Version July 2025
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of approximately 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis.
Dosage guidance:
Safety: IV haloperidol administration is associated with dose-dependent QTc prolongation at individual doses >2 mg. Avoid single doses ≥2 mg IV in patients with baseline QTc >450 msec or with risk factors for QTc prolongation. Some experts recommend continuous cardiac monitoring during administration and for 2 to 3 hours after administration. In patients with QTc >500 msec or QTc increase >60 msec on treatment, consider switching to a different route or antipsychotic, or lowering IV haloperidol dose (Ref). Antipsychotics are not indicated for use in catatonia and may worsen psychosis and increase the risk for neuroleptic malignant syndrome in patients with catatonia (Ref).
Clinical considerations: For the treatment of psychiatric disorders, consult a psychiatry specialist for all management decisions; select antipsychotic carefully based on patient preference, clinical characteristics, history, comorbidities, and medication adverse effects profile (Ref). For all indications with short-acting IM/IV haloperidol dosing, concomitant IM/IV antiparkinsonism medications (eg, benztropine, diphenhydramine) may be useful for preventing acute dystonic reactions (Ref).
Agitation/Aggression (severe, acute) associated with psychiatric disorders (eg, schizophrenia) (labeled use), substance intoxication, or other organic causes (off-label use): Note: Antipsychotics are appropriate when psychosis is suspected to be the primary cause of agitation/aggression (Ref). Avoid in suspected or confirmed intoxications with anticholinergic substances; other agents are used preferentially in some intoxications (eg, stimulants) or alcohol withdrawal. Depending on presentation, may combine with a benzodiazepine (Ref); once symptoms stabilize, transition to oral maintenance therapy. Concomitant IM or IV antiparkinsonism medications (eg, benztropine, diphenhydramine) may be useful for preventing acute dystonic reactions due to short-acting IM haloperidol (Ref).
IV (off-label route) and IM (short-acting injectable [lactate]): 2 to 10 mg; repeat dose every ≥15 minutes until acute symptoms are controlled; once acute symptoms are controlled, may repeat every 0.5 to 6 hours as needed; up to 30 mg/day (Ref).
Oral: 2 to 10 mg; repeat dose every 6 hours as needed; up to 30 mg/day. A lower initial dose of 0.5 to 1 mg may be sufficient for some patients (Ref).
Bipolar disorder:
Acute mania, episodes with mixed features and acute hypomania (either as monotherapy or as adjunctive therapy) (off-label use): Note: Haloperidol may worsen depressive symptoms. It is not recommended for the treatment of acute bipolar major depression or for maintenance in bipolar disorder (Ref).
Oral: Initial: 2 to 15 mg/day or 0.2 mg/kg/day (up to 15 mg/day), in 1 or 2 divided doses. May increase dose based on response and tolerability in increments of ≤5 mg as frequently as every 2 days up to 30 mg/day (Ref).
Delirium, hyperactive (treatment): Note: Nonpharmacologic interventions and treatment of underlying conditions are initial steps to prevent and manage delirium. Antipsychotics may be used as short-term adjunctive treatment if distressing symptoms (eg, agitation, anxiety, combative behavior) are present (Ref). Reassess daily for continued need; consider discontinuation and/or taper as symptoms resolve, especially at transitions of care to prevent unnecessary continuation of therapy (Ref).
ICU (off-label use): IV (off-label route), IM (short-acting injectable [lactate]): Initial range: 0.5 to 20 mg depending on degree of agitation (mild: 0.5 to 2.5 mg; moderate: 2 to 5 mg; severe: 10 to 20 mg); if inadequate response, may repeat or increase bolus dose every 15 to 30 minutes until calm achieved, then administer a maintenance dose (~25% of total loading dose needed to achieve calm) every 6 to 12 hours if needed (Ref). Note: Continuous infusions have been used for refractory symptoms; regimens vary. One regimen includes an optional loading dose of 2.5 mg, followed by 0.5 to 2 mg/hour (Ref).
Non-ICU (off-label use): IM, IV (off-label route) (short-acting injectable [lactate]), Oral: Initial: 0.5 to 1 mg; if needed, may repeat every 30 minutes until calm. Maximum 5 mg/day (Ref).
Nausea and vomiting in advanced or terminal illness (palliative care) (alternative agent) (off-label use): Note: Identify and treat potentially reversible causes; used in conjunction with other agents/treatments in bowel obstruction-associated symptoms (Ref).
IV, SUBQ (off-label routes) (short-acting injectable [lactate]), Oral: 0.5 to 2 mg every 6 to 8 hours; for nausea associated with bowel obstruction, may titrate up to 20 mg/day IV in divided doses if needed (Ref).
Continuous SUBQ infusion (off-label route) (short-acting injectable [lactate]): Typical range for initial treatment: 1 to 5 mg per 24 hours (Ref).
Postoperative nausea and vomiting, prevention, moderate- to high-risk patients (alternative agent) (off-label use): Note: In general, combined with one or more other prophylactic interventions.
IV (off-label route) (short-acting injectable [lactate]): 0.5 to 2 mg as a single dose after induction of anesthesia or at the end of surgery (Ref).
Postpartum psychosis (alternative agent) (off-label use):
Note: Use for acute stabilization of agitation and aggression in patients who cannot take oral medications (Ref).
IM (short-acting injectable [lactate]):
Mild agitation: 0.5 to 2 mg once. May repeat every 30 minutes.
Moderate agitation: 2 to 5 mg once. May repeat every 30 minutes.
Severe agitation: 10 mg once. May repeat every 30 minutes (Ref).
Schizophrenia:
Note: Some experts prefer second generation antipsychotics for initial treatment due to the potential for fewer extrapyramidal symptoms (Ref); data suggesting differences in efficacy are lacking (Ref).
Oral: Initial: 1 to 10 mg/day in 1 to 3 divided doses, or if this is a first episode of psychosis, consider initiating at a reduced dose (eg, 0.5 to 5 mg/day in 1 to 3 divided doses) because these patients will be more sensitive to adverse effects. May increase daily dose based on response and tolerability in increments of 1 to 10 mg every 3 to 7 days; monitor for akathisia and parkinsonism during titration. Usual maintenance dose range: 2 to 20 mg/day in divided doses; use lowest effective maintenance dose. Although the manufacturer's labeling includes oral doses of up to 100 mg/day, doses >30 mg/day are generally not recommended due to tolerability (eg, extrapyramidal symptoms) (Ref).
IM (decanoate ER long-acting injectable suspension):
Regimen with overlap of oral haloperidol:
Note: Establish tolerability with short-acting haloperidol prior to initiating IM decanoate injection.
Initial: IM: A single dose of 10 to 15 times the daily oral dose. If the initial dose conversion requires >100 mg ER injection, administer in 2 divided injections; do not exceed 100 mg with the first dose, and administer the balance 3 to 7 days later. If the initial dose conversion requires ≥400 mg ER injection, administer in a series of 3 divided injections administered every 3 to 7 days. Maximum total initial dose: 450 mg. Initiate maintenance dosing ≤4 weeks after total initial dose is completed, based on response and tolerability (Ref).
Oral overlap: Oral: Starting 1 to 2 months after completion of the initial decanoate dose, gradually decrease oral dose (eg, by 25% each week) over a 1-month period. Adjust oral dose and rate of oral dose tapering based on clinical response and tolerability (Ref).
Maintenance dose: IM: Adjust dose based on response and tolerability; usual maintenance dose is 10 to 15 times the previous daily oral dose (eg, 50 to 200 mg) administered at ≤4-week intervals. Maximum dose: 450 mg every 4 weeks.
Regimen without overlap of oral haloperidol:
Note: Establish tolerability with short-acting haloperidol prior to initiating IM decanoate injection.
Initial loading dose: IM: 20 times the daily oral dose. If the initial dose conversion requires >100 mg ER injection, administer in 2 divided injections; do not exceed 100 mg with the first dose, and administer the balance 3 to 7 days later. If the initial dose conversion requires ≥400 mg ER injection, administer in a series of 3 divided injections administered every 3 to 7 days. Maximum total initial dose: 450 mg. Discontinue previous oral haloperidol and initiate maintenance IM dosing ≤4 weeks after total initial dose is completed, based on response and tolerability (Ref).
Oral overlap: Oral haloperidol is typically discontinued after the initial long-acting injectable dose with this regimen (Ref).
Maintenance dose: IM: May reduce dose during months 2 and 3 based on response and tolerability (eg, by ~25% each month), then continue to adjust as needed (Ref). Usual maintenance dose is 10 to 15 times the previous daily oral dose (eg, 50 to 200 mg) administered at ≤4-week intervals (Ref). Maximum dose: 450 mg every 4 weeks.
Tourette syndrome, management of tics (alternative agent): Oral: Initial: 1 to 2 mg/day in 1 to 3 divided doses; may increase dose based on response and tolerability in increments of 0.5 to 2 mg every 2 to 3 days up to 12 mg/day. Note: Although manufacturer's labeling includes a maximum dose of up to 100 mg/day, doses ≥12 mg/day are not recommended (Ref).
Dosing conversion:
IM (short-acting injectable [lactate]) to oral haloperidol: Use the total IM (as short-acting injectable [lactate]) dose administered in the preceding 24 hours as an initial approximation of the total daily dose requirement for the oral formulation. Initiate the first oral dose within 12 to 24 hours of the last IM dose of short-acting injectable (lactate). Adjust dose based on response and tolerability. Note: Bioavailability of oral administration is about 60% relative to short-acting injectable lactate; dose adjustment may be needed when switching from short-acting injectable (lactate) to oral (Ref).
Oral to long-acting injectable (decanoate): See "Schizophrenia" dosing.
Discontinuation of therapy:
Oral: In the treatment of chronic psychiatric disease, switching therapy rather than discontinuation is generally advised if side effects are intolerable or treatment is not effective. If patient insists on stopping treatment, gradual dose reduction (ie, over several weeks to months) is advised to detect a re-emergence of symptoms and to avoid withdrawal reactions (eg, agitation, alternating feelings of warmth and chill, anxiety, diaphoresis, dyskinesias, GI symptoms, insomnia, irritability, myalgia, paresthesia, psychosis, restlessness, rhinorrhea, tremor, vertigo) unless discontinuation is due to significant adverse effects. Monitor closely to allow for detection of prodromal symptoms of disease recurrence (Ref).
Long-acting injectable: Switching to other treatments is generally advised if side effects are intolerable or treatment is not effective. However, if a patient insists on stopping treatment, gradual dose reduction to avoid withdrawal reactions is generally not needed with long-acting injectable antipsychotics. The risk of withdrawal symptoms from discontinuation of long-acting injectables is low because the rate of drug elimination is slow. Monitor closely to allow for detection of prodromal symptoms of disease recurrence (Ref).
Switching antipsychotics: An optimal universal strategy for switching antipsychotic drugs has not been established. Strategies include cross-titration (gradually discontinuing the first antipsychotic while gradually increasing the new antipsychotic) and abrupt change (abruptly discontinuing the first antipsychotic and either increasing the new antipsychotic gradually or starting it at a treatment dose). In patients with schizophrenia at high risk of relapse, the current medication may be maintained at full dose as the new medication is increased (ie, overlap); once the new medication is at therapeutic dose, the first medication is gradually decreased and discontinued over 1 to 2 weeks (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function: Mild to severe impairment: No dosage adjustment necessary (~1% of drug eliminated in urine) (Ref).
