Components:
Method of action:
Treatment option:
Medically reviewed by Kovalenko Svetlana Olegovna, PharmD. Last updated on 05.04.2022
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Adult patients aged 18 years and above
- Treatment of schizophrenia and schizoaffective disorder.
- Acute treatment of delirium when non-pharmacological treatments have failed.
- Treatment of moderate to severe manic episodes associated with bipolar I disorder.
- Treatment of acute psychomotor agitation associated with psychotic disorder or manic episodes of bipolar I disorder.
- Treatment of persistent aggression and psychotic symptoms in patients with moderate to severe Alzheimer's dementia and vascular dementia when non-pharmacological treatments have failed and when there is a risk of harm to self or others.
- Treatment of tic disorders, including Tourette's syndrome, in patients with severe impairment after educational, psychological and other pharmacological treatments have failed.
- Treatment of mild to moderate chorea in Huntington's disease, when other medicinal products are ineffective or not tolerated.
Paediatric patients
Treatment of:
- Schizophrenia in adolescents aged 13 to 17 years when other pharmacological treatments have failed or are not tolerated.
- Persistent, severe aggression in children and adolescents aged 6 to 17 years with autism or pervasive developmental disorders, when other treatments have failed or are not tolerated.
- Tic disorders, including Tourette's syndrome, in children and adolescents aged 10 to 17 years with severe impairment after educational, psychological and other pharmacological treatments have failed.
Posology
Since individual response to neuroleptic drugs is variable, dosage for all indications should be individually determined and is best initiated and titrated under close clinical supervision.
To determine the initial dose, consideration should be given to the patient's age, severity of symptoms and previous response to other neuroleptic drugs.
Patients who are elderly or debilitated or those with previously reported adverse reactions to neuroleptic drugs may require less Lemonamin solution and half the normal starting dose may be sufficient for therapeutic response.
Lemonamin should be used at the minimum dose that is clinically effective
Method of administration
For Oral Administration Only
Adults
Schizophrenia, psychoses and mania
Use as an antipsychotic agent for schizophrenia, psychoses, mania and hypomania, organic brain damage (depending on symptoms).
Acute phase:
Doses between 2 and 20 mg/day should be administered either as a single dose or in divided doses.
Chronic phase:
1-3 mg orally three times a day, may be increased up to 20 mg per day in divided doses, depending on the response.
Psychomotor anti-agitation
Use as a psychomotor anti-agitation agent for mental or behavioural problems such as aggression, hyperactivity and self-mutilation in the mentally retarded and in patients with organic brain damage (depending on symptoms), violent or dangerously impulsive behaviour.
Acute phase:
Moderate symptomatology 1.5 - 3.0mg bd or tds
Severe symptomatology (resistant patients) 3.0 - 5.0mg bd or tds
Chronic phase:
0.5-1 mg three times a day orally, may be increased to 2-3 mg three times a day, if required, to obtain a response.
Maintenance Dosage:
Once satisfactory control of symptoms has been achieved, dosage should be gradually reduced to the lowest effective maintenance dose. Too rapid a dosage reduction should be avoided.
Restlessness or agitation in the elderly:
Treatment should start with half the dosage stated for adults and adjusted according to the results if necessary.
Gilles de la Tourette Syndrome, severe tics, intractable hiccup:
Starting dose 1.5mg tds adjusted according to response. A daily maintenance dose of 10mg may be required in Gilles de la Tourette Syndrome
The maximum daily dose for all treatment is 20mg
Paediatric population
Childhood Schizophrenia
The recommended doses below provide a total dose in the approximate range 0.03 to 0.15 mg/kg/day, when administered orally in divided doses (two or three times a day).
Children 3 to 12 years of age
The recommended
- starting dose is a total 0.5 mg/day orally, preferably in divided doses
- target dose range is a total 1 to 4 mg/day orally, in divided doses
- maximum dose is a total 6 mg/day orally, in divided doses.
Adolescents 13 to 17 years of age
The recommended
- starting dose is a total 0.5 mg/day orally, preferably in divided doses
- target dose range is a total 1 to 6 mg/day orally, in divided doses
- maximum dose is a total 10 mg/day orally, in divided doses.
Childhood Psychomotor anti-agitation
The recommended doses below provide a total dose in the approximate range 0.02 to 0.075 mg/kg/day when administered orally in divided doses (two to three times a day).
Children 3 to 12 years of age
The recommended
- starting dose is a total 0.25 mg/day orally, preferably in divided doses.
- target dose range is a total 0.5 to 3 mg/day orally, in divided doses.
- maximum dose is a total 3 mg/day orally, in divided doses.
Adolescents 13 to 17 years of age
The recommended
- starting dose is a total 0.25 mg/day orally, preferably in divided doses.
- target dose range is a total 2 to 6 mg/day orally, in divided doses.
- maximum dose is a total 6 mg/day orally, in divided doses.
Gilles de la Tourette Syndrome: Oral maintenance doses of up to 10mg/day in most patients
Posology
Adults
A low initial dose is recommended, which subsequently may be adjusted according to the patient's response. Patients must always be maintained on the minimal effective dose.
Oral solution:
The dose recommendations for Lemonamin oral solution are presented in Table 1.
