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Antipsychotics for initial management of the acutely agitated adult patient with psychosis

	Formulation	Route	Initial dose (mg)	Frequency (hours)	Maximum initial dose per 24 hours (mg)	Time to peak plasma concentration (hours)	Notes
First-generation agents
Haloperidol	Short-acting lactate injection	IM, IV	2 to 5	0.5 to 2*	20^¶	0.5 to 1	Sedation, hypotension and prolongation of QTc interval more pronounced with injection. ↑ EPS risk.
Haloperidol	Oral solution	PO	0.5 to 5	6	30	2
Droperidol	Injection (short-acting)	IM, IV	2.5 to 5	2 to 4*	40	0.5	Rapid onset of 3 to 10 minutes advantageous in severely agitated violent patients. Dose related QTc prolongation and risk of cardiac arrhythmias. ↑ EPS risk.
Fluphenazine	Short-acting hydrochloride injection	IM	1.25	6	10	ND	1 mg short-acting IM injection is equivalent to approximately 2.5 mg oral. ↑ EPS risk.
Fluphenazine	Oral solution	PO	1 to 2.5	6	10	3
Second-generation agents
Aripiprazole	Disintegrating tablet, oral solution	PO	10 to 15	2	30	3 to 5	Less sedating. Minimal prolongation of QTc interval or orthostatic hypotension.
Olanzapine	Injection (short-acting)	IM	5 to 10	2 to 4	30	0.25 to 0.75	Decreased clearance in female and/or non-smoking patients.
Olanzapine	Disintegrating tablet	PO	5 to 10	0.5 to 2	20	5	Decreased clearance in female and/or non-smoking patients.
Risperidone	Disintegrating tablet, oral solution	PO	1 to 2	0.5 to 2	6	1.5	Decreased clearance in renal and/or hepatic impairment.
Ziprasidone	Short-acting mesylate injection	IM	10 to 20	2 to 4	40	0.5 to 1	Dose related QTc prolongation and risk of cardiac arrhythmias.

The approach to pharmacologic treatment of the acutely agitated patient, including specific medication choices and combinations depending upon presentation (eg, toxic ingestion, withdrawal syndrome, or known psychiatric history) is provided in the accompanying topic reviews and in an algorithm.
Dose reduction by one-half is needed for older adults, debilitated patients, and if used in combination with other sedation. Refer to accompanying text for discussion of electrocardiograph and other monitoring for agents known to cause prolongation of the QTc interval.

IM: intramuscular; IV: intravenous; EPS: extrapyramidal symptoms; PO: per os (by mouth); ND: no data.
* It may be necessary to repeat initial dose or fraction thereof after 15 to 20 minutes in patients with severe agitation until desired level of sedation attained.
¶ Selected patients without schizophrenia may need a higher cumulative haloperidol dose (eg, up to 30 mg) during the first 24 hours of treatment to achieve and maintain adequate sedation.

Graphic 60846 Version 14.0