Pharm

Haloperidol

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Haloperidol, Haldol, Haloperidol Lactate, Haloperidol Decanoate

  • See Also
  1. Antipsychotic Medication
  2. Psychosis
  • Indications
  1. Psychosis
  2. Delirium
  3. Schizophrenia
  4. Tic Disorders (including Tourette's Syndrome)
  5. Acute Mania
  • Contraindications
  1. Pregnancy and Lactation
  2. Phencyclidine (PCP) Overdose
  3. Anticholinergic Syndromes
  4. Alcohol or Benzodiazepine Withdrawal
  5. Hepatic Insufficiency
  6. Neuroleptic Malignant Syndrome
  • Mechanism
  1. First Generation Antipsychotic
  • Dosing
  • Haloperidol Immediate Release
  1. Dosing Range
    1. Adult: 5-10 mg PO, IM, or IV
    2. Peds: 0.5-1 mg PO, IM or IV
    3. Adolescent: 1-5 mg PO, IM or IV
    4. Elderly: 0.5-2 mg PO, IM or IV
  2. Dosing Intervals: Scheduled and repeated dosing intervals
    1. May repeat every 30-60 minutes
    2. Maximum: 300 mg/24 hours (avoid cummulative dose over 100 mg in 24 hours)
    3. May dose regularly every 6-8 hours
      1. Typical effective dose: 5 mg PO, IV, or IM tid (lower doses in the elderly)
    4. Total dose >3 mg/day is associated with Extrapyramidal Side Effects
  1. Haloperidol alone
    1. Child: 0.05 to 0.15 mg/kg PO/IM/IV (up to 2-5 mg for teen)
    2. Adult: 5 mg IV or 10 mg PO/IM prn
    3. May repeat dose in 10 to 30 minutes if needed
    4. Consider with Benadryl 50 mg or Cogentin 1 mg to prevent Dystonic Reaction
    5. Monitor Electrocardiogram for QTc Prolongation (esp. IV dosing, risk of Torsades de Pointes)
  2. Haloperidol with Midazolam and Benadryl q30 minutes prn (Mnemonic: B52)
    1. Benadryl 50 mg (prevents Dystonia)
    2. Haloperidol 5 mg (up to 10 mg)
    3. Midazolam 2 mg (up to 4 mg) - Midazolam is preferred over Ativan for IM Benzodiazepine)
    4. Draw up the 3 agents into same syringe and deliver IM
      1. May repeat once with additional 5 mg Haloperidol and 2 mg Midazolam
  1. Adult Oral Dosing
    1. Start 0.5 to 5 mg (or up to 2 mg in elderly) orally every 8 to 12 hours
    2. Target 6 to 20 mg/day
    3. Maximum: 100 mg/day
  2. Adult IM Dosing
    1. Start 2 to 5 mg IM every 8 hours
    2. Maximum: 20 mg/day
  3. Children (age 3 to 12 years, 15 to 40 kg)
    1. Dose: 0.05 to 0.15 mg/kg/day divided every 8 to 12 hours
  4. Adult Monthly IM Injection: Haloperidol Decanoate (depot form)
    1. Stabilize on oral dosing before initiating depot IM dosing
    2. Haloperidol Decanoate 100 mg IM every 4 weeks (equivalent to 10 mg/day oral formulation)
    3. Cost effective (may be as low as $19 generic)
  • Dosing
  • Tourette Syndrome
  1. Adult Oral Dosing
    1. Start 0.5 to 5 mg (or up to 2 mg in elderly) orally every 8 to 12 hours
    2. Target 6 to 20 mg/day
    3. Maximum: 100 mg/day
    4. May also use IM dosing or monthly preparation as above
  2. Children (age 3 to 12 years, 15 to 40 kg)
    1. Dose: 0.05 to 0.075 mg/kg/day divided every 8 to 12 hours
    2. May increase dose by up to 0.5 mg weekly to maximum of 6 mg/day
  • Precautions
  1. Intravenous doses have a much shorter duration of action than other routes
  2. Antipsychotics are associated with increased mortality in the elderly
  • Adverse effects
  1. Serious
    1. See Extrapyramidal Side Effects (EPSE)
    2. Neuroleptic Malignant Syndrome
    3. Hypotension
    4. Dystonia
    5. Seizures
    6. Prolonged QT interval
      1. Risk of Torsades de Pointes
      2. Dose related effect with higher risk at higher doses
  2. Common
    1. Insomnia
    2. Restlessness
    3. Anxiety
    4. Sedation
    5. Headache
    6. Weight gain
    7. Hyperprolactinemia
    8. Blood dyscrasia
  • Safety
  1. Avoid in pregnancy
    1. Limb malformations with first trimester exposure
    2. Neonatal withdrawal and Extrapyramidal Effects with third trimester exposure
  2. Avoid in Lactation
  • Monitoring
  1. Electrocardiogram (EKG)
    1. With Parenteral dosing (esp. IV), monitor Electrocardiogram for QTc Prolongation (risk of Torsades de Pointes)
  2. Serum Prolactin
    1. Obtain if indicated
  3. Complete Blood Count (indicated if history of Leukopenia)
    1. Baseline
    2. Monthly in first 3 months of therapy
  4. Serum Haloperidol Level
    1. Therapeutic range: 2 to 15 ng/ml
  • Resources
  1. Haloperidol (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=c559b0b0-4087-d12a-e718-c18ccb6811e6
  • References
  1. (2016) Med Lett Drugs Ther 58(1510): 160-5
  2. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 42-3
  3. Hamilton (2020) Tarascon Pocket Pharmacopoeia