Table 1: Haloperidol dose recommendations for adults aged 18 years and above
| Treatment of schizophrenia and schizoaffective disorder - 2 to 10 mg/day orally, as a single dose or in 2 divided doses. Patients with first-episode schizophrenia generally respond to 2 to 4 mg/day, whereas patients with multiple-episode schizophrenia may need doses up to 10 mg /day. - Adjustments to the dose may be made every 1 to 7 days. - Doses above 10 mg/day have not demonstrated superior efficacy to lower doses in the majority of patients and may cause an increased incidence of extrapyramidal symptoms. The individual benefit-risk should be assessed when considering doses above 10 mg/day. - The maximum dose is 20 mg/day because safety concerns outweigh the clinical benefits of treatment at higher doses. |
| Acute treatment of delirium when non-pharmacological treatments have failed - 1 to 10 mg/day orally, as a single dose or in 2 to 3 divided doses. - Treatment should be started at the lowest possible dose, and the dose should be adjusted in increments at 2- to 4-hour intervals if agitation continues, up to a maximum of 10 mg/day. |
| Treatment of moderate to severe manic episodes associated with bipolar I disorder - 2 to 10 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 3 days. - Doses above 10 mg/day have not demonstrated superior efficacy to lower doses in the majority of patients and may cause an increased incidence of extrapyramidal symptoms. The individual benefit-risk should be assessed when considering doses above 10 mg/day. - The maximum dose is 15 mg/day because safety concerns outweigh the clinical benefits of treatment at higher doses. - The continued use of Lemonamin should be evaluated early in treatment. |
| Treatment of acute psychomotor agitation associated with psychotic disorder or manic episodes of bipolar I disorder - 5 to 10 mg orally, repeated after 12 hours if necessary to a maximum of 20 mg/day. - The continued use of Lemonamin should be evaluated early in treatment. - When switching from haloperidol intramuscular injection, Lemonamin orally should be initiated at a 1:1 dose conversion rate followed by dose adjustment according to clinical response. |
| Treatment of persistent aggression and psychotic symptoms in patients with moderate to severe Alzheimer's dementia and vascular dementia when non-pharmacological treatments have failed and when there is a risk of harm to self or others - 0.5 to 5 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 3 days. - The need for continued treatment must be reassessed after no more than 6 weeks. |
| Treatment of tic disorders, including Tourette's syndrome, in patients with severe impairment after educational, psychological and other pharmacological treatments have failed - 0.5 to 5 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 7 days. - The need for continued treatment must be reassessed every 6 to 12 months. |
| Treatment of mild to moderate chorea in Huntington's disease, when other medicinal products are ineffective or not tolerated - 2 to 10 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 3 days. |
2 mg/ml oral solution:
The Lemonamin 2 mg/ml oral solution in a bottle with an oral syringe is intended to be used for single doses of 0.5 mg haloperidol and above (equivalent to 0.25 ml and above).
The quantity (ml) required to achieve a given single dose using Lemonamin 2 mg/ml oral solution is presented in Table 2.
Table 2: Conversion table for Lemonamin 2 mg/ml oral solution
| mg haloperidol | ml Lemonamin (bottle with oral syringe) |
| 0.1 mg | - |
| 0.2 mg | - |
| 0.3 mg | - |
| 0.4 mg | - |
| 0.5 mg | 0.25 ml |
| 1 mg | 0.5 ml |
| 2 mg | 1 ml |
| 5 mg | 2.5 ml |
| 10 mg | 5 ml |
| 15 mg | 7.5 ml |
| 20 mg | 10 ml |
Treatment withdrawal
Gradual withdrawal of haloperidol is advisable.
Missed dose
If patients miss a dose, it is recommended that they take the next dose as usual, and do not take a double dose.
Special populations
Elderly
The following initial haloperidol doses are recommended in elderly patients:
- Treatment of persistent aggression and psychotic symptoms in patients with moderate to severe Alzheimer's dementia and vascular dementia when non-pharmacological treatments have failed and when there is a risk of harm to self or others - 0.5 mg/day.
- All other indications - half the lowest adult dose.
The haloperidol dose may be adjusted according to the patient's response. Careful and gradual dose up-titration in elderly patients is recommended.
The maximum dose in elderly patients is 5 mg/day.
Doses above 5 mg/day should only be considered in patients who have tolerated higher doses and after reassessment of the patient's individual benefit-risk profile.
Renal impairment
The influence of renal impairment on the pharmacokinetics of haloperidol has not been evaluated. No dose adjustment is recommended, but caution is advised when treating patients with renal impairment. However, patients with severe renal impairment may require a lower initial dose, with subsequent adjustments at smaller increments and at longer intervals than in patients without renal impairment.
Hepatic impairment
The influence of hepatic impairment on the pharmacokinetics of haloperidol has not been evaluated. Since haloperidol is extensively metabolised in the liver, it is recommended to halve the initial dose, and adjust the dose with smaller increments and at longer intervals than in patients without hepatic impairment.
Paediatric population
The dose recommendations for Lemonamin oral solution are presented in Table 4.
Table 4: Haloperidol dose recommendations for paediatric population
| Treatment of schizophrenia in adolescents aged 13 to 17 years when other pharmacological treatments have failed or are not tolerated - The recommended dose is 0.5 to 3 mg/day, administered orally in divided doses (2 to 3 times a day). - It is recommended to assess the individual benefit-risk when considering doses above 3 mg/day. - The maximum recommended dose is 5 mg/day. - The treatment duration must be individually evaluated. |
| Treatment of persistent, severe aggression in children and adolescents aged 6 to 17 years with autism or pervasive developmental disorders, when other treatments have failed or are not tolerated - The recommended doses are 0.5 to 3 mg/day in children aged 6 to 11 years and 0.5 to 5 mg/day in adolescents aged 12 to 17 years, administered orally in divided doses (2 to 3 times a day). - The need for continued treatment must be reassessed after 6 weeks. |
| Treatment of tic disorders, including Tourette's syndrome, in children and adolescents aged 10 to 17 years with severe impairment after educational, psychological and other pharmacological treatments have failed - The recommended doses are 0.5 to 3 mg/day in children and adolescents aged 10 to 17 years, administered orally in divided doses (2 to 3 times a day). - The need for continued treatment must be reassessed every 6 to 12 months. |
The safety and efficacy of Lemonamin oral solution in children below the ages defined in the indications have not been established. Data are not available for children aged less than 3 years.
Method of administration
Lemonamin oral solution is for oral use. It may be mixed with water to facilitate dose administration, but it must not be mixed with any other liquid. The diluted solution must be taken immediately.
Posology
Adults
A low initial dose is recommended, which subsequently may be adjusted according to the patient's response. Patients must always be maintained on the minimal effective dose.
Oral solution:
The dose recommendations for HALDOL oral solution are presented in Table 1.