Hemodialysis, intermittent (thrice weekly): Unlikely to be dialyzed (large volume of distribution): No supplemental dose or dosage adjustment necessary (Ref); use with caution.
Peritoneal dialysis: Unlikely to be dialyzed (large volume of distribution): No dosage adjustment necessary (Ref); use with caution.
CRRT: Unlikely to be dialyzed (large volume of distribution): No dosage adjustment necessary (Ref).
PIRRT (eg, sustained low-efficiency diafiltration): Unlikely to be dialyzed (large volume of distribution): No dosage adjustment necessary (Ref).
The liver dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Matt Harris, PharmD, MHS, BCPS, FAST, FCCP; Jeong Park, PharmD, MS, BCTXP, FCCP, FAST; Arun Jesudian, MD; Sasan Sakiani, MD.
Note: Haloperidol is highly protein bound and undergoes extensive liver metabolism (Ref). The impact of liver impairment on the pharmacokinetics of haloperidol has not been studied, but the elimination half-life is expected to be prolonged and may increase risk of exposure-related toxicity (eg, QT prolongation) (Ref).
Liver impairment prior to treatment initiation: Note: Haloperidol should be used with caution for indications that require scheduled maintenance dosing (eg, schizophrenia, bipolar disorder) in patients with cirrhosis due to concern for accumulation and risk of dose-dependent adverse effects; consider other agents with more favorable adverse effect profiles (eg, second generation antipsychotics) (Ref).
Initial or dose titration in patients with preexisting liver cirrhosis:
Child-Turcotte-Pugh class A and B: IM, IV, oral: Initial: Administer ≤50% of the usual indication-specific recommended dose; gradually titrate based on response and tolerability to the lowest effective dose and frequency not to exceed the indication-specific maximum recommended dose (Ref).
Child-Turcotte-Pugh class C: IM, IV, oral: Initial: Administer ≤25% of the usual indication-specific recommended dose; gradually titrate based on response and tolerability to the lowest effective dose and frequency; consider intermittent dosing if possible based on indication (Ref).
Note: Avoid for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic therapies have failed and patient may harm self or others. If used, consider deprescribing attempts to assess continued need and/or lowest effective dose. Of note, use in certain indications (eg, schizophrenia, bipolar disorder) may be appropriate (Ref). For the treatment of psychiatric disorders, consult a psychiatry specialist for all management decisions (Ref).
Indication-specific dosing:
Agitation/Aggression (severe, acute) associated with psychiatric disorders (eg, schizophrenia) (labeled use), substance intoxication, or other organic causes (off-label uses):
IM, IV, oral: Refer to adult dosing for full details. Consider dosages in the lower initial range of recommended adult dosing (eg, 0.5 to 1 mg) (Ref).
Delirium, hyperactive (treatment):
IM, IV: Refer to adult dosing for full details. Consider dosages in the lower initial range of recommended adult dosing (eg, 0.5 to 1 mg) (Ref).
All other indications: Refer to adult dosing; doses in the lower range of recommended adult dosing are generally sufficient. Titrate dosage slowly and monitor carefully.
(For additional information see "Haloperidol: Pediatric drug information")
Dosage guidance:
Dosing: Individualize dosing based on patient response. Gradually decrease dose to the lowest effective maintenance dosage once a satisfactory therapeutic response is obtained. Dosing presented as fixed (mg) dosing and weight-based (mg/kg) dosing; use caution when prescribing and dispensing.
Agitation (palliative care): Limited data available: Children ≥3 years and Adolescents: Oral: 0.01 mg/kg/dose 3 times daily as needed; to manage new-onset acute episode: 0.025 to 0.05 mg/kg once then may repeat 0.025 mg/kg/dose in one hour as needed (Ref).
Agitation, acute: Limited data available:
Oral: Recommended for acute agitation in patients with suspected ethanol, benzodiazepine, or unknown intoxication, a known psychiatric disorder, hallucinations, or unknown etiology (Ref).
Weight-directed: Children and Adolescents: Oral: 0.025 to 0.075 mg/kg/dose; may repeat dose every 1 to 2 hours; not to exceed maximum daily dose: Patients ≤40 kg: 6 mg/day; patients >40 kg: 15 mg/day. In adults, usual total dose required is 10 to 20 mg (Ref).
Fixed dose: Oral: Children: 0.5 to 2 mg; Adolescents: 2 to 5 mg; may repeat dose every 1 to 2 hours; not to exceed maximum daily dose: Patients ≤40 kg: 6 mg/day; patients >40 kg: 15 mg/day. In adults, usual total dose required is 10 to 20 mg (Ref).
Parenteral: Recommended for acute agitation in patients with psychosis or mania, or suspected ethanol, benzodiazepine, or unknown intoxication, a known psychiatric disorder, hallucinations, or unknown etiology (Ref); if extrapyramidal symptoms (EPS) are a concern, consider concomitant diphenhydramine.
Weight-directed: Children and Adolescents: IM (lactate, immediate release): 0.025 to 0.075 mg/kg/dose; may repeat dose every 20 to 30 minutes; not to exceed maximum daily dose: Patients ≤40 kg: 6 mg/day; patients >40 kg: 15 mg/day. In adults, usual total dose required is 10 to 20 mg (Ref).
Fixed dose: Children and Adolescents: IM (lactate, immediate release): Children: 0.5 to 2 mg; Adolescents: 2 to 5 mg; may repeat dose every 20 to 30 minutes; not to exceed maximum daily dose: Patients ≤40 kg: 6 mg/day; patients >40 kg: 15 mg/day. In adults, usual total dose required is 10 to 20 mg (Ref).
Behavior disorders, nonpsychotic:
Note: For treatment of bipolar disorder (acute mania, nonpsychotic), haloperidol is not considered first line; initially second-generation antipsychotics and mood stabilizers are preferred (Ref). For management of disruptive behavior disorders without psychosis, therapy typically initiated with stimulants; haloperidol (first-generation antipsychotics) is no longer routinely used as initial therapy but may be necessary in refractory or complex cases (Ref).
Children ≥3 years and Adolescents: Limited data available in ages >12 years: Oral: Initial: 0.5 mg/day in 2 to 3 divided doses; may increase total daily dose by 0.5 mg every 5 to 7 days to usual maintenance range of 0.05 to 0.075 mg/kg/day in 2 to 3 divided doses; in the management of disruptive behavior disorders, a range of 0.5 to 10 mg/day has been suggested; maximum daily dose for patients 3 to 12 years of age and ≤40 kg: 6 mg/day in divided doses (children with severe, nonpsychotic disturbance did not show improvement with doses >6 mg/day); a maximum daily dose of 15 mg/day in divided doses has been suggested in adolescents with psychosis (Ref).
Delirium, critical care setting: Limited data available; optimal dose not established:
Note: Antipsychotics may be used as short-term adjunctive treatment; reassess frequently for continued need and consider taper/discontinuation as symptoms resolve (Ref). The administration of IV haloperidol is associated with QT prolongation and torsades de pointes; in adults without concomitant risk factors, this effect is dose dependent and was reported with cumulative IV doses ≥2 mg; in all patients, increased monitoring is necessary at baseline and during administration (Ref); ensure appropriate monitoring including extrapyramidal symptoms (EPS) effects.
Infants ≥3 months, Children, and Adolescents: IV (lactate, immediate release): Note: Reported experience in infants is very limited and suggests that lower doses may be required:
Loading dose: Note: Dosing is presented as a fixed dose (not a weight-based dose).
Weight 3.5 to <10 kg: IV: 0.05 mg (fixed dose) infused slowly over 30 to 45 minutes; may repeat twice for a maximum of 3 total doses (Ref).
Weight ≥10 kg: IV: 0.15 to 0.25 mg (fixed dose) infused slowly over 30 to 45 minutes; may repeat twice for a maximum of 3 total doses (Ref).
Maintenance dose: Note: Dosing is presented as weight-based dosing (ie, mg/kg/day) administered in divided doses:
Note: Use lowest effective dose, evaluate delirium symptoms daily, optimize nonpharmacologic treatments and discontinue/titrate therapy after clinical improvement and resolution (Ref):
Weight 3.5 to <10 kg: IV: Initial: 0.01 to 0.05 mg/kg/day in divided doses every 6 to 24 hours; may increase dose based on clinical response; higher doses have been associated with an increased incidence of EPS and sedation (Ref).
Weight ≥10 kg: IV: Initial: 0.05 to 0.5 mg/kg/day in divided doses every 6 to 24 hours; may increase dose based on clinical response; higher doses have been associated with an increased incidence of EPS and sedation; a maximum single pediatric dose is not defined in the literature; in adults, single doses of 10 mg are reserved for severe cases of delirium and up to 20 mg in some cases (Ref).
Psychotic disorders: Note: Not generally used as initial therapy for management of schizophrenia in pediatric patients; second-generation (atypical) antipsychotics typically preferred first line (Ref).
Children ≥3 years and Adolescents: Limited data available in ages >12 years: Oral: Initial: 0.5 mg/day in 2 to 3 divided doses; increase total daily dose by 0.5 mg every 5 to 7 days to usual maintenance range of 0.05 to 0.15 mg/kg/day in 2 to 3 divided doses; in pediatric schizophrenia efficacy trials (reported mean ages: 9 to 16 years), a mean dose range of 8 to 10 mg/day was reported; higher doses may be necessary in severe or refractory cases; maximum dose not established in children; in adolescents, maximum daily dose: 15 mg/day (Ref).
Tourette syndrome, tic disorder: Note: Compared to placebo, haloperidol is probably more likely than placebo to reduce tic severity; a higher risk of drug-induced movement disorders (compared to placebo) was observed in Tourette syndrome/tic trials with haloperidol; may be considered when treatment benefits outweigh risks (Ref).
Children ≥3 years and Adolescents: Oral: Initial: 0.25 to 0.5 mg/day in 2 to 3 divided doses; increase daily dose by 0.25 to 0.5 mg every 5 to 7 days to usual daily dose maintenance range of 1 to 4 mg/day in 2 to 3 divided doses has been reported (weight-directed maintenance per the manufacturer: 0.05 to 0.075 mg/kg/day in 2 to 3 divided doses); maximum daily dose: 15 mg/day; however, children with severe, nonpsychotic disturbance did not show improvement with doses >6 mg/day (Ref).
