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Risperidone

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Risperidone, Risperdal, Risperdal Consta, Rykindo, Risperdal M-Tab, Perseris, Uzedy

  • See Also
  1. Antipsychotic Medication
  2. Psychosis
  3. Paliperidone
  • Class
  1. Atypical Antipsychotic (Second Generation agent)
  2. Neuroleptic
  • Indications
  1. Schizophrenia
  2. Bipolar Disorder
  3. Autism related irritability
  4. Agitation in Dementia (not FDA approved)
  5. Obsessive Compulsive Disorder Adjunctive Therapy (not FDA approved)
  6. Posttraumatic Stress Disorder (not FDA approved)
  • Mechanism
  1. Antagonist at Serotonin, Dopamine, alpha adrenergic and Histamine H1 receptors
  2. Active metabolites include Paliperidone
  • Adverse Effects
  1. Sedation or Somnolence
  2. Insomnia
  3. Hypotension
  4. Weight gain
  5. Hyperglycemia and increased Diabetes Mellitus risk
  6. Constipation
  7. Sialorrhea
  8. Dizziness
  9. Serum Prolactin increased
  10. Extrapyramidal Side Effects
    1. Low risk when daily dose under 10 mg
    2. Hyperkinesis
    3. Exacerbates Parkinson's Disease movement, Fall Risk (and increased risk of Neuroleptic Malignant Syndrome)
    4. Akathisia
    5. Dystonia
  11. Peristent Tardive Dyskinesia
    1. Lower Incidence than with other Neuroleptics
  1. Precautions
    1. Do not stop abruptly
    2. Decrease dose in liver and kidney Impairment, and in the elderly
    3. Somnolence may be decreased by splitting dose twice daily
  2. Initial
    1. Adult: 1 mg orally twice daily
    2. Child age 13 to 17 years: 0.5 mg orally daily (or divided twice daily)
    3. Elderly: 0.25 mg daily to 0.5 mg orally twice daily
  3. Slow titration to average dosing
    1. Adult: 2 to 4 mg orally daily (or divided twice daily)
    2. Child: 0.5 to 1.5 mg orally daily or divided twice daily
    3. Elderly with Dementia: 0.5 to 0.75 mg orally twice daily
  4. Maximum
    1. Adult: 16 mg/day
  1. Adult Immediate Release Tablet
    1. Start 2 mg orally daily (or divided twice daily)
    2. Increase by 1 to 2 mg/day every 2 days
    3. Target: 4 to 8 mg/day (2 to 3 mg daily in Bipolar Disorder)
    4. Maximum: 16 mg/day (6 mg/day in Bipolar Disorder)
      1. Doses >6 mg do not appear more effective than lower doses
  2. Children Ages 13 to 17 years old Immediate Release Tablet
    1. Start 0.5 mg orally daily
    2. Increase by 0.5 to 1 mg/day every 24 hours or more
    3. Target: 3 mg/day (as effective as 6 mg/day dose)
    4. Maximum: 6 mg/day
  3. Decreased dose in elderly, debiltated patients, or in renal (eGFR <30 ml/min) or liver impaired function
    1. Start 0.5 mg orally daily or twice daily
    2. Increase by 0.5 to 1 mg/day every few days (weekly for doses >1.5 mg)
    3. Maximum: 6 mg/day (most effective dose is 3 mg/day or less)
  4. Adult Long-Acting IM Injection (Risperdal Consta, Rykindo)
    1. Trial oral dosing before starting IM Injection
    2. Start 25 mg IM every 2 weeks
    3. Continue oral Risperidone for the first 3 weeks of IM Injections
    4. May increase IM dose by 12.5 mg every 4 weeks up to a maximum of 50 mg IM
  5. Adult Long-Acting SQ Injection (Perseris)
    1. Trial oral dosing before starting IM Injection
    2. Base Perseris SQ dose on Risperidone oral dosing
      1. Risperidone oral daily dose <3 mg/day: Avoid Perseris
      2. Risperidone oral daily dose 3 mg/day: Perseris 90 mg SQ every month
      3. Risperidone oral daily dose 4 mg/day: Perseris 120 mg SQ every month
      4. Risperidone oral daily dose >4 mg/day: Avoid Perseris
  6. Adult Long-Acting SQ Injection (Uzedy)
    1. Trial oral dosing before starting IM Injection
    2. Base Uzedy SQ dose on Risperidone oral dosing
      1. Risperidone oral daily dose 2 mg/day: Uzedy 50 mg SQ monthly (or 100 mg q2 months)
      2. Risperidone oral daily dose 3 mg/day: Uzedy 75 mg SQ monthly (or 150 mg q2 months)
      3. Risperidone oral daily dose 4 mg/day: Uzedy 100 mg SQ monthly (or 200 mg q2 months)
      4. Risperidone oral daily dose 5 mg/day: Uzedy 125 mg SQ monthly (or 250 mg q2 months)
  • Dosing
  • Autism Related Irritability (Age 5 to 16 years old)
  1. Weight <20 kg
    1. Start 0.25 mg orally daily
    2. May increase after 4 days to target dose 0.5 mg orally daily
    3. May increase every 14 days as needed in 0.25 mg/day increments
  2. Weight >20 kg
    1. Start 0.5 mg orally daily
    2. May increase after 4 days to target dose 1 mg orally daily
    3. May increase every 14 days as needed in 0.5 mg/day increments
  3. Target Dose: 0.5 to 3 mg daily
  • Monitoring
  1. See Antipsychotics
  2. Consider EKG, Electrolyte and Magnesium monitoring due to QT Interval prolongation risk
  • Drug Interactions
  1. Metabolized by CYP2D6, CYP3A4
  2. Increase Antipsychotic levels (toxicity risk): Monitor for toxicity
    1. Clozapine
    2. Fluoxetine
    3. Paroxetine
  3. Decrease Antipsychotic levels (lower efficacy)
    1. Barbiturates
    2. Carbamazepine
    3. Phenytoin
    4. Rifampin
  4. Other effects
    1. Increased Antihypertensive effect (may result in Hypotension)
    2. Raises Serum Prolactin levels
    3. Avoid concurrent use of other medications prolonging QT Interval
      1. See Prolonged QT Interval due to Medication
  • Safety
  1. Avoid in Lactation
  2. Pregnancy Category C
    1. However, increased risk of birth malformations with first and second trimester exposure
    2. Huybrechts (2016) JAMA Psychiatry 73(9): 938-46 +PMID: 27540849 [PubMed]
  • Resources
  1. Risperidone Tablet (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=43aa2a4f-1123-4f86-800b-9218882f7bcd
  2. Risperidone Consta SQ (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=bb34ee82-d2c2-43b8-ba21-2825c0954691
  3. Risperidone Uzedy SQ monthly (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=734eb776-4be0-4808-834b-0d8b0f9e021e
  • 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
  4. Jeste (2000) Am J Psychiatry 157:1150-5 [PubMed]
  5. Motsinger (2003) Am Fam Physician 67(11):2335-40 [PubMed]