Table 1: Haloperidol dose recommendations for adults aged 18 years and above
| Treatment of schizophrenia and schizoaffective disorder - 2 to 10 mg/day orally, as a single dose or in 2 divided doses. Patients with first-episode schizophrenia generally respond to 2 to 4 mg/day, whereas patients with multiple-episode schizophrenia may need doses up to 10 mg /day. - Adjustments to the dose may be made every 1 to 7 days. - Doses above 10 mg/day have not demonstrated superior efficacy to lower doses in the majority of patients and may cause an increased incidence of extrapyramidal symptoms. The individual benefit-risk should be assessed when considering doses above 10 mg/day. - The maximum dose is 20 mg/day because safety concerns outweigh the clinical benefits of treatment at higher doses. |
| Acute treatment of delirium when non-pharmacological treatments have failed - 1 to 10 mg/day orally, as a single dose or in 2 to 3 divided doses. - Treatment should be started at the lowest possible dose, and the dose should be adjusted in increments at 2- to 4-hour intervals if agitation continues, up to a maximum of 10 mg/day. |
| Treatment of moderate to severe manic episodes associated with bipolar I disorder - 2 to 10 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 3 days. - Doses above 10 mg/day have not demonstrated superior efficacy to lower doses in the majority of patients and may cause an increased incidence of extrapyramidal symptoms. The individual benefit-risk should be assessed when considering doses above 10 mg/day. - The maximum dose is 15 mg/day because safety concerns outweigh the clinical benefits of treatment at higher doses. - The continued use of HALDOL should be evaluated early in treatment. |
| Treatment of acute psychomotor agitation associated with psychotic disorder or manic episodes of bipolar I disorder - 5 to 10 mg orally, repeated after 12 hours if necessary to a maximum of 20 mg/day. - The continued use of HALDOL should be evaluated early in treatment. - When switching from haloperidol intramuscular injection, HALDOL orally should be initiated at a 1:1 dose conversion rate followed by dose adjustment according to clinical response. |
| Treatment of persistent aggression and psychotic symptoms in patients with moderate to severe Alzheimer's dementia and vascular dementia when non-pharmacological treatments have failed and when there is a risk of harm to self or others - 0.5 to 5 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 3 days. - The need for continued treatment must be reassessed after no more than 6 weeks. |
| Treatment of tic disorders, including Tourette's syndrome, in patients with severe impairment after educational, psychological and other pharmacological treatments have failed - 0.5 to 5 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 7 days. - The need for continued treatment must be reassessed every 6 to 12 months. |
| Treatment of mild to moderate chorea in Huntington's disease, when other medicinal products are ineffective or not tolerated - 2 to 10 mg/day orally, as a single dose or in 2 divided doses. - Adjustments to the dose may be made every 1 to 3 days. |
2 mg/ml oral solution:
The HALDOL 2 mg/ml oral solution in a bottle with an oral syringe is intended to be used for single doses of 0.5 mg haloperidol and above (equivalent to 0.25 ml and above).
The quantity (ml) required to achieve a given single dose using HALDOL 2 mg/ml oral solution is presented in Table 2.
Table 2: Conversion table for HALDOL 2 mg/ml oral solution
| mg haloperidol | ml HALDOL (bottle with oral syringe) |
| 0.1 mg | - |
| 0.2 mg | - |
| 0.3 mg | - |
| 0.4 mg | - |
| 0.5 mg | 0.25 ml |
| 1 mg | 0.5 ml |
| 2 mg | 1 ml |
| 5 mg | 2.5 ml |
| 10 mg | 5 ml |
| 15 mg | 7.5 ml |
| 20 mg | 10 ml |
Treatment withdrawal
Gradual withdrawal of haloperidol is advisable.
Missed dose
If patients miss a dose, it is recommended that they take the next dose as usual, and do not take a double dose.
Special populations
Elderly
The following initial haloperidol doses are recommended in elderly patients:
- Treatment of persistent aggression and psychotic symptoms in patients with moderate to severe Alzheimer's dementia and vascular dementia when non-pharmacological treatments have failed and when there is a risk of harm to self or others - 0.5 mg/day.
- All other indications - half the lowest adult dose.
The haloperidol dose may be adjusted according to the patient's response. Careful and gradual dose up-titration in elderly patients is recommended.
The maximum dose in elderly patients is 5 mg/day.
Doses above 5 mg/day should only be considered in patients who have tolerated higher doses and after reassessment of the patient's individual benefit-risk profile.
Renal impairment
The influence of renal impairment on the pharmacokinetics of haloperidol has not been evaluated. No dose adjustment is recommended, but caution is advised when treating patients with renal impairment. However, patients with severe renal impairment may require a lower initial dose, with subsequent adjustments at smaller increments and at longer intervals than in patients without renal impairment.
Hepatic impairment
The influence of hepatic impairment on the pharmacokinetics of haloperidol has not been evaluated. Since haloperidol is extensively metabolised in the liver, it is recommended to halve the initial dose, and adjust the dose with smaller increments and at longer intervals than in patients without hepatic impairment.
Paediatric population
The dose recommendations for HALDOL oral solution are presented in Table 4.
Table 4: Haloperidol dose recommendations for paediatric population
| Treatment of schizophrenia in adolescents aged 13 to 17 years when other pharmacological treatments have failed or are not tolerated - The recommended dose is 0.5 to 3 mg/day, administered orally in divided doses (2 to 3 times a day). - It is recommended to assess the individual benefit-risk when considering doses above 3 mg/day. - The maximum recommended dose is 5 mg/day. - The treatment duration must be individually evaluated. |
| Treatment of persistent, severe aggression in children and adolescents aged 6 to 17 years with autism or pervasive developmental disorders, when other treatments have failed or are not tolerated - The recommended doses are 0.5 to 3 mg/day in children aged 6 to 11 years and 0.5 to 5 mg/day in adolescents aged 12 to 17 years, administered orally in divided doses (2 to 3 times a day). - The need for continued treatment must be reassessed after 6 weeks. |
| Treatment of tic disorders, including Tourette's syndrome, in children and adolescents aged 10 to 17 years with severe impairment after educational, psychological and other pharmacological treatments have failed - The recommended doses are 0.5 to 3 mg/day in children and adolescents aged 10 to 17 years, administered orally in divided doses (2 to 3 times a day). - The need for continued treatment must be reassessed every 6 to 12 months. |
The safety and efficacy of HALDOL oral solution in children below the ages defined in the indications have not been established. Data are not available for children aged less than 3 years.
