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Haloperidol

Oral
Intramuscular
Class
Antipsychotics
Subclass
Butyrophenones
Substance name
Haloperidol
Common formulations
Solution, Tablet
See also
Haloperidol decanoate LA (Haldol®)
Dosage and administration
Adults patients
Treatment
Psychotic disorders • Moderate symptoms
•
Start at: 0.5-2 mg PO BID-TID
•
Maximum: 100 mg per day
Titrate to the lowest effective maintenance dose once satisfactory therapeutic response is achieved.
Psychotic disorders • Severe symptoms
•
Start at: 3-5 mg PO BID-TID
•
Maximum: 100 mg per day
Titrate to the lowest effective maintenance dose once satisfactory therapeutic response is achieved.
Tourette's syndrome • Moderate symptoms
•
Start at: 0.5-2 mg PO BID-TID
•
Maximum: 100 mg per day
Titrate to the lowest effective maintenance dose once satisfactory therapeutic response is achieved.
Tourette's syndrome • Severe symptoms
•
Start at: 3-5 mg PO BID-TID
•
Maximum: 100 mg per day
Titrate to the lowest effective maintenance dose once satisfactory therapeutic response is achieved.
Delirium • Off-label
•
Maintenance: 0.5-1 mg PO QID PRN
•
Maximum: 30 mg per day
Delirium in patients with advanced cancer • Off-label
•
0.5-4 mg PO daily
Nausea and vomiting in patients with advanced cancer • Off-label
•
1.5-5 mg PO q4-6h
Adjunctive treatment
Adjunctive treatment for alcohol withdrawal syndrome • Off-label
•
0.5-5 mg PO q4h
Administered in combination with benzodiazepines.
Other off-label uses
•
Treatment of OCD
Indications for use
Labeled indications
Adults
•
Treatment of Tourette's syndrome (moderate symptoms)
•
Treatment of Tourette's syndrome (severe symptoms)
•
Treatment of psychotic disorders (moderate symptoms)
•
Treatment of psychotic disorders (severe symptoms)
Off-label indications
Adults
•
Treatment of delirium
•
Treatment of delirium in patients with advanced cancer
•
Treatment of nausea and vomiting in patients with advanced cancer
•
Treatment of OCD
•
Adjunctive treatment for alcohol withdrawal syndrome
Safety risks
Boxed warnings
Increased risk of mortality
•
Do not use haloperidol in elderly patients with dementia-related psychosis because of the increased risk of mortality.
Contraindications
Hypersensitivity to haloperidol or its components
Dementia with Lewy Bodies
Severe toxic CNS depression or comatose states from any cause
Warnings and precautions
Cerebrovascular events
•
Use caution in patients with risk factors for cerebrovascular adverse reactions.
CNS depression
•
Use caution in patients receiving CNS depressants, such as anesthetics or opioids, or using alcohol.
Decreased WBC count, decreased blood neutrophil count
•
Maintain a high level of suspicion, as haloperidol has been associated with an increased risk of leukopenia, neutropenia, and agranulocytosis. Discontinue haloperidol in case of severe neutropenia (absolute neutrophil count < 1,000/mcL).
Depression
•
Use caution in patients receiving haloperidol to control mania in cyclic disorders.
Dyskinesia
•
Do not discontinue abruptly in patients taking the drug for a prolonged period.
Encephalopathy
•
Use caution in patients receiving concomitant therapy with lithium.
Extrapyramidal signs
•
Use caution in patients receiving concomitant therapy with antiparkinsonian agents. Consider continuing antiparkinsonian therapy after haloperidol is discontinued because of the difference in excretion rates.
Falls
•
Maintain a high level of suspicion, as haloperidol has been associated with an increased risk of motor instability, somnolence, and orthostatic hypotension, leading to falls and fall-related injuries.
Hypotension, angina pectoris
•
Use caution in patients with severe cardiovascular disorders.
Increased serum haloperidol levels
•
Use caution in patients receiving CYP3A4 inhibitors (such as alprazolam, itraconazole, ketoconazole, nefazodone, ritonavir), CYP2D6 inhibitors (such as chlorpromazine, promethazine, quinidine, paroxetine, sertraline, venlafaxine), combined CYP3A4 and CYP2D6 inhibitors (fluoxetine or fluvoxamine with ritonavir), or buspirone. Consider decreasing haloperudol dose as necessary.
Increased serum prolactin
•
Maintain a high level of suspicion, as antipsychotic drugs can elevate prolactin levels, with elevation persisting during chronic administration.
Neuroleptic malignant syndrome
•
Maintain a high level of suspicion, as haloperidol has been associated with an increased risk of neuroleptic malignant syndrome. Discontinue haloperidol immediately if neuroleptic malignant syndrome develops.
Neurotoxicity
•
Use caution in patients with thyrotoxicosis.
Prolonged QT interval, torsade de pointes
•
Use caution in patients receiving higher than recommended doses of haloperidol, intravenous haloperidol, as well as in patients with other QT-prolonging conditions, such as hypokalemia, hypomagnesemia, hypocalcemia, underlying cardiac abnormalities, familial long QT syndrome, hypothyroidism, or concomitant therapy with other QT-prolonging agents.
Seizure
•
Use caution in patients with a history of seizures, EEG abnormalities, or receiving anticonvulsant medications.
Somnolence, motor impairment
•
Use extreme caution in patients performing activities requiring mental alertness, such as driving or operating machinery.
Tardive dyskinesia
•
Maintain a high level of suspicion, as haloperidol has been associated with an increased risk of tardive dyskinesia, especially in elderly women.
Specific populations
Renal impairment
eGFR 0-90 mL/min/1.73 m²
•
Use acceptable. No dose adjustment required.
Renal replacement therapy
Peritoneal dialysis
•
Use acceptable. No dose adjustment required.
Hepatic impairment
Any severity
•
Use acceptable. No dose adjustment required. Haloperidol concentrations may increase in patients with hepatic impairment, as it is primarily metabolized by the liver and protein binding may decrease.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Use only if benefits outweigh potential risks. Evidence of fetal harm in humans. Monitor neonates for extrapyramidal and/or withdrawal symptoms.
Adverse reactions
Unknown frequency
•
Tachycardia, hypotension, hypertension, ↑QT interval, ventricular arrhythmia, extrapyramidal signs, akathisia, dystonia, parkinsonism, dysphagia, dyspnea, tardive dyskinesia, dyskinesia, insomnia, restlessness, euphoria, agitation, depression, anxiety, lethargy, headache, confusion, vertigo, seizure, hallucinations, behavioral or personality changes, hyperpyrexia, ↓ WBC count, ↓ blood neutrophil count, agranulocytosis, anemia, ↑ LFTs, jaundice, maculopapular rash, acneiform lesions, hair loss, photosensitivity of skin, breast enlargement, mastalgia, menstrual irregularity, gynecomastia, erectile dysfunction, ↑ libido, ↑ blood glucose, ↓ blood glucose, ↓ serum sodium, loss of ability to do everyday tasks, constipation, diarrhea, hypersalivation, nausea, vomiting, dry mouth, blurred vision, urinary retention, diaphoresis, priapism, laryngospasm, bronchospasm, visual disturbances, ↑ blood ammonia, orthostatic hypotension, falls, ↑ serum prolactin, torsades de pointes, neuroleptic malignant syndrome, cataract, oculogyric crisis
Interactions
Drug(s)
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