Discontinuation of psychosis therapy: Children and Adolescents: The manufacturer and American Academy of Child and Adolescent Psychiatry (AACAP), American Psychiatric Association (APA), Canadian Psychiatric Association (CPA), National Institute for Health and Care Excellence (NICE), and World Federation of Societies of Biological Psychiatry (WFSBP) guidelines recommend gradually tapering antipsychotics to avoid withdrawal symptoms and minimize the risk of relapse (Ref); risk for withdrawal symptoms may be highest with highly anticholinergic or dopaminergic antipsychotics (Ref). When stopping antipsychotic therapy in patients with schizophrenia, the CPA guidelines recommend a gradual taper over 6 to 24 months and the APA guidelines recommend reducing the dose by 10% each month (Ref). Continuing antiparkinsonism agents for a brief period after discontinuation may prevent withdrawal symptoms (Ref). When switching antipsychotics, three strategies have been suggested: Cross-titration (gradually discontinuing the first antipsychotic while gradually increasing the new antipsychotic), overlap and taper (maintaining the dose of the first antipsychotic while gradually increasing the new antipsychotic, then tapering the first antipsychotic), and abrupt change (abruptly discontinuing the first antipsychotic and either increasing the new antipsychotic gradually or starting it at a treatment dose). Evidence supporting ideal switch strategies and taper rates is limited and results are conflicting (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Children ≥3 years and Adolescents: There are no dosage adjustments provided in the manufacturer's labeling.
Hemodialysis/peritoneal dialysis: Supplemental dose is not necessary.
Children ≥3 years and Adolescents: There are no dosage adjustments provided in manufacturer's labeling.
Angioedema may occur with use of haloperidol (Ref).
Mechanism: Unknown; both a nonallergic and allergic mechanism have been proposed with antipsychotic-induced angioedema, including IgE-related hypersensitivity, kinin-dependent processes, or C1-esterase inhibition deficiencies (Ref).
Onset: Varied; within minutes to hours following parenteral haloperidol therapy and within <24 hours to days following oral haloperidol therapy (Ref). Late onset (years) has been described with other antipsychotics (Ref).
Risk factors:
• Cross-reactivity: The risk of cross-reactivity between antipsychotics as it relates to angioedema events is not well established; however, cross-reactivity has been described between clozapine and olanzapine, haloperidol and iloperidone, and haloperidol and aripiprazole (Ref).
Haloperidol causes extrapyramidal symptoms (EPS), also known as drug-induced movement disorders, in all ages (Ref). Antipsychotics can cause 4 main EPS: Acute dystonia, drug-induced parkinsonism, akathisia, and tardive dyskinesia (Ref). EPS presenting as dysphagia, esophageal dysmotility, or pulmonary aspiration, have also been reported with antipsychotics, which may not be recognized as EPS (Ref).
Mechanism: EPS: Dose-related; due to antagonism of dopaminergic D2 receptors in nigrostriatal pathways; high levels of dopamine 2 receptor occupancy have been observed for haloperidol (Ref). Tardive dyskinesia: Time related (delayed); results from chronic exposure to dopamine 2 receptor antagonists leading to up-regulation of these receptors over time (Ref).
Onset:
Antipsychotics in general:
Acute dystonia: Rapid; in the majority of cases, dystonia usually occurs within the first 5 days after initiating antipsychotic therapy (and even with the first dose, particularly in patients receiving parenteral antipsychotics) or a dosage increase (Ref).
Drug-induced parkinsonism: Varied; onset may be delayed from days to weeks, with 50% to 75% of cases occurring within 1 month and 90% within 3 months of antipsychotic initiation, a dosage increase, or a change in the medication regimen (such as adding another antipsychotic agent or discontinuing an anticholinergic medication) (Ref).
Akathisia: Varied; may begin within several days after antipsychotic initiation but usually increases with treatment duration, occurring within 1 month in up to 50% of cases, and within 3 months in 90% of cases (Ref).
Tardive dyskinesia: Delayed; symptoms usually appear after 1 to 2 years of continuous exposure to a dopamine 2 receptor antagonist, and almost never before 3 months, with an insidious onset, evolving into a full syndrome over days and weeks, followed by symptom stabilization, and then a chronic waxing and waning of symptoms (Ref).
Esophageal dysfunction (associated with EPS): Varied; ranges from weeks to months following initiation (Ref)
Risk factors:
EPS (in general):
• Prior history of EPS (Ref)
• Higher doses (Ref)
• Specific antipsychotic: Haloperidol has a high propensity to cause EPS (Ref)
Acute dystonia:
• Males (Ref)
• Young age (Ref)
Drug-induced parkinsonism:
• Females (Ref)
• Older patients (Ref)
Akathisia:
• Higher antipsychotic dosages (Ref)
• Polypharmacy (Ref)
• Mood disorders (Ref)
• Females (Ref)
• Older patients (Ref)
Tardive dyskinesia:
• Age >55 years (Ref)
• Cognitive impairment (Ref)
• Concomitant treatment with anticholinergic medications (Ref)
• Diabetes (Ref)
• Diagnosis of schizophrenia or affective disorders (Ref)
• Female sex (Ref)
• Greater total antipsychotic exposure (especially first-generation antipsychotics) (Ref)
• History of extrapyramidal symptoms (Ref)
• Substance misuse or dependence (Ref)
• Race (White or African descent). Note: Although early literature supported race as a potential risk factor for tardive dyskinesia (Ref), newer studies have challenged this assertion (Ref).
Esophageal dysfunction (associated with EPS):
• Certain comorbidities such as neurologic degenerative disease, dementia, stroke, Parkinson disease, or myasthenia gravis (Ref)
• Older adults >75 years of age (may be risk factor due to age-related muscle atrophy, cognitive impairment, reduced esophageal peristalsis) (Ref)
Leukopenia, neutropenia, and thrombocytopenia have been reported with haloperidol (Ref). Agranulocytosis and pancytopenia have also been reported (Ref).
Mechanism: Unclear and poorly understood (Ref).
Onset: Varied; in general, drug-induced neutropenia usually manifests after 1 or 2 weeks of exposure and agranulocytosis usually appears 3 to 4 weeks following initiation of therapy; however, the onset may be insidious (Ref).
Risk factors:
• History of drug-induced leukopenia/neutropenia or preexisting low WBC or absolute neutrophil count
• Older adults (Ref)
Haloperidol causes hyperprolactinemia, which may lead to gynecomastia, galactorrhea not associated with childbirth, amenorrhea, sexual disorder, and infertility (Ref). Although long-term effects of antipsychotic-induced elevated prolactin levels have not been fully evaluated, some studies have also suggested a possible association between hyperprolactinemia and an increased risk for breast and/or pituitary tumors and osteopenia/osteoporosis (Ref).
Mechanism: Dose-related (although a dose response is not consistently observed) and possibly time-related; antagonism of dopamine D2 receptors in the tuberoinfundibular dopaminergic pathway which causes disinhibition of prolactin release resulting in hyperprolactinemia (Ref). Haloperidol has been shown to have a strong D2 receptor occupancy and antagonistic properties in the pituitary (Ref).
Onset: Varied; onset is typically within a few days or weeks following initiation or a dosage increase and usually persists throughout treatment (although partial tolerance may develop). Onset may also arise after long-term stable use (Ref).
Risk factors:
• Specific antipsychotic: Haloperidol is considered to be a prolactin-elevating antipsychotic with an intermediate to high risk for hyperprolactinemia (Ref)
• Higher doses (Ref)
• Females (particularly those of reproductive age) (Ref)
• Younger patients (Ref)
All antipsychotics are associated with metabolic syndrome, which is comprised of significant weight gain (increase of ≥7% from baseline), hyperglycemia, diabetes mellitus, dyslipidemia, and hypertension. Although metabolic abnormalities are usually associated with second-generation (atypical) antipsychotics, the syndrome also occurs in varying degrees with the first-generation (typical) antipsychotics, including haloperidol (Ref).
Mechanism: The mechanism for metabolic abnormalities and weight gain is not entirely understood and is likely multifactorial. Multiple proposed mechanisms, including actions at serotonin, dopamine, histamine, and muscarinic receptors, with differing effects explained by differing affinity of antipsychotics at these receptors (Ref).
Onset: Weight gain: Varied; antipsychotic-induced weight gain usually occurs rapidly in the initial period following initiation, then gradually decreases and flattens over several months with patients continuing to gain weight in the long term (Ref).
Risk factors:
Weight gain:
• Family history of obesity (Ref)
• Parental BMI (Ref)
• Children and adolescents (Ref)
• Rapid weight gain in the initial period: Younger age, lower baseline BMI, more robust response to antipsychotic and increase in appetite; rapid weight gain of >5% in the first month has been observed as the best predictor for significant long-term weight gain (Ref)
• Duration of therapy (although weight gain plateaus, patients continue to gain weight over time) (Ref)
• Schizophrenia, regardless of medication, is associated with a higher prevalence of obesity compared to the general population due to components of the illness such as negative symptoms, sedentary lifestyles, unhealthy diets (Ref)
• Specific antipsychotic: Haloperidol is usually associated with a low propensity for causing weight gain (Ref)
Lipid/glucose metabolism abnormalities:
• Specific antipsychotic: Haloperidol is usually associated with low risk of causing lipid and/or glucose metabolism abnormalities (Ref)
Older adults with dementia-related psychosis treated with antipsychotics are at an increased risk of death compared to placebo. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature (Ref). For haloperidol specifically, increased risk of mortality has also been observed with the cause of death varying and attributed to a number of causes including pneumonia, acute myocardial infarction, venous thromboembolism, stroke, hip fracture, and cardiac arrhythmias (Ref). Of note, haloperidol is not approved for the treatment of dementia-related psychosis.
Mechanism: Unknown; possible mechanisms include arrhythmia, cardiac arrest, and extrapyramidal effects that may increase the risk of falls, aspirations, and pneumonia. In addition, haloperidol has been found to induce apoptosis and cause neurotoxicity, which also may play a role (Ref).
Risk factors:
• Antipsychotic class (a higher risk of increased mortality has been observed for first-generation antipsychotics, and haloperidol specifically, compared to second-generation antipsychotics) (Ref)
• Higher antipsychotic dosage (Ref)
• Dementia-related psychosis (eg, Lewy body dementia, Parkinson disease dementia)
• Older adults
All antipsychotics have been associated with neuroleptic malignant syndrome (NMS) in all ages. First-generation antipsychotic-associated NMS seems to occur at a higher frequency, severity, and lethality compared to second-generation antipsychotic-associated NMS (Ref). There are numerous reports of NMS occurring with haloperidol, either as monotherapy or in combination with other medications (Ref).
Mechanism: Non-dose-related; idiosyncratic. Believed to be due to a reduction in CNS dopaminergic tone, along with the dysregulation of autonomic nervous system activity (Ref).
Onset: Varied; in general, most patients develop NMS within 2 weeks of initiating an antipsychotic or a dosage increase, and in some patients, prodromal symptoms emerge within hours of initiation; once the syndrome starts, the full syndrome usually develops in 3 to 5 days (Ref). However, there are many cases of NMS occurring months after stable antipsychotic therapy (Ref).
Risk factors:
Antipsychotics in general:
• Antipsychotic class: First-generation antipsychotics seem to have a higher risk of NMS compared to atypical antipsychotics (Ref)
• Specific antipsychotic: Potent agents such as haloperidol are thought to confer the greatest risk (Ref)
• Males (twice as likely to develop NMS compared to females) (Ref)
• Dehydration (Ref)
• High-dose antipsychotic treatment (Ref)
• Concomitant lithium or benzodiazepine (potential risk factors) (Ref)
• Catatonia (Ref)
• Polypharmacy (Ref)
• Pharmacokinetic interactions (Ref)
• IM administration (Ref)
• Rapid dosage escalation (Ref)
• Psychomotor agitation (Ref)
Haloperidol has been associated with a moderate to high risk of prolonged QT interval on ECG, torsades de pointes (TdP), and sudden cardiac death in all ages (Ref). In general, intravenous haloperidol is associated with a higher risk of QTc prolongation than the oral and IM route; however, the higher risk attributed to intravenous haloperidol has been questioned and recent evidence suggests it has been confounded by its use in medically ill patients with concomitant risk factors (Ref).