Method of administration
HALDOL oral solution is for oral use. It may be mixed with water to facilitate dose administration, but it must not be mixed with any other liquid. The diluted solution must be taken immediately.
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- Comatose state.
- Central nervous system (CNS) depression.
- Parkinson's disease.
- Dementia with Lewy bodies.
- Progressive supranuclear palsy.
- Known QTc interval prolongation or congenital long QT syndrome.
- Recent acute myocardial infarction.
- Uncompensated heart failure.
- History of ventricular arrhythmia or torsades de pointes.
- Uncorrected hypokalaemia.
- Concomitant treatment with medicinal products that prolong the QT interval.
Please also refer to 'Drug Interactions' section. Caution is advised in patients with renal failure and phaeochromocytoma.
Administer with care to patients with severe cardiovascular disorders, because of the possibility of transient hypotension. Should hypotension occur and a vasopressor be required, adrenaline should not be used since Lemonamin may block its vasopressor activity and further lowering of the blood pressure may occur.
Cases of sudden and unexplained death have been reported in psychiatric patients receiving antipsychotic drugs, including Lemonamin. However, the limited nature of the available data makes it difficult to determine the contributory role, if any, of the drug. Ventricular arrhythmias have been reported rarely. In most instances, they were of questionable relationship to Lemonamin treatments, they may occur more frequently with high doses and in pre-disposed patients.
The risk-benefit of Lemonamin treatment should be fully assessed before treatment is commenced and patients with risk factors for ventricular arrhythmias such as cardiac disease, family history of sudden death and/or QT prolongation; uncorrected electrolyte disturbances; subarachnoid haemorrhage, metabolic abnormalities such as hypokalaemia, hypocalcaemia or hypomagnesaemia, starvation, alcohol abuse, or those receiving concomitant therapy with other drugs known to prolong the QT interval , should be monitored carefully (ECGs and potassium levels), particularly during the initial phase of treatment, to obtain steady plasma levels. Lemonamin should be used in caution in patients known to be slow metabolisers of CYP2D6, and during the use of cytochrome P450 inhibitors.
Caution should be used in patients with cardiovascular disease or family history of QT prolongation and a baseline ECG should be carried out prior to treatment. During therapy, the need for ECG monitoring should be assessed in an individual patient basis. Whilst on therapy, reduce the dose if QT interval is prolonged and discontinue if QTc is >500ms. Periodic electrolyte monitoring recommended, especially for patients taking diuretics, or during intercurrent illness and avoid concomitant neuroleptics.
Cases of venous thromboembolism (VTE) have been reported with antipsychotic drugs. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with Lemonamin 10mg/5ml Oral Solution and preventive measures undertaken.
Acute withdrawal symptoms including nausea, vomiting and insomnia have very rarely been described after abrupt cessation of high doses of antipsychotic drugs. Relapse may also occur and gradual withdrawal is advisable.
In schizophrenia, the response to antipsychotic drug treatment may be delayed. If drugs are withdrawn, recurrence of symptoms may not become apparent for several weeks or months.
As with all antipsychotic agents, Lemonamin should not be used alone where depression is predominant. It may be combined with antidepressants to treat those conditions in which depression and psychosis coexist. Lemonamin may impair the metabolism of tricyclic antidepressants (clinical significance unknown). If concomitant anti-parkinson medication is required, it may have to be continued after Lemonamin is discontinued to take account of any differences in excretion rates. The physician should keep in mind the possible anticholinergic effects associated with anti-parkinson agents.
An approximately 3-fold increased risk of cerebrovascular adverse events have been seen in randomised placebo controlled clinical trials in the dementia population with some atypical antipsychotics. The mechanism for this increased risk is not known. Lemonamin should be used with caution in patients with risk factors for stroke.
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 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 about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., 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.
Lemonamin 10mg/5ml Oral Solution is not licensed for the treatment of dementia-related behavioural disturbances.
Neuroleptic malignant syndrome
In common with other antipsychotic drugs, Lemonamin has been associated with neuroleptic malignant syndrome: a rare idiosyncratic response characterised by hyperthermia, generalised muscle rigidity, autonomic instability, altered consciousness. Hyperthermia is often an early sign of this syndrome. Antipsychotic treatment should be withdrawn immediately and appropriate supportive therapy and careful monitoring instituted.
Tardive dyskinesia
As with all antipsychotic agents, tardive dyskinesia may appear in some patients on long-term therapy or after drug discontinuation. The syndrome is mainly characterised by rhythmic involuntary movements of the tongue, face, mouth or jaw. The manifestations may be permanent in some patients. The syndrome may be masked when treatment is reinstituted, when the dosage is increased or when a switch is made to a different antipsychotic drug. Treatment should be discontinued as soon as possible.
Extrapyramidal symptoms
In common with all neuroleptics, extrapyramidal symptoms may occur, e.g. tremor, rigidity, hypersalivation, bradykinesia, akathisia, acute dystonia.
Available safety data in the paediatric population indicate a risk of extrapyramidal symptoms, including tardive dyskinesia, and sedation. No long-term safety data are available.
Antiparkinson drugs of the anticholinergic type may be prescribed as required, but should not be prescribed routinely as a preventive measure. If concomitant antiparkinson medication is required, it may have to be continued after stopping Lemonamin if its excretion is faster than that of Lemonamin in order to avoid the development or aggravation of extrapyramidal symptoms. The physician should keep in mind the possible increase in intraocular pressure when anticholinergic drugs, including antiparkinson agents, are administered concomitantly with Lemonamin.
Seizures/Convulsions
It has been reported that seizures can be triggered by Lemonamin. Caution is advised in patients suffering from epilepsy and in conditions predisposing to convulsions (e.g., alcohol withdrawal and brain damage).
Hepatobiliary concerns
As Lemonamin is metabolised by the liver, caution is advised in patients with liver disease. Isolated cases of liver function abnormalities or hepatitis, most often cholestatic, have been reported.
Endocrine system concerns
Thyroxin may facilitate Lemonamin toxicity. Antipsychotic therapy in patients with hyperthyroidism should be used only with great caution and must always be accompanied by therapy to achieve a euthyroid state.
