHOTIC BEFORE INITIATING LONG-ACTING THERAPY REQUIRED TO ASSESS PATIENT TOLERANCE/HYPERSENSITIVITY

2015

KINETICS
Cmax: w/in 1 hr risperidone/3-17hrs metab
t: 20hr (avg of risperidone+active metab)
3-20hr risperidone / 21-30hr metab
Steady State: 1-5dy risperidone/5-6dy metab
Elimination: Hepatic to active metabolites
Renal-Risperidone+metabolite
Hemodialysis: No data
Onset: 3 weeks after initial injection
Cmax: 4-6wk
Clinical effects of each dose seen
3wks after injection
t: 3-6dys
Steady State: 8 wks after 1st inj
Duration of Action: 2 wk
Elimination: Hepatic to active metabolites
Renal-Risperidone+metabolite
Hemodialysis: No data

KINETICS
Cmax: 24 hr
t: 23hr
Steady State: 4-5dys
Elimination: Renal
Hemodialysis: No data

Cmax: 13dy
Drug release starts as early as day 1 &
continues for up to 126 days.
Cmax: deltoid 28% > gluteal injection
t: 25-49dy
Elimination: Renal
Hemodialysis: No data