Mechanism: Likely dose-related (Ref). Haloperidol prolongs cardiac repolarization by blocking the rapid component of the delayed rectifier potassium current (Ikr) (Ref).
Risk factors:
Drug-induced QTc prolongation/TdP (in general):
• Females (Ref)
• Age >65 years (Ref)
• Structural heart disease (eg, history of myocardial infarction or heart failure with a reduced ejection fraction) (Ref)
• History of drug-induced TdP (Ref)
• Genetic defects of cardiac ion channels (Ref)
• Congenital long QT syndrome (Ref)
• Baseline QTc interval prolongation (eg, >500 msec) or lengthening of the QTc by ≥60 msec (Ref)
• Electrolyte disturbances (eg, hypokalemia, hypocalcemia, hypomagnesemia) (Ref)
• Bradycardia (Ref)
• Hepatic impairment (Ref)
• Kidney impairment (Ref)
• Co-administration of multiple medications (≥2) that prolong the QT interval or increase drug interactions that increase serum drug concentrations of QTc prolonging medications (Ref)
• Substance use (Ref)
Additional risk factors for haloperidol:
• IV administration (Ref)
• Higher doses (eg, ≥35 mg per day (Ref))
Antipsychotics have been associated with sexual disorders in both males and females. Antipsychotic treatment has been associated with effects on all phases of sexual activity (libido, arousal, and orgasm); however, many patients with schizophrenia experience more frequent sexual dysfunction, with or without antipsychotic treatment. The following adverse reactions have been observed with haloperidol: Decreased libido, erectile dysfunction, and orgasm abnormal (Ref).
Mechanism: Antipsychotic-induced sexual dysfunction has been attributed to many potential mechanisms, including dopamine receptor antagonism, dopamine D2 receptor antagonism in the hypothalamic infundibular system causing hyperprolactinemia, histamine receptor antagonism, cholinergic receptor antagonism, and alpha-adrenergic receptor antagonism (Ref). Of note, haloperidol is associated with a high propensity for elevating prolactin (Ref).
Risk factors:
• Hyperprolactinemia (although a correlation with sexual dysfunction has been observed, a relationship has not been confirmed) (Ref)
• Schizophrenia (the prevalence of antipsychotic-induced sexual dysfunction in patients with schizophrenia is high [~50% to 60% compared with 31% of men in the general population]) (Ref)
• Specific antipsychotic: Some studies have observed a high prevalence of sexual dysfunction with haloperidol (Ref)
Antipsychotics may impair the body's ability to regulate core body temperature, which may cause a potentially life-threatening heat stroke during predisposing conditions such a heat wave or strenuous exercise. There are also several case reports of potentially life-threatening hypothermia associated with haloperidol use (Ref).
Mechanism: Non-dose-related; idiosyncratic. Exact mechanism is unknown; however, body temperature is regulated by the hypothalamus with involvement of the dopamine, serotonin, and norepinephrine neurotransmitters. D2 antagonism may cause an increase in body temperature, while 5-HT2A (serotonin) receptor antagonism may cause a decrease in body temperature. In addition, antagonism of peripheral alpha-adrenergic receptors has also been suggested as a factor in the hypothermic effect, by inhibiting peripheral responses to cooling (vasoconstriction and shivering) (Ref).
Onset: Hypothermia: Varied; antipsychotic-induced hypothermia cases indicate a typical onset in the period shortly after initiation of therapy or a dosage increase (first 7 to 10 days) (Ref).
Risk factors:
Heat stroke:
• Psychiatric illness (regardless of medication use) (Ref)
• Dehydration (Ref)
• Strenuous exercise (Ref)
• Heat exposure (Ref)
• Concomitant medication possessing anticholinergic effects (Ref)
Hypothermia:
• In general, predisposing risk factors include: Older adults, cerebrovascular accident, preexisting brain damage, hypothyroidism, malnutrition, shock, sepsis, adrenal insufficiency, diabetes, disability, burns, exfoliative dermatitis benzodiazepine use, polypharmacy, alcohol intoxication, immobility, kidney or liver failure (Ref)
• Schizophrenia (regardless of antipsychotic use) (Ref)
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%: Nervous system: Extrapyramidal reaction, parkinsonism
1% to 10%:
Gastrointestinal: Abdominal pain, constipation, sialorrhea, xerostomia
Nervous system: Akathisia, akinesia, drowsiness, headache, hypertonia, tremor
Neuromuscular & skeletal: Bradykinesia, dystonia, hyperkinetic muscle activity
Ophthalmic: Oculogyric crisis
<1%:
Cardiovascular: Hypotension, orthostatic hypotension, tachycardia
Dermatologic: Acneiform eruption
Endocrine & metabolic: Heavy menstrual bleeding, weight gain
Genitourinary: Dysmenorrhea, mastalgia
Local: Injection-site reaction
Nervous system: Cogwheel rigidity, dizziness, mask-like face, restlessness, sedated state, trismus
Neuromuscular & skeletal: Dyskinesia, hypokinesia, muscle rigidity, muscle twitching, torticollis
Ophthalmic: Blurred vision, nystagmus disorder
Frequency not defined:
Dermatologic: Diaphoresis
Endocrine & metabolic: Hyperglycemia, hyponatremia, increased libido, menstrual disease
Gastrointestinal: Anorexia, diarrhea, dyspepsia
Genitourinary: Breast engorgement, lactation
Nervous system: Anxiety, euphoria, lethargy, psychotic symptoms (exacerbation), vertigo
Ophthalmic: Cataract, retinopathy, visual disturbance
Respiratory: Increased depth of respiration
Postmarketing:
Cardiovascular: Edema, extrasystoles (Ref), hypertension, prolonged QT interval on ECG (Ref), torsades de pointes (Ref), ventricular arrhythmia (Ref), ventricular fibrillation (Ref), ventricular tachycardia
Dermatologic: Alopecia, exfoliative dermatitis, hyperhidrosis, maculopapular rash, pruritus, skin photosensitivity, skin rash, urticaria (Ref)
Endocrine & metabolic: Amenorrhea (Ref), decreased libido (Ref), galactorrhea not associated with childbirth (Ref), gynecomastia (Ref), heatstroke, hyperammonemia, hyperprolactinemia (Ref), hypoglycemia (Ref), SIADH, weight loss
Gastrointestinal: Cholestasis, dysphagia (Ref), nausea, vomiting
Genitourinary: Abnormal orgasm (Ref), erectile dysfunction (Ref), priapism, sexual disorder (Ref), urinary retention
Hematologic & oncologic: Agranulocytosis (Ref), anemia, leukocytosis (Ref), leukopenia (Ref), lymphocytosis with monocytosis, neutropenia (Ref), pancytopenia (Ref), thrombocytopenia (Ref)
Hepatic: Acute hepatic failure, hepatic impairment, hepatitis, jaundice
Hypersensitivity: Anaphylaxis, angioedema (Ref), facial edema (Ref), hypersensitivity angiitis (Ref), hypersensitivity reaction
Local: Abscess at injection site
Nervous system: Agitation, confusion, depression, hyperthermia (Ref), hypothermia (Ref), insomnia, motor dysfunction, neonatal withdrawal (Ref), neuroleptic malignant syndrome (Ref), opisthotonus, seizure (Ref)
Neuromuscular & skeletal: Dystonic reaction (laryngeal) (Ref), laryngospasm, rhabdomyolysis (Ref), tardive dyskinesia (Ref), tardive dystonia
Respiratory: Bronchopneumonia, bronchospasm (Ref), dyspnea, exacerbation of asthma (can be severe) (Ref), laryngeal edema, pulmonary aspiration (Ref)
Miscellaneous: Fever (Ref)
Hypersensitivity to haloperidol or any component of the formulation; Parkinson disease; severe CNS depression; coma; dementia with Lewy bodies.
Canadian labeling: Additional contraindications (not in US labeling): Significant depressive states; previous spastic diseases; young children; patients of childbearing potential; breastfeeding; IV administration (IM injection).
Concerns related to adverse effects:
• CNS depression: May cause CNS depression, which may impair physical or mental abilities; patients must be cautioned about performing tasks that require mental alertness (eg, operating machinery, driving).
• Falls: May increase the risk for falls due to somnolence, orthostatic hypotension, and motor or sensory instability.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with severe cardiovascular disease because of the possibility of transient hypotension and/or precipitation of angina pain.
• Bipolar disorder: Use with caution in patients with bipolar disorder; when used to control mania, there may be a rapid mood swing to depression. Haloperidol does not possess antidepressant effects (Cipriani 2006).
• Myasthenia gravis: Use with caution in patients with myasthenia gravis; may exacerbate condition (Mehrizi 2012).
• Parkinson disease: Haloperidol is contraindicated in patients with Parkinson disease; these patients are reported to be more sensitive to antipsychotic medications and use may result in severe extrapyramidal symptoms, confusion, sedation, and falls.
• Thyroid dysfunction: Avoid in thyrotoxicosis; severe neurotoxicity (rigidity, inability to walk or talk) may occur with use.
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer's labeling.
• Sesame oil: Some decanoate products may contain sesame oil.
Other warnings/precautions:
• Discontinuation of therapy: When discontinuing antipsychotic therapy, gradually taper antipsychotics to avoid physical withdrawal symptoms and rebound symptoms (APA [Keepers 2020]; WFSBP [Hasan 2012]). Withdrawal symptoms may include agitation, alternating feelings of warmth and cold, anxiety, diaphoresis, dyskinesia, GI symptoms, insomnia, irritability, myalgia, paresthesia, psychosis, restlessness, rhinorrhea, tremor, and vertigo (Lambert 2007; Moncrieff 2020). The risk of withdrawal symptoms is highest following abrupt discontinuation of highly anticholinergic or dopaminergic antipsychotics (Cerovecki 2013). Patients with chronic symptoms, repeated relapses, and clear diagnostic features of schizophrenia are at risk for poor outcomes if medications are discontinued (APA [Keepers 2020]).
• Parenteral administration: Hypotension may occur, particularly with parenteral administration. Although the short-acting form (lactate) is used clinically intravenously, the IV use of the injection is not an FDA-approved route of administration; the decanoate form should never be administered intravenously.