Hormonal effects of antipsychotic neuroleptic drugs include hyperprolactinaemia, which may cause galactorrhoea, gynaecomastia and oligo- or amenorrhoea. Very rare cases of hypoglycaemia and of Syndrome of Inappropriate ADH Secretion have been reported.
Excipient Warnings
This product contains parahydroxybenzoates which may cause allergic reactions (possibly delayed)
Increased mortality in elderly people with dementia
Rare cases of sudden death have been reported in psychiatric patients receiving antipsychotics, including haloperidol.
Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death. Analyses of seventeen placebo-controlled studies (modal duration of 10 weeks), largely in patients taking atypical antipsychotics, revealed a risk of death in 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 study, the rate of death in patients treated with antipsychotics was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that treatment of elderly patients with haloperidol is also associated with increased mortality. This association may be stronger for haloperidol than for atypical antipsychotic medicinal products, is most pronounced in the first 30 days after the start of treatment, and persists for at least 6 months. The extent to which this association is attributable to the medicinal product, as opposed to being confounded by patient characteristics, has not yet been elucidated.
Cardiovascular effects
QTc prolongation and/or ventricular arrhythmias, in addition to sudden death, have been reported with haloperidol. The risk of these events appears to increase with high doses, high plasma concentrations, in predisposed patients or with parenteral use, particularly intravenous administration.
Caution is advised in patients with bradycardia, cardiac disease, family history of QTc prolongation or history of heavy alcohol exposure.).
A baseline ECG is recommended before treatment. During therapy, the need for ECG monitoring for QTc interval prolongation and for ventricular arrhythmias must be assessed in all patients. Whilst on therapy, it is recommended to reduce the dose if QTc is prolonged, but haloperidol must be discontinued if the QTc exceeds 500 ms.
Electrolyte disturbances such as hypokalaemia and hypomagnesaemia increase the risk for ventricular arrhythmias and must be corrected before treatment with haloperidol is started. Therefore, baseline and periodic electrolyte monitoring is recommended.
Tachycardia and hypotension (including orthostatic hypotension) have also been reported. Caution is recommended when haloperidol is administered to patients manifesting hypotension or orthostatic hypotension.
Cerebrovascular events
In randomised, placebo-controlled clinical studies in the dementia population, there was an approximately 3-fold increased risk of cerebrovascular adverse events with some atypical antipsychotics. Observational studies comparing the stroke rate in elderly patients exposed to any antipsychotic to the stroke rate in those not exposed to such medicinal products found an increased stroke rate among exposed patients. This increase may be higher with all butyrophenones, including haloperidol. The mechanism for this increased risk is not known. An increased risk cannot be excluded for other patient populations. Lemonamin must be used with caution in patients with risk factors for stroke.
Neuroleptic malignant syndrome
Haloperidol has been associated with neuroleptic malignant syndrome: a rare idiosyncratic response characterized by hyperthermia, generalised muscle rigidity, autonomic instability, altered consciousness and increased serum creatine phosphokinase levels. Hyperthermia is often an early sign of this syndrome. Antipsychotic treatment must be withdrawn immediately and appropriate supportive therapy and careful monitoring instituted.
Tardive dyskinesia
Tardive dyskinesia may appear in some patients on long-term therapy or after discontinuation of the medicinal product. The syndrome is mainly characterized by rhythmic involuntary movements of the tongue, face, mouth or jaw. The manifestations may be permanent in some patients. The syndrome may be masked when treatment is reinstituted, when the dose is increased or when a switch is made to a different antipsychotic. If signs and symptoms of tardive dyskinesia appear, the discontinuation of all antipsychotics, including Lemonamin, must be considered.
Extrapyramidal symptoms
Extrapyramidal symptoms may occur (e.g. tremor, rigidity, hypersalivation, bradykinesia, akathisia, acute dystonia). The use of haloperidol has been associated with the development of akathisia, characterised by a subjectively unpleasant or distressing restlessness and need to move, often accompanied by an inability to sit or stand still. This is most likely to occur within the first few weeks of treatment. In patients who develop these symptoms, increasing the dose may be detrimental.
Acute dystonia may occur during the first few days of treatment with Lemonamin, but later onset as well as onset after dose increases has been reported. Dystonic symptoms can include, but are not limited to, torticollis, facial grimacing, trismus, tongue protrusion, and abnormal eye movements, including oculogyric crisis. Males and younger age groups are at higher risk of experiencing such reactions. Acute dystonia may necessitate stopping the medicinal product.
Antiparkinson medicinal products of the anticholinergic type may be prescribed as required to manage extrapyramidal symptoms, but it is recommended that they are not prescribed routinely as a preventive measure. If concomitant treatment with an antiparkinson medicinal product is required, it may have to be continued after stopping Lemonamin if its excretion is faster than that of haloperidol in order to avoid the development or aggravation of extrapyramidal symptoms. The possible increase in intraocular pressure must be considered when anticholinergic medicinal products, including antiparkinson medicinal products, are administered concomitantly with Lemonamin.
Seizures/convulsions
It has been reported that seizures can be triggered by haloperidol. Caution is advised in patients suffering from epilepsy and in conditions predisposing to seizures (e.g. alcohol withdrawal and brain damage).
Hepatobiliary concerns
As haloperidol is metabolised by the liver, dose adjustment and caution is advised in patients with hepatic impairment. Isolated cases of liver function abnormalities or hepatitis, most often cholestatic, have been reported.
Endocrine system concerns
Thyroxin may facilitate haloperidol toxicity. Antipsychotic therapy in patients with hyperthyroidism must be used only with caution and must always be accompanied by therapy to achieve a euthyroid state.
Hormonal effects of antipsychotics include hyperprolactinaemia, which may cause galactorrhoea, gynaecomastia and oligomenorrhea or amenorrhoea. Tissue culture studies suggest that cell growth in human breast tumours may be stimulated by prolactin. Although no clear association with the administration of antipsychotics and human breast tumours has been demonstrated in clinical and epidemiological studies, caution is recommended in patients with relevant medical history. Lemonamin must be used with caution in patients with pre-existing hyperprolactinaemia and in patients with possible prolactin-dependent tumours.
Hypoglycaemia and syndrome of inappropriate antidiuretic hormone secretion have been reported with haloperidol.
Venous thromboembolism
Cases of venous thromboembolism (VTE) have been reported with antipsychotics. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with Lemonamin and preventive measures undertaken.
Treatment response and withdrawal
In schizophrenia, the response to antipsychotic treatment may be delayed.
If antipsychotics are withdrawn, recurrence of symptoms related to the underlying condition may not become apparent for several weeks or months.
There have been very rare reports of acute withdrawal symptoms (including nausea, vomiting and insomnia) after abrupt withdrawal of high doses of antipsychotics. Gradual withdrawal is advisable as a precautionary measure.
Patients with depression
It is recommended that Lemonamin is not used alone in patients in whom depression is predominant. It may be combined with antidepressants to treat those conditions in which depression and psychosis coexist.
Switch from mania to depression
There is a risk in the treatment of manic episodes of bipolar disorder for patients to switch from mania to depression. Monitoring of patients for the switch to a depressive episode with the accompanying risks such as suicidal behaviour is important in order to intervene when such switches occur.
Poor metabolisers of CYP2D6
Lemonamin should be used with caution in patients who are known poor metabolisers of cytochrome P450 (CYP) 2D6 and who are coadministered a CYP3A4 inhibitor.
Paediatric population
Available safety data in the paediatric population indicate a risk of developing extrapyramidal symptoms, including tardive dyskinesia, and sedation. Limited long-term safety data are available.
Increased mortality in elderly people with dementia
Rare cases of sudden death have been reported in psychiatric patients receiving antipsychotics, including haloperidol.
Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death. Analyses of seventeen placebo-controlled studies (modal duration of 10 weeks), largely in patients taking atypical antipsychotics, revealed a risk of death in 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 study, the rate of death in patients treated with antipsychotics was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that treatment of elderly patients with haloperidol is also associated with increased mortality. This association may be stronger for haloperidol than for atypical antipsychotic medicinal products, is most pronounced in the first 30 days after the start of treatment, and persists for at least 6 months. The extent to which this association is attributable to the medicinal product, as opposed to being confounded by patient characteristics, has not yet been elucidated.
Cardiovascular effects
QTc prolongation and/or ventricular arrhythmias, in addition to sudden death, have been reported with haloperidol. The risk of these events appears to increase with high doses, high plasma concentrations, in predisposed patients or with parenteral use, particularly intravenous administration.
Caution is advised in patients with bradycardia, cardiac disease, family history of QTc prolongation or history of heavy alcohol exposure.).
A baseline ECG is recommended before treatment. During therapy, the need for ECG monitoring for QTc interval prolongation and for ventricular arrhythmias must be assessed in all patients. Whilst on therapy, it is recommended to reduce the dose if QTc is prolonged, but haloperidol must be discontinued if the QTc exceeds 500 ms.
Electrolyte disturbances such as hypokalaemia and hypomagnesaemia increase the risk for ventricular arrhythmias and must be corrected before treatment with haloperidol is started. Therefore, baseline and periodic electrolyte monitoring is recommended.
Tachycardia and hypotension (including orthostatic hypotension) have also been reported. Caution is recommended when haloperidol is administered to patients manifesting hypotension or orthostatic hypotension.
Cerebrovascular events
In randomised, placebo-controlled clinical studies in the dementia population, there was an approximately 3-fold increased risk of cerebrovascular adverse events with some atypical antipsychotics. Observational studies comparing the stroke rate in elderly patients exposed to any antipsychotic to the stroke rate in those not exposed to such medicinal products found an increased stroke rate among exposed patients. This increase may be higher with all butyrophenones, including haloperidol. The mechanism for this increased risk is not known. An increased risk cannot be excluded for other patient populations. HALDOL must be used with caution in patients with risk factors for stroke.
Neuroleptic malignant syndrome
Haloperidol has been associated with neuroleptic malignant syndrome: a rare idiosyncratic response characterized by hyperthermia, generalised muscle rigidity, autonomic instability, altered consciousness and increased serum creatine phosphokinase levels. Hyperthermia is often an early sign of this syndrome. Antipsychotic treatment must be withdrawn immediately and appropriate supportive therapy and careful monitoring instituted.
Tardive dyskinesia
Tardive dyskinesia may appear in some patients on long-term therapy or after discontinuation of the medicinal product. The syndrome is mainly characterized by rhythmic involuntary movements of the tongue, face, mouth or jaw. The manifestations may be permanent in some patients. The syndrome may be masked when treatment is reinstituted, when the dose is increased or when a switch is made to a different antipsychotic. If signs and symptoms of tardive dyskinesia appear, the discontinuation of all antipsychotics, including HALDOL, must be considered.
Extrapyramidal symptoms
Extrapyramidal symptoms may occur (e.g. tremor, rigidity, hypersalivation, bradykinesia, akathisia, acute dystonia). The use of haloperidol has been associated with the development of akathisia, characterised by a subjectively unpleasant or distressing restlessness and need to move, often accompanied by an inability to sit or stand still. This is most likely to occur within the first few weeks of treatment. In patients who develop these symptoms, increasing the dose may be detrimental.
Acute dystonia may occur during the first few days of treatment with HALDOL, but later onset as well as onset after dose increases has been reported. Dystonic symptoms can include, but are not limited to, torticollis, facial grimacing, trismus, tongue protrusion, and abnormal eye movements, including oculogyric crisis. Males and younger age groups are at higher risk of experiencing such reactions. Acute dystonia may necessitate stopping the medicinal product.
Antiparkinson medicinal products of the anticholinergic type may be prescribed as required to manage extrapyramidal symptoms, but it is recommended that they are not prescribed routinely as a preventive measure. If concomitant treatment with an antiparkinson medicinal product is required, it may have to be continued after stopping HALDOL if its excretion is faster than that of haloperidol in order to avoid the development or aggravation of extrapyramidal symptoms. The possible increase in intraocular pressure must be considered when anticholinergic medicinal products, including antiparkinson medicinal products, are administered concomitantly with HALDOL.
Seizures/convulsions
It has been reported that seizures can be triggered by haloperidol. Caution is advised in patients suffering from epilepsy and in conditions predisposing to seizures (e.g. alcohol withdrawal and brain damage).
Hepatobiliary concerns
As haloperidol is metabolised by the liver, dose adjustment and caution is advised in patients with hepatic impairment. Isolated cases of liver function abnormalities or hepatitis, most often cholestatic, have been reported.
Endocrine system concerns
Thyroxin may facilitate haloperidol toxicity. Antipsychotic therapy in patients with hyperthyroidism must be used only with caution and must always be accompanied by therapy to achieve a euthyroid state.
Hormonal effects of antipsychotics include hyperprolactinaemia, which may cause galactorrhoea, gynaecomastia and oligomenorrhea or amenorrhoea. Tissue culture studies suggest that cell growth in human breast tumours may be stimulated by prolactin. Although no clear association with the administration of antipsychotics and human breast tumours has been demonstrated in clinical and epidemiological studies, caution is recommended in patients with relevant medical history. HALDOL must be used with caution in patients with pre-existing hyperprolactinaemia and in patients with possible prolactin-dependent tumours.
Hypoglycaemia and syndrome of inappropriate antidiuretic hormone secretion have been reported with haloperidol.
Venous thromboembolism
Cases of venous thromboembolism (VTE) have been reported with antipsychotics. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with HALDOL and preventive measures undertaken.
Treatment response and withdrawal
In schizophrenia, the response to antipsychotic treatment may be delayed.
If antipsychotics are withdrawn, recurrence of symptoms related to the underlying condition may not become apparent for several weeks or months.
There have been very rare reports of acute withdrawal symptoms (including nausea, vomiting and insomnia) after abrupt withdrawal of high doses of antipsychotics. Gradual withdrawal is advisable as a precautionary measure.
Patients with depression
It is recommended that HALDOL is not used alone in patients in whom depression is predominant. It may be combined with antidepressants to treat those conditions in which depression and psychosis coexist.
Switch from mania to depression
There is a risk in the treatment of manic episodes of bipolar disorder for patients to switch from mania to depression. Monitoring of patients for the switch to a depressive episode with the accompanying risks such as suicidal behaviour is important in order to intervene when such switches occur.
Poor metabolisers of CYP2D6
HALDOL should be used with caution in patients who are known poor metabolisers of cytochrome P450 (CYP) 2D6 and who are coadministered a CYP3A4 inhibitor.
Paediatric population
Available safety data in the paediatric population indicate a risk of developing extrapyramidal symptoms, including tardive dyskinesia, and sedation. Limited long-term safety data are available.
Some degree of sedation or impairment of alertness may occur, particularly with higher doses and at the start of treatment and may be potentiated by alcohol or other CNS depressants. Patients should be advised not to undertake activities requiring alertness such as driving or operating machinery during treatment, until their susceptibility is known.
Lemonamin has a moderate influence on the ability to drive and use machines. Some degree of sedation or impairment of alertness may occur, particularly with higher doses and at the start of treatment and may be potentiated by alcohol. It is recommended that patients be advised not to drive or operate machines during treatment, until their susceptibility is known.
HALDOL has a moderate influence on the ability to drive and use machines. Some degree of sedation or impairment of alertness may occur, particularly with higher doses and at the start of treatment and may be potentiated by alcohol. It is recommended that patients be advised not to drive or operate machines during treatment, until their susceptibility is known.
The safety of haloperidol was evaluated in 284 haloperidol-treated patients who participated in 3 placebo-controlled clinical studies and in 1295 haloperidol-treated patients who participated in 16 double-blind active comparator-controlled clinical studies.
Based on pooled safety data from these clinical studies, the most commonly reported adverse reactions were: extrapyramidal disorder (34%), insomnia (19%), agitation (15%), hyperkinesia (13%), headache (12%), psychotic disorder (9%), depression (8%), weight increased (8%), tremor (8%), hypertonia (7%), orthostatic hypotension (7%), dystonia (6%) and somnolence (5%).
In addition, the safety of haloperidol decanoate was evaluated in 410 patients who participated in 3 comparator studies (1 comparing haloperidol decanoate versus fluphenazine and 2 comparing the decanoate formulation to oral haloperidol), 9 open label studies and 1 dose response study.
Table 5 lists adverse reactions as follows:
- Reported in clinical studies with haloperidol.
- Reported in clinical studies with haloperidol decanoate and relate to the active moiety.
- From postmarketing experience with haloperidol and haloperidol decanoate.
Adverse reaction frequencies are based on (or estimated from) clinical trials or epidemiology studies with haloperidol, and classified using the following convention:
| Very common: Common: Uncommon: Rare: Very rare: Not known: | >1/10 >1/100 to <1/10 >1/1,000 to <1/100 >1/10,000 to <1/1,000 <1/10,000 cannot be estimated from the available data. |
The adverse reactions are presented by System Organ Class and in order of decreasing seriousness within each frequency category.