For the management of delirium in pediatric patients, intravenous haloperidol has been widely studied for efficacy and has been frequently used due to lower sedative effects and rapid onset of action; however, its use is associated with adverse effects (Harrison 2006; Slooff 2014; Turkel 2014). Newer atypical antipsychotics have shown similar efficacy with less adverse effects and are being utilized more frequently. Intravenous haloperidol for delirium may be considered in patients that are unresponsive to an atypical agent or who require intravenous therapy; ECG monitoring could be considered (Turkel 2014).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Concentrate, Oral, as lactate [strength expressed as base]:
Generic: 2 mg/mL (5 mL, 15 mL, 120 mL)
Solution, Intramuscular, as decanoate [strength expressed as base]:
Haldol Decanoate: 50 mg/mL (1 mL); 100 mg/mL (1 mL) [contains benzyl alcohol, sesame oil]
Generic: 50 mg/mL (1 mL, 5 mL); 100 mg/mL (1 mL, 5 mL)
Solution, Injection, as lactate [strength expressed as base]:
Haldol: 5 mg/mL (1 mL [DSC])
Generic: 5 mg/mL (1 mL, 10 mL)
Solution, Injection, as lactate [strength expressed as base, preservative free]:
Generic: 5 mg/mL (1 mL)
Tablet, Oral:
Generic: 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg
Yes
Concentrate (Haloperidol Lactate Oral)
2 mg/mL (per mL): $2.66 - $2.67
Solution (Haldol Decanoate Intramuscular)
50 mg/mL (per mL): $104.49
100 mg/mL (per mL): $199.19
Solution (Haloperidol Decanoate Intramuscular)
50 mg/mL (per mL): $7.56 - $33.70
100 mg/mL (per mL): $9.10 - $61.78
Solution (Haloperidol Lactate Injection)
5 mg/mL (per mL): $0.48 - $7.19
Tablets (Haloperidol Oral)
0.5 mg (per each): $0.33 - $0.89
1 mg (per each): $0.20 - $1.07
2 mg (per each): $0.24 - $1.25
5 mg (per each): $0.23 - $1.09
10 mg (per each): $0.26 - $2.01
20 mg (per each): $0.45 - $3.62
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intramuscular:
Generic: 5 mg/mL (1 mL, 10 mL)
Solution, Intramuscular, as decanoate [strength expressed as base]:
Generic: 100 mg/mL (1 mL, 5 mL)
Solution, Injection, as lactate [strength expressed as base]:
Generic: 5 mg/mL (1 mL)
Tablet, Oral:
Generic: 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg [DSC]
Long-acting injectable decanoate: Administer IM only; do not administer decanoate IV. A 21-gauge needle is recommended. The maximum volume per injection site should not exceed 3 mL. Z-track injection techniques are recommended to limit leakage after injections (Ref). Experts recommend administering in the gluteal muscle by deep IM injection, however haloperidol by deltoid injection has been studied with positive results (Ref).
Short-acting injectable lactate: Administer IM; IV and SUBQ administration (off-label routes) have also been reported. Rate of IV administration not well defined; rates of a maximum of 5 mg/minute (Ref) and 0.125 mg/kg over 1 to 2 minutes (Ref) have been reported. Consult individual institutional policies and procedures prior to IV administration. SUBQ administration is usually done in the palliative care setting, either as intermittent administration or as a continuous SUBQ infusion (Ref).
Oral: Administer with food or milk to decrease GI distress. Avoid skin contact with oral suspension or solution; may cause contact dermatitis.
Parenteral:
IM: Lactate (immediate release): May be administered undiluted IM.
IV: Infusion or IVPB: Lactate (immediate release): May be administered undiluted (5 mg/mL), or diluted in D5W. Rate of IV administration is not well defined but should be slow; in pediatric delirium patients, loading doses have been administered over 30 to 45 minutes (Ref); in adults, rates of a maximum of 5 mg/minute (Ref) and 0.125 mg/kg (in 10 mL NS) over 1 to 2 minutes (Ref) have been reported. Note: The administration of IV haloperidol is associated with QT prolongation and torsades de pointes; in adults without concomitant risk factors, this effect is dose dependent and was reported with cumulative IV doses ≥2 mg; in all patients, increased monitoring is necessary at baseline and during administration (Ref). Consult individual institutional policies and procedures prior to administration.
Agitation/Aggression (severe, acute) associated with psychiatric disorders, substance intoxication, or other organic causes (tablet, concentrate, and short-acting lactate injection): Treatment of acute agitation in patients with psychiatric disorders. May be used off label for the treatment of substance intoxication and other organic causes of agitation (Moore 2024; Wilson 2012b).
Limitation of use: Avoid in suspected or confirmed intoxications with anticholinergic substances; other agents are used preferentially in some intoxications (eg, stimulants) or alcohol withdrawal (Moore 2024).
Behavioral disorders, nonpsychotic (tablet, concentrate): Treatment of severe behavioral problems in children with combative, explosive hyperexcitability that cannot be accounted for by immediate provocation. Reserve for use in these children only after failure to respond to psychotherapy or medications other than antipsychotics.
Hyperactivity (tablet, concentrate): Short-term treatment of hyperactive children who show excessive motor activity with accompanying conduct disorders consisting of some or all of the following symptoms: impulsivity, difficulty sustaining attention, aggression, mood lability, or poor frustration tolerance. Reserve for use in these children only after failure to respond to psychotherapy or medications other than antipsychotics.
Schizophrenia:
IM decanoate: Treatment of patients with schizophrenia who require prolonged parenteral antipsychotic therapy.
Tablet, concentrate: Treatment of manifestations of psychotic disorders such as schizophrenia.
Tourette syndrome, management of tics (tablet, concentrate): Control of tics and vocal utterances in Tourette syndrome in adults and children.
Bipolar disorder (acute mania, episodes with mixed features or acute hypomania); Chemotherapy-induced breakthrough nausea and vomiting; Delirium, hyperactive (treatment); Nausea and vomiting in advanced or terminal illness (palliative care); Postoperative nausea and vomiting, prevention, moderate- to high-risk patients; Postpartum psychosis
Haldol may be confused with Halcion, Halog, Stadol
Beers Criteria: Antipsychotics are identified in the Beers Criteria as potentially inappropriate medications to be avoided in patients 65 years and older due to an increased risk of stroke and a greater rate of cognitive decline and mortality in patients with dementia. Evidence also suggests there may be an increased risk of mortality with use independent of dementia. Avoid antipsychotics for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic therapies have failed and patient may harm self or others. In addition, antipsychotics should be used with caution in older adults due to their potential to cause or exacerbate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia; monitor sodium closely with initiation or dosage adjustments in older adults. Use of antipsychotics may be appropriate for labeled indications, including schizophrenia, bipolar disorder, Parkinson disease psychosis, adjunctive therapy in major depressive disorder, or for short-term use as an antiemetic (Beers Criteria [AGS 2023]).
Antipsychotics are identified in the Screening Tool of Older Person's Prescriptions (STOPP) criteria as a potentially inappropriate medication in older adults (≥65 years of age) for treatment of sleep disorder. Some disease states of concern include dementia, parkinsonism, recurrent falls, dysphagia, QTc prolongation, and coronary, cerebral, or peripheral vascular disease (O’Mahony 2023).
KIDs List: Dopamine antagonists, when used in pediatric patients <18 years of age, are identified on the Key Potentially Inappropriate Drugs in Pediatrics (KIDs) list; use should be avoided in infants and used with caution in children and adolescents due to risk of acute dystonia (dyskinesia), and with intravenous administration an increased risk of respiratory depression, extravasation, and death (strong recommendation; moderate quality of evidence) (PPA [Meyers 2020]).
Haldol [US and multiple international markets] may be confused with Halotestin brand name for fluoxymesterone [Great Britain]
Substrate of CYP1A2 (Minor), CYP2D6 (Major), CYP3A4 (Major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential;
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Acrivastine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Agents With Seizure Threshold Lowering Potential: May increase adverse/toxic effects of Haloperidol. Specifically, the risk of seizures may be increased. Risk C: Monitor
Alcohol (Ethyl): CNS Depressants may increase CNS depressant effects of Alcohol (Ethyl). Risk C: Monitor
Alizapride: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Amifampridine: Agents With Seizure Threshold Lowering Potential may increase neuroexcitatory and/or seizure-potentiating effects of Amifampridine. Risk C: Monitor
Amiodarone: May increase QTc-prolonging effects of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification
Amisulpride (Oral): May increase QTc-prolonging effects of Haloperidol. Risk C: Monitor
Anti-Parkinson Agents (Dopamine Agonist): Antipsychotic Agents (First Generation [Typical]) may decrease therapeutic effects of Anti-Parkinson Agents (Dopamine Agonist). Management: Avoid concomitant therapy if possible. If antipsychotic use is necessary, consider using atypical antipsychotics such as clozapine, quetiapine, or ziprasidone at lower initial doses, or a non-dopamine antagonist (eg, pimavanserin). Risk D: Consider Therapy Modification
ARIPiprazole Lauroxil: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of ARIPiprazole Lauroxil. Specifically, the risk of seizures may be increased. Risk C: Monitor
ARIPiprazole: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of ARIPiprazole. Specifically, the risk of seizures may be increased. Risk C: Monitor
Artemether and Lumefantrine: May increase serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor
Articaine: May increase CNS depressant effects of CNS Depressants. Management: Consider reducing the dose of articaine if possible when used in patients who are also receiving CNS depressants. Monitor for excessive CNS depressant effects with any combined use. Risk D: Consider Therapy Modification
Asenapine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Asenapine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Azelastine (Nasal): May increase CNS depressant effects of CNS Depressants. Risk X: Avoid
Benperidol: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Benperidol. Specifically, the risk of seizures may be increased. Risk C: Monitor
Benperidol: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Blonanserin: CNS Depressants may increase CNS depressant effects of Blonanserin. Management: Use caution if coadministering blonanserin and CNS depressants; dose reduction of the other CNS depressant may be required. Strong CNS depressants should not be coadministered with blonanserin. Risk D: Consider Therapy Modification
Bornaprine: May increase adverse/toxic effects of Antipsychotic Agents. Specifically, tardive dyskinesia symptoms may be potentiated. Risk C: Monitor
Brexanolone: CNS Depressants may increase CNS depressant effects of Brexanolone. Risk C: Monitor
Brexpiprazole: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Brexpiprazole. Specifically, the risk of seizures may be increased. Risk C: Monitor
Brimonidine (Topical): May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Bromopride: May increase adverse/toxic effects of Antipsychotic Agents. Risk X: Avoid
Bromperidol: May increase CNS depressant effects of CNS Depressants. Risk X: Avoid
Buclizine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Buprenorphine: CNS Depressants may increase CNS depressant effects of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. Risk D: Consider Therapy Modification
BuPROPion: May increase neuroexcitatory and/or seizure-potentiating effects of Agents With Seizure Threshold Lowering Potential. Risk C: Monitor
Cabergoline: May decrease therapeutic effects of Antipsychotic Agents. Risk X: Avoid
Cannabinoid-Containing Products: CNS Depressants may increase CNS depressant effects of Cannabinoid-Containing Products. Risk C: Monitor
CarBAMazepine: May decrease serum concentration of Haloperidol. Risk C: Monitor
Cariprazine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Cariprazine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Cetirizine (Systemic): May increase CNS depressant effects of CNS Depressants. Management: Consider avoiding this combination if possible. If required, monitor for excessive sedation or CNS depression, limit the dose and duration of combination therapy, and consider CNS depressant dose reductions. Risk D: Consider Therapy Modification
Chloral Hydrate/Chloral Betaine: CNS Depressants may increase CNS depressant effects of Chloral Hydrate/Chloral Betaine. Management: Consider alternatives to the use of chloral hydrate or chloral betaine and additional CNS depressants. If combined, consider a dose reduction of either agent and monitor closely for enhanced CNS depressive effects. Risk D: Consider Therapy Modification
Chlormethiazole: May increase CNS depressant effects of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. Risk D: Consider Therapy Modification
Chlorphenesin Carbamate: May increase adverse/toxic effects of CNS Depressants. Risk C: Monitor
Clofazimine: May increase serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor
Clothiapine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Clothiapine. Specifically, the risk of seizures may be increased. Risk C: Monitor
CloZAPine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of CloZAPine. Specifically, the risk of seizures may be increased. Risk C: Monitor
CNS Depressants: May increase adverse/toxic effects of CNS Depressants. Risk C: Monitor
CYP2D6 Inhibitors (Moderate): May increase serum concentration of Haloperidol. Risk C: Monitor
CYP2D6 Inhibitors (Strong): May increase serum concentration of Haloperidol. Risk C: Monitor
CYP3A4 Inducers (Strong): May decrease serum concentration of Haloperidol. Risk C: Monitor
CYP3A4 Inhibitors (Strong): May increase serum concentration of Haloperidol. Risk C: Monitor
Dabrafenib: Haloperidol may increase QTc-prolonging effects of Dabrafenib. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Dantrolene: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Daridorexant: May increase CNS depressant effects of CNS Depressants. Management: Dose reduction of daridorexant and/or any other CNS depressant may be necessary. Use of daridorexant with alcohol is not recommended, and the use of daridorexant with any other drug to treat insomnia is not recommended. Risk D: Consider Therapy Modification
Deutetrabenazine: May increase adverse/toxic effects of Antipsychotic Agents. Specifically, the risk for akathisia, parkinsonism, or neuroleptic malignant syndrome may be increased. Risk C: Monitor
DexmedeTOMIDine: CNS Depressants may increase CNS depressant effects of DexmedeTOMIDine. Management: Monitor for increased CNS depression during coadministration of dexmedetomidine and CNS depressants, and consider dose reductions of either agent to avoid excessive CNS depression. Risk D: Consider Therapy Modification
Dexmethylphenidate-Methylphenidate: Antipsychotic Agents may increase adverse/toxic effects of Dexmethylphenidate-Methylphenidate. Dexmethylphenidate-Methylphenidate may increase adverse/toxic effects of Antipsychotic Agents. Specifically, the risk of extrapyramidal symptoms may be increased when these agents are combined. Risk C: Monitor
Difelikefalin: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Difenoxin: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Dihydralazine: CNS Depressants may increase hypotensive effects of Dihydralazine. Risk C: Monitor
Dimethindene (Topical): May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Domperidone: Haloperidol may increase QTc-prolonging effects of Domperidone. Risk X: Avoid
Donepezil: May increase neurotoxic (central) effects of Antipsychotic Agents. Risk C: Monitor
Dothiepin: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Doxylamine: CNS Depressants may increase CNS depressant effects of Doxylamine. Risk C: Monitor
DroPERidol: May increase CNS depressant effects of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Risk D: Consider Therapy Modification
Emedastine (Systemic): May increase CNS depressant effects of CNS Depressants. Management: Consider avoiding this combination if possible. If required, monitor for excessive sedation or CNS depression, limit the dose and duration of combination therapy, and consider CNS depressant dose reductions. Risk C: Monitor
Encorafenib: May increase QTc-prolonging effects of Haloperidol. Encorafenib may decrease serum concentration of Haloperidol. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and reduced haloperidol concentrations and efficacy when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Entacapone: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
EPINEPHrine (Systemic): Haloperidol may decrease vasoconstricting effects of EPINEPHrine (Systemic). Management: Consider alternatives to this combination and monitor for reduced epinephrine efficacy, and possible paradoxical effects (ie, hypotension), when combined. Use of alternative vasopressor agents (eg, phenylephrine, metaraminol, norepinephrine) is preferred. Risk D: Consider Therapy Modification
Esketamine (Nasal): May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Flunarizine: CNS Depressants may increase CNS depressant effects of Flunarizine. Risk X: Avoid
Flunitrazepam: CNS Depressants may increase CNS depressant effects of Flunitrazepam. Management: Reduce the dose of CNS depressants when combined with flunitrazepam and monitor patients for evidence of CNS depression (eg, sedation, respiratory depression). Use non-CNS depressant alternatives when available. Risk D: Consider Therapy Modification
Fluorouracil Products: Haloperidol may increase QTc-prolonging effects of Fluorouracil Products. Management: Monitor for QTc interval prolongation and ventricular arrhythmias, including torsades de pointes when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Flupentixol: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Flupentixol. Specifically, the risk of seizures may be increased. Risk C: Monitor
FluPHENAZine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of FluPHENAZine. Specifically, the risk of seizures may be increased. Risk C: Monitor
FluvoxaMINE: May increase serum concentration of Haloperidol. Risk C: Monitor
Fusidic Acid (Systemic): May increase serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Consider avoiding this combination if possible. If required, monitor patients closely for increased adverse effects of the CYP3A4 substrate. Risk D: Consider Therapy Modification
Glycopyrrolate (Systemic): May decrease serum concentration of Haloperidol. Management: Consider avoiding concurrent use of glycopyrrolate and haloperidol.Monitor patients closely for signs/symptoms of reduced clinical response to haloperidol if concurrent use with glycopyrrolate is required. Risk D: Consider Therapy Modification
Guanethidine: Antipsychotic Agents may decrease therapeutic effects of Guanethidine. Risk C: Monitor
Huperzine A: May increase neurotoxic (central) effects of Antipsychotic Agents. Risk C: Monitor
HydrOXYzine: May increase CNS depressant effects of CNS Depressants. Management: Consider a decrease in the CNS depressant dose, as appropriate, when used together with hydroxyzine. Increase monitoring of signs/symptoms of CNS depression in any patient receiving hydroxyzine together with another CNS depressant. Risk D: Consider Therapy Modification
Iloperidone: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Iloperidone. Specifically, the risk of seizures may be increased. Risk C: Monitor
Indomethacin: May increase CNS depressant effects of Haloperidol. Risk C: Monitor
Iohexol: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Iohexol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iohexol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic antiseizure drugs. Risk D: Consider Therapy Modification
Iomeprol: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Iomeprol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iomeprol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic antiseizure drugs. Risk D: Consider Therapy Modification
Iopamidol: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Iopamidol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iopamidol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic antiseizure drugs. Risk D: Consider Therapy Modification
Ixabepilone: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Kava Kava: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Ketotifen (Systemic): May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Kratom: May increase CNS depressant effects of CNS Depressants. Risk X: Avoid
Lefamulin: May increase QTc-prolonging effects of QT-prolonging CYP3A4 Substrates. Management: Do not use lefamulin tablets with QT-prolonging CYP3A4 substrates. Lefamulin prescribing information lists this combination as contraindicated. Risk X: Avoid
Lemborexant: May increase CNS depressant effects of CNS Depressants. Management: Dosage adjustments of lemborexant and of concomitant CNS depressants may be necessary when administered together because of potentially additive CNS depressant effects. Close monitoring for CNS depressant effects is necessary. Risk D: Consider Therapy Modification
Levocetirizine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Levoketoconazole: QT-prolonging CYP3A4 Substrates may increase QTc-prolonging effects of Levoketoconazole. Levoketoconazole may increase serum concentration of QT-prolonging CYP3A4 Substrates. Risk X: Avoid
Lithium: May increase neurotoxic effects of Antipsychotic Agents. Lithium may decrease serum concentration of Antipsychotic Agents. Specifically noted with chlorpromazine. Risk C: Monitor
Lofepramine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Lofexidine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Loxapine: CNS Depressants may increase CNS depressant effects of Loxapine. Management: Consider reducing the dose of CNS depressants administered concomitantly with loxapine due to an increased risk of respiratory depression, sedation, hypotension, and syncope. Risk D: Consider Therapy Modification
Lumateperone: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Lumateperone. Specifically, the risk of seizures may be increased. Risk C: Monitor
Lurasidone: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Lurasidone. Specifically, the risk of seizures may be increased. Risk C: Monitor
Magnesium Sulfate: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Mavorixafor: May increase serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk X: Avoid
Melitracen [INT]: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Mequitazine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Metergoline: Antipsychotic Agents may decrease therapeutic effects of Metergoline. Metergoline may decrease therapeutic effects of Antipsychotic Agents. Risk C: Monitor
Metergoline: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Methadone: Haloperidol may increase QTc-prolonging effects of Methadone. Haloperidol may increase CNS depressant effects of Methadone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation or those taking IV haloperidol may be at even higher risk. Risk D: Consider Therapy Modification
Methotrimeprazine: CNS Depressants may increase CNS depressant effects of Methotrimeprazine. Methotrimeprazine may increase CNS depressant effects of CNS Depressants. Management: Reduce the usual dose of CNS depressants by 50% if starting methotrimeprazine until the dose of methotrimeprazine is stable. Monitor patient closely for evidence of CNS depression. Risk D: Consider Therapy Modification
Methoxyflurane: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Methyldopa: Haloperidol may increase adverse/toxic effects of Methyldopa. Risk C: Monitor
Metoclopramide: May increase adverse/toxic effects of Antipsychotic Agents. Risk X: Avoid
MetyroSINE: CNS Depressants may increase sedative effects of MetyroSINE. Risk C: Monitor
MetyroSINE: May increase adverse/toxic effects of Antipsychotic Agents. Specifically, the risk for extrapyramidal symptoms and excessive sedation may be increased. Risk C: Monitor
Minocycline (Systemic): May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Molindone: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Molindone. Specifically, the risk of seizures may be increased. Risk C: Monitor
Moxonidine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Nabilone: May increase CNS depressant effects of CNS Depressants. Risk X: Avoid
Nalfurafine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Noscapine: CNS Depressants may increase adverse/toxic effects of Noscapine. Risk X: Avoid
OLANZapine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of OLANZapine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Olopatadine (Nasal): May increase CNS depressant effects of CNS Depressants. Risk X: Avoid
Ondansetron: May increase QTc-prolonging effects of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Opicapone: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Opioid Agonists: CNS Depressants may increase CNS depressant effects of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider Therapy Modification
Opipramol: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Orphenadrine: CNS Depressants may increase CNS depressant effects of Orphenadrine. Risk X: Avoid
Oxomemazine: May increase CNS depressant effects of CNS Depressants. Risk X: Avoid
Oxybate Salt Products: CNS Depressants may increase CNS depressant effects of Oxybate Salt Products. Management: Consider alternatives to this combination when possible. If combined, dose reduction or discontinuation of one or more CNS depressants (including the oxybate salt product) should be considered. Interrupt oxybate salt treatment during short-term opioid use Risk D: Consider Therapy Modification
OxyCODONE: CNS Depressants may increase CNS depressant effects of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider Therapy Modification
Paliperidone: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Paliperidone. Specifically, the risk of seizures may be increased. Risk C: Monitor
Paliperidone: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Paraldehyde: CNS Depressants may increase CNS depressant effects of Paraldehyde. Risk X: Avoid
Peginterferon Alfa-2b: May decrease serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Risk C: Monitor
Pentamidine (Systemic): Haloperidol may increase QTc-prolonging effects of Pentamidine (Systemic). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Perampanel: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Periciazine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Periciazine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Periciazine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Perphenazine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Perphenazine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Phenobarbital-Primidone: May decrease serum concentration of Haloperidol. Risk C: Monitor
Pimozide: May increase QTc-prolonging effects of Haloperidol. Risk X: Avoid
Pipamperone: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Pipamperone. Specifically, the risk of seizures may be increased. Risk X: Avoid
Piperaquine: Haloperidol may increase QTc-prolonging effects of Piperaquine. Risk X: Avoid
Piribedil: Antipsychotic Agents may decrease therapeutic effects of Piribedil. Piribedil may decrease therapeutic effects of Antipsychotic Agents. Management: Use of piribedil with antiemetic neuroleptics is contraindicated, and use with antipsychotic neuroleptics, except for clozapine, is not recommended. Risk X: Avoid
Pizotifen: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Polyethylene Glycol-Electrolyte Solution: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Polyethylene Glycol-Electrolyte Solution. Specifically, the risk of seizure may be increased. Risk C: Monitor
Posaconazole: May increase serum concentration of QT-prolonging CYP3A4 Substrates. Such increases may lead to a greater risk for proarrhythmic effects and other similar toxicities. Risk X: Avoid
Procarbazine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Prochlorperazine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Prochlorperazine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Promazine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Promazine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Promethazine: May increase anticholinergic effects of Haloperidol. Promethazine may increase CNS depressant effects of Haloperidol. Promethazine may increase serum concentration of Haloperidol. Risk C: Monitor
Psilocybin: Haloperidol may decrease therapeutic effects of Psilocybin. Haloperidol may increase adverse/toxic effects of Psilocybin. Risk C: Monitor
QT-prolonging Agents (Indeterminate Risk - Avoid): May increase QTc-prolonging effects of Haloperidol. Risk C: Monitor
QT-prolonging Agents (Indeterminate Risk - Caution): May increase QTc-prolonging effects of Haloperidol. Risk C: Monitor
QT-prolonging Antidepressants (Moderate Risk): May increase QTc-prolonging effects of Haloperidol. Haloperidol may increase serotonergic effects of QT-prolonging Antidepressants (Moderate Risk). This could result in serotonin syndrome. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and serotonin syndrome/serotonin toxicity (SS/ST) or NMS when these agents are combined. Patients with additional risk factors for QTc prolongation or SS/ST may be at even higher risk. Risk C: Monitor
QT-prolonging Antipsychotics (Moderate Risk): May increase QTc-prolonging effects of Haloperidol. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and serotonin syndrome/serotonin toxicity (SS/ST) or NMS when these agents are combined. Patients with additional risk factors for QTc prolongation or SS/ST may be at even higher risk. Risk C: Monitor
QT-prolonging Class IA Antiarrhythmics (Highest Risk): May increase QTc-prolonging effects of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification
QT-prolonging Class IC Antiarrhythmics (Moderate Risk): May increase QTc-prolonging effects of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Class III Antiarrhythmics (Highest Risk): May increase QTc-prolonging effects of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification
QT-Prolonging Inhalational Anesthetics (Moderate Risk): Haloperidol may increase QTc-prolonging effects of QT-Prolonging Inhalational Anesthetics (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias, including torsades de pointes when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Kinase Inhibitors (Highest Risk): May increase QTc-prolonging effects of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification
QT-prolonging Kinase Inhibitors (Moderate Risk): May increase QTc-prolonging effects of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Miscellaneous Agents (Highest Risk): May increase QTc-prolonging effects of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification
QT-prolonging Miscellaneous Agents (Moderate Risk): May increase QTc-prolonging effects of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk): May increase QTc-prolonging effects of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Quinolone Antibiotics (Moderate Risk): Haloperidol may increase QTc-prolonging effects of QT-prolonging Quinolone Antibiotics (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk): Haloperidol may increase QTc-prolonging effects of QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk). QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk) may increase serum concentration of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification
QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk): Haloperidol may increase QTc-prolonging effects of QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Quinagolide: Antipsychotic Agents may decrease therapeutic effects of Quinagolide. Risk C: Monitor
Quinidine (Non-Therapeutic): May increase QTc-prolonging effects of QT-prolonging CYP2D6 Substrates. Quinidine (Non-Therapeutic) may increase serum concentration of QT-prolonging CYP2D6 Substrates. Risk X: Avoid
Rilmenidine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
RisperiDONE: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of RisperiDONE. Specifically, the risk of seizures may be increased. Risk C: Monitor
Rivastigmine: May increase neurotoxic (central) effects of Antipsychotic Agents. Risk C: Monitor
Ropeginterferon Alfa-2b: CNS Depressants may increase adverse/toxic effects of Ropeginterferon Alfa-2b. Specifically, the risk of neuropsychiatric adverse effects may be increased. Management: Avoid coadministration of ropeginterferon alfa-2b and other CNS depressants. If this combination cannot be avoided, monitor patients for neuropsychiatric adverse effects (eg, depression, suicidal ideation, aggression, mania). Risk D: Consider Therapy Modification
Saquinavir: May increase QTc-prolonging effects of Haloperidol. Risk X: Avoid
Serotonergic Agents (High Risk): May increase adverse/toxic effects of Antipsychotic Agents. Specifically, serotonergic agents may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor
Sertindole: Haloperidol may increase QTc-prolonging effects of Sertindole. Risk X: Avoid
Sodium Phosphates: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Sodium Phosphates. Specifically, the risk of seizure or loss of consciousness may be increased in patients with significant sodium phosphate-induced fluid or electrolyte abnormalities. Risk C: Monitor
St John's Wort: May decrease serum concentration of Haloperidol. Risk C: Monitor
Sulpiride: Antipsychotic Agents may increase adverse/toxic effects of Sulpiride. Risk X: Avoid
Suvorexant: CNS Depressants may increase CNS depressant effects of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Risk D: Consider Therapy Modification
Tetrabenazine: May increase adverse/toxic effects of Antipsychotic Agents. Specifically, the risk for NMS and extrapyramidal symptoms may be increased. Risk C: Monitor
Thalidomide: CNS Depressants may increase CNS depressant effects of Thalidomide. Risk X: Avoid
Thioridazine: Haloperidol may increase QTc-prolonging effects of Thioridazine. Thioridazine may increase serum concentration of Haloperidol. Risk X: Avoid
Thiothixene: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Thiothixene. Specifically, the risk of seizures may be increased. Risk C: Monitor
Tobacco (Smoked): May decrease serum concentration of Haloperidol. Risk C: Monitor
Trifluoperazine: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Trifluoperazine. Specifically, the risk of seizures may be increased. Risk C: Monitor
Trimeprazine: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Triptorelin: Hyperprolactinemic Agents may decrease therapeutic effects of Triptorelin. Risk X: Avoid
Urea Cycle Disorder Agents: Haloperidol may decrease therapeutic effects of Urea Cycle Disorder Agents. More specifically, Haloperidol may increase plasma ammonia concentrations and thereby increase the doses of Urea Cycle Disorder Agents needed to maintain concentrations in the target range. Risk C: Monitor
Valerian: May increase CNS depressant effects of CNS Depressants. Risk C: Monitor
Vasopressin: Drugs Suspected of Causing SIADH may increase therapeutic effects of Vasopressin. Specifically, the pressor and antidiuretic effects of vasopressin may be increased. Risk C: Monitor
Zolpidem: CNS Depressants may increase CNS depressant effects of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider Therapy Modification
Zuclopenthixol: Agents With Seizure Threshold Lowering Potential may increase adverse/toxic effects of Zuclopenthixol. Specifically, the risk of seizures may be increased. Risk C: Monitor
Zuranolone: May increase CNS depressant effects of CNS Depressants. Management: Consider alternatives to the use of zuranolone with other CNS depressants or alcohol. If combined, consider a zuranolone dose reduction and monitor patients closely for increased CNS depressant effects. Risk D: Consider Therapy Modification
Evaluate pregnancy status and provide preconception counseling prior to initiating treatment in patients who could become pregnant (APA [Keepers 2020]; BAP [McAllister-Williams 2017]; CANMAT [Yatham 2018]). Patients effectively treated may continue their current antipsychotic medication when planning a pregnancy unless contraindications exist (ACOG 2023; BAP [McAllister-Williams 2017]); the lowest effective dose and avoidance of polytherapy is recommended (BAP [Barnes 2020]; BAP [McAllister-Williams 2017]; CANMAT [Yatham 2018]). Management of mental health conditions in patients who could become pregnant should be based on a shared decision-making process that considers the possibility of pregnancy during treatment and the risks of discontinuing antipsychotic therapy (ACOG 2023; BAP [McAllister-Williams 2017]; CANMAT [Yatham 2018]).
Antipsychotic agents may be associated with sexual dysfunction. First generation (typical) antipsychotics, including haloperidol, may cause hyperprolactinemia, resulting in menstrual disorders or impaired spermatogenesis. Consider changing to a medication that is prolactin-sparing in patients with clinical symptoms. Contraception should be provided if pregnancy is not desired, as unintended pregnancies may occur when changing to a prolactin-sparing medication (APA [Keepers 2020]; BAP [McAllister-Williams 2017]).
Haloperidol crosses the placenta in humans (Kuniyoshi 1985; Newport 2007).
Outcome data following exposure to first generation (typical) antipsychotics (FGAs) as a class do not show a significant increased risk of major congenital malformations (BAP [Barnes 2020]); however, outcomes vary due to differences in study design (BAP [McAllister-Williams 2017]; Coughlin 2015; Gentile 2010; Huybrechts 2023; Liu 2023; Wang 2021). Limb malformations have been reported with in utero haloperidol exposure, although a causal association has not been established. Additional studies are needed for individual agents and specific outcomes (BAP [Barnes 2020]). Data related to the long-term effects of in utero antipsychotic exposure on infant neurodevelopment and behavior are limited (BAP [McAllister-Williams 2017]; Straub 2022).
Antipsychotic use during the third trimester of pregnancy increases the risk for extrapyramidal symptoms and/or withdrawal symptoms in newborns following delivery (Viguera 2023). Symptoms in the newborn may include agitation, feeding disorder, hypertonia, hypotonia, respiratory distress, somnolence, and tremor. These effects may require prolonged hospitalization or be self-limiting. Tapering the dose late in pregnancy to reduce the risk of symptoms is not recommended (APA [Keepers 2020]).
Some antipsychotics may be associated with metabolic side effects. Available studies that evaluated the risk of developing gestational diabetes mellitus (GDM) during antipsychotic therapy have conflicting results, possibly due to differences in study design (ACOG 2023; Uguz 2019). Pregnant patients with diabetes mellitus or GDM may continue antipsychotic treatment (ACOG 2023). Consider the metabolic risks of the specific antipsychotic if treatment is initiated for the first time during pregnancy (Heinonen 2022). Screening for GDM should continue as part of standard prenatal care; early screening is not needed due to psychiatric medication exposure (ACOG 2023; BAP [McAllister-Williams 2017]).
Due to pregnancy-induced physiologic changes, some pharmacokinetic properties of haloperidol may be altered. Haloperidol concentrations may be decreased in pregnant patients. Regular therapeutic drug monitoring (eg, every 3 months) is recommended if treatment with haloperidol is required during pregnancy (Pennazio 2022; Schoretsanitis 2020; Westin 2018).
Untreated and undertreated mental health conditions are associated with adverse pregnancy outcomes (ACOG 2023). Adverse obstetric and neonatal outcomes are associated with schizophrenia; however, comparisons between treated and untreated pregnancies are limited (BAP [McAllister-Williams 2017]). Untreated bipolar disorder is associated with fetal growth restriction, preterm birth, and adverse neurodevelopment, and may increase the risk of postpartum psychosis, worsening mood, and postpartum hospitalization. Discontinuing effective medications during pregnancy increases the risk of symptom relapse (ACOG 2023).
Patients effectively treated for schizophrenia or bipolar disorder prepregnancy may use the same medication during pregnancy unless contraindications exist (ACOG 2023; APA [Keeper 2020]). Second generation (atypical) antipsychotics are better tolerated and have fewer extrapyramidal adverse effects than FGAs (ACOG 2023). Haloperidol has the most safety data among FGAs (BAP [McAllister-Williams 2017]).
Management of mental health conditions should be made as part of a shared decision-making process (ACOG 2023; BAP [McAllister-Williams 2017]). Treatment should not be withheld or discontinued based only on pregnancy status. When medications are used, the lowest effective dose of a single agent is recommended. Optimize dosing prior to changing a medication or adding additional agents whenever possible. Close monitoring for symptom improvement with a validated screening tool during pregnancy is recommended. Manage side effects as needed (ACOG 2023). Long acting/depot preparations should not be initiated during pregnancy but may be continued when the risk of recurrence is high (BAP [Barnes 2020]).
Haloperidol is present in breast milk.
Data related to the presence of haloperidol in breast milk are available from multiple reports (Kuniyoshi 1985; Stewart 1980; Whalley 1981; Yoshida 1998):
• Haloperidol can be detected in the plasma and urine of breastfed infants. Breast milk concentrations may be higher than maternal plasma levels (Whalley 1981; Yoshida 1998).
• Haloperidol was initiated in a lactating patient at 5 weeks postpartum for major depressive disorder with psychosis. Breast milk was expressed once treatment was initiated to maintain lactation. Haloperidol breast milk concentrations after 6 days of therapy were 5 ng/mL, 11 hours after the dose (mean daily dose 29.2 mg). The dose of haloperidol was gradually decreased to 7 mg/day from treatment days 13 to 19, then to 2 mg/day on treatment day 20, then discontinued. Haloperidol was not detectable in breast milk 3 days following the last 7 mg/day dose (Stewart 1980).
• One review evaluated the presence of haloperidol in breast milk by taking the breast milk concentration and dividing it by the maternal blood concentration to calculate a penetration ratio. Using data from 10 patients in 2 studies, the mean penetration ratio of haloperidol in breast milk was 3.11 (range 0.59 to 6.67). Maternal doses ranged from 1 to 40 mg/day (Schoretsanitis 2020).
Hypersomnia, poor feeding, and slowing motor movements were observed in a breastfed infant following maternal use of haloperidol. The mother had been on risperidone during pregnancy; haloperidol was added 2 weeks postpartum. Symptoms in the infant started 3 days after haloperidol was initiated and were resolved within 5 days after breastfeeding was discontinued (Uguz 2019).
Infants exposed to haloperidol via breast milk have been evaluated for development. In a study of 9 infants exposed to haloperidol via breast milk, the Bayley scale of infant development as well as the Amiel-Tison neurological exam were performed at intervals between 1 and 30 months of age, with the initial exams done prior to the initiation of maternal haloperidol when possible. No infants were exposed to haloperidol in utero. Infant development was normal in all but 3 infants, whose Bayley scores fell to low borderline levels at 12 to 18 months of age. These infants were also exposed to chlorpromazine via breast milk and may have had other factors contributing to these scores (Yoshida 1998).
Drowsiness, irritability, motor abnormalities, poor feeding, sedation, and slowed development have been reported in infants exposed to antipsychotics via breast milk. Monitor breastfed infants, especially those who are premature or of low birth weight, or when other sedative drugs are also prescribed (BAP [Barnes 2020]; BAP [McAllister-Williams 2017]).
Breastfeeding is not recommended by the manufacturer. Consider sedative properties when initiating an antipsychotic medication for the first time postpartum (BAP [Barnes 2020]).
Haloperidol may be used for the treatment of postpartum psychosis. Avoidance of breastfeeding overnight during the initial stages of therapy is suggested to help maintain maternal sleep preservation (ACOG 2023).
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Frequency of Antipsychotic Monitoring in Haloperidola,b | ||
|---|---|---|
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Monitoring parameter |
Frequency of monitoring |
Comments |
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a For all monitoring parameters, it is appropriate for check at baseline and when clinically relevant (based on symptoms or suspected adverse reactions) in addition to the timeline. b ADA 2004; APA [Keepers 2020]; Landi 2005; Seppala 2018; manufacturer's labeling. c Risk factors for extrapyramidal symptoms (EPS) include prior history of EPS, high doses of antipsychotics, young age (children and adolescents at higher risk than adults), and dopaminergic affinity of individual antipsychotic. d Risk factors for tardive dyskinesia include age >55 years; females; White or African ethnicity; presence of a mood disorder, intellectual disability, or CNS injury; and past or current EPS. | ||
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Adherence |
Every visit |
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|
Blood chemistries (electrolytes, renal function, liver function, TSH) |
As clinically indicated |
|
|
CBC |
As clinically indicated |
Check frequently during the first few months of therapy in patients with preexisting low WBC or history of drug-induced leukopenia/neutropenia |
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Extrapyramidal symptoms |
Every visit; 4 weeks after initiation and dose change; annually. Use a formalized rating scale at least annually or every 6 months if high risk.c |
|
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Fall risk |
As clinically indicated |
Evaluate regularly in patients ≥60 years of age |
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Fasting plasma glucose/HbA1c |
4 months after initiation; annually |
Check more frequently than annually if abnormal. Follow diabetes guidelines. |
|
Lipid panel |
4 months after initiation; annually |
Check more frequently than annually if abnormal. Follow lipid guidelines. |
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Mental status and alertness |
Every visit |
|
|
Metabolic syndrome history |
Annually |
Evaluate for personal and family history of obesity, diabetes, dyslipidemia, hypertension, or cardiovascular disease. |
|
Ocular exam |
As clinically indicated |
Particularly important for those taking thioridazine or chlorpromazine, or those with diabetes and other conditions that impact sight. |
|
Prolactin |
Ask about symptoms at every visit until dose is stable. Check prolactin level if symptoms are reported. |
Hyperprolactinemia symptoms: Changes in menstruation, libido, gynecomastia, development of galactorrhea, and erectile and ejaculatory function. |
|
Tardive dyskinesia |
Every visit; annually. Use a formalized rating scale at least annually or every 6 months if high risk.d |
|
|
Vital signs (BP, orthostatics, temperature, pulse, signs of infection) |
As clinically indicated |
|
|
Weight/Height/BMI |
Every visit for first 6 months, then quarterly |
Consider monitoring waist circumference at baseline and annually, especially in patients with or at risk for metabolic syndrome. Consider changing antipsychotic if BMI increases by ≥1 unit. |
Additional monitoring parameters with IV administration when single doses exceed 2 mg: ECG (baseline and regularly [eg, continuously]) during administration to detect emerging QTc interval prolongation. Some experts recommend continuous cardiac monitoring during administration and for 2 to 3 hours after administration (AHA/ACC [Drew 2010]; Jibson 2024). Monitor serum electrolytes (especially potassium and magnesium) at baseline and throughout therapy).
Schizophrenia:
Timing of serum samples: Draw trough just before next dose (Hiemke 2018).
Therapeutic reference range: 1 to 10 ng/mL (SI: 2.66 to 26.6 nmol/L) (Hiemke 2018). Note: Dosing should be based on therapeutic response as opposed to serum concentrations; however, therapeutic drug monitoring can be used to confirm adherence (APA [Keepers 2020]).
Laboratory alert level: Variable; levels ranging from 15 ng/mL (SI: 39.9 nmol/L) to 50 ng/mL (SI: 133 nmol/L) have been identified as supratherapeutic and resulting in toxicity (Darby 1995; Hiemke 2018).
Haloperidol is a butyrophenone antipsychotic that nonselectively blocks postsynaptic dopaminergic D2 receptors in the brain (Richelson 1999; Risch 1996).
Onset of action:
Oral tablet or concentrate:
Bipolar disorder, acute mania: Initial effects may be observed within days of treatment with continued improvements over 1 to 2 weeks (Goikolea 2013; Tohen 2000; Welten 2016).
Schizophrenia: Initial effects may be observed within 1 to 2 weeks of treatment with continued improvements through 4 to 6 weeks (Agid 2003; Levine 2010).
Short-acting injectable lactate:
IM: Agitation: Initial effects within 15 minutes with mean time to sedation 24.8 to 28.3 minutes (Isenberg 2015; Klein 2018; Nobay 2004).
IV: Sedation: Initial effects within 3 to 20 minutes (Jacobi 2002), with peak effect: ~30 to 45 minutes (Forsman 1976; Magliozzi 1985).
Duration:
Short-acting injectable lactate (dose dependent):
IM: Sedation: Mean: 126.5 minutes (Nobay 2004).
IV: Sedation: Reported range: 3 to 24 hours (Magliozzi 1985).
Distribution:
Oral tablet or concentrate: Vz/F: 52.6 ± 14.5 L/kg (Kudo 1999).
Short-acting injectable lactate: IV: Vz: 9.5 to 21.7 L/kg (Kudo 1999).
Protein binding: 88.4% to 92.5% (Kudo 1999).
Metabolism: Hepatic: 50% to 60% glucuronidation (inactive); 23% CYP3A4-mediated reduction to inactive metabolites (some back-oxidation to haloperidol); and 20% to 30% CYP3A4-mediated N-dealkylation, including minor oxidation pathway to toxic pyridinium derivative (Kudo 1999).
Bioavailability: Oral tablet or concentrate: 60% to 70% (Kudo 1999).
Half-life elimination:
Long-acting injectable decanoate: 21 days.
Oral tablet or concentrate: 14 to 37 hours (Kudo 1999).
Short-acting injectable lactate:
IM: 20 hours (Kudo 1999).
IV: 14 to 26 hours (Kudo 1999).
Time to peak, serum:
Long-acting injectable decanoate: 6 days.
Oral tablet or concentrate: 2 to 6 hours (Kudo 1999).
Short-acting injectable lactate:
IM: 20 minutes (Kudo 1999).
Excretion: Urine (30%, 1% as unchanged drug) (Kudo 1999).