Table 5: Adverse reactions
| System Organ Class | Adverse Reaction | ||||
| Frequency | |||||
| Very Common | Common
| Uncommon
| Rare
| Not known | |
| Blood and lymphatic system disorders | Leukopenia | Pancytopenia Agranulocytosis Thrombocytopenia Neutropenia | |||
| Immune system disorders | Hypersensitivity | Anaphylactic reaction | |||
| Endocrine disorders | Hyperprolactinaemia | Inappropriate antidiuretic hormone secretion | |||
| Metabolic and nutritional disorders | Hypoglycaemia | ||||
| Psychiatric disorders | Agitation Insomnia | Psychotic disorder Depression | Confusional state Loss of libido Libido decreased Restlessness | ||
| Nervous system disorders | Extrapyramidal disorder Hyperkinesia Headache | Tardive dyskinesia Akathisia Bradykinesia Dyskinesia Dystonia Hypokinesia Hypertonia Dizziness Somnolence Tremor | Convulsion Parkinsonism Sedation Muscle contractions involuntary | Neuroleptic malignant syndrome Motor dysfunction Nystagmus | Akinesia Cogwheel rigidity Masked facies |
| Eye disorders | Oculogyric crisis Visual disturbance | Vision blurred | |||
| Cardiac disorders | Tachycardia | Ventricular fibrillation Torsade de pointes Ventricular tachycardia Extrasystoles | |||
| Vascular disorders | Hypotension Orthostatic hypotension | ||||
| Respiratory, thoracic and mediastinal disorders | Dyspnoea | Bronchospasm | Laryngeal oedema Laryngospasm | ||
| Gastrointestinal disorders | Vomiting Nausea Constipation Dry mouth Salivary hypersecretion | ||||
| Hepatobiliary disorders | Liver function test abnormal | Hepatitis Jaundice | Acute hepatic failure Cholestasis | ||
| Skin and subcutaneous tissue disorders | Rash | Photosensitivity reaction Urticaria Pruritus Hyperhidrosis | Angioedema Dermatitis exfoliative Leukocytoclastic vasculitis | ||
| Musculoskeletal and connective tissue disorders | Torticollis Muscle rigidity Muscle spasms Musculoskeletal stiffness | Trismus Muscle twitching | Rhabdomyolysis | ||
| Renal and urinary disorders | Urinary retention | ||||
| Pregnancy, puerperium and perinatal conditions | Drug withdrawal syndrome neonatal | ||||
| Reproductive system and breast disorders | Erectile dysfunction | Amenorrhoea Galactorrhoea Dysmenorrhoea Breast pain Breast discomfort | Menorrhagia Menstrual disorder Sexual dysfunction | Priapism Gynaecomastia | |
| General disorders and administration site conditions | Hyperthermia Oedema Gait disturbance | Sudden death Face oedema Hypothermia | |||
| Investigations | Weight increased Weight decreased | Electrocardiogram QT prolonged | |||
Electrocardiogram QT prolonged, ventricular arrhythmias (ventricular fibrillation, ventricular tachycardia), torsade de pointes and sudden death have been reported with haloperidol.
Class effects of antipsychotics
Cardiac arrest has been reported with antipsychotics.
Cases of venous thromboembolism, including cases of pulmonary embolism and cases of deep vein thrombosis, have been reported with antipsychotics. The frequency is unknown.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.
Symptoms and signs
The manifestations of haloperidol overdose are an exaggeration of the known pharmacological effects and adverse reactions. The most prominent symptoms are severe extrapyramidal reactions, hypotension and sedation. An extrapyramidal reaction is manifest by muscular rigidity and a generalised or localised tremor. Hypertension rather than hypotension is also possible.
In extreme cases, the patient would appear comatose with respiratory depression and hypotension that could be severe enough to produce a shock-like state. The risk of ventricular arrhythmias, possibly associated with QTc prolongation, must be considered.
Treatment
There is no specific antidote. Treatment is supportive. The efficacy of activated charcoal has not been established. Dialysis is not recommended in the treatment of overdose because it removes only very small amounts of haloperidol.
For comatose patients, a patent airway must be established by use of an oropharyngeal airway or endotracheal tube. Respiratory depression may necessitate artificial respiration.
It is recommended that ECG and vital signs be monitored, and that monitoring continues until the ECG is normal. Treatment of severe arrhythmias with appropriate anti-arrhythmic measures is recommended.
Hypotension and circulatory collapse may be counteracted by use of intravenous fluids, plasma or concentrated albumin and vasopressor agents, such as dopamine or noradrenaline. Adrenaline must not be used because it might cause profound hypotension in the presence of haloperidol.
In cases of severe extrapyramidal reactions, parenteral administration of an antiparkinson medicinal product is recommended.
Pharmacotherapeutic group: psycholeptics; antipsychotics; butyrophenone derivatives, ATC code: N05AD01.
Mechanism of action
Haloperidol is an antipsychotic belonging to the butyrophenones group. It is a potent central dopamine type 2 receptor antagonist, and at recommended doses, has low alpha-1 antiadrenergic activity and no antihistaminergic or anticholinergic activity.
Pharmacodynamic effects
Haloperidol suppresses delusions and hallucinations as a direct consequence of blocking dopaminergic signalling in the mesolimbic pathway. The central dopamine blocking effect has activity on the basal ganglia (nigrostriatal bundles). Haloperidol causes efficient psychomotor sedation, which explains the favourable effect on mania and other agitation syndromes.
The activity on the basal ganglia probably underlies the undesirable extrapyramidal motor effects (dystonia, akathisia and parkinsonism).
The antidopaminergic effects of haloperidol on lactotropes in the anterior pituitary explain hyperprolactinaemia due to inhibition of dopamine-mediated tonic inhibition of prolactin secretion.
Absorption
The average bioavailability of haloperidol after administration of the tablet or oral solution is 60 to 70%. Peak plasma levels of haloperidol are generally attained within 2 to 6 hours of oral dosing. A high inter-subject variability in plasma concentrations was observed. Steady state is reached within 1 week of treatment initiation.
Distribution
Mean haloperidol plasma protein binding in adults is approximately 88 to 92%. There is a high inter-subject variability for plasma protein binding. Haloperidol is rapidly distributed to various tissues and organs, as indicated by the large volume of distribution (mean values 8 to 21 l/kg after intravenous dosing). Haloperidol crosses the blood-brain barrier easily. It also crosses the placenta and is excreted in breast milk.
Biotransformation
Haloperidol is extensively metabolised in the liver. The main metabolic pathways of haloperidol in humans include glucuronidation, ketone reduction, oxidative N-dealkylation and formation of pyridinium metabolites. The metabolites of haloperidol are not considered to make a significant contribution to its activity; however, the reduction pathway accounts approximately for 23% of the biotransformation, and back-conversion of the reduced metabolite of haloperidol to haloperidol cannot be fully ruled out. The cytochrome P450 enzymes CYP3A4 and CYP2D6 are involved in haloperidol metabolism. Inhibition or induction of CYP3A4, or inhibition of CYP2D6, may affect haloperidol metabolism. A decrease in CYP2D6 enzyme activity may result in increased haloperidol concentrations.
Elimination
The terminal elimination half-life of haloperidol is on average 24 hours (range of means 15 to 37 hours) after oral administration. Haloperidol apparent clearance after extravascular administration ranges from 0.9 to 1.5 l/h/kg and is reduced in poor metabolisers of CYP2D6. Reduced CYP2D6 enzyme activity may result in increased concentrations of haloperidol. The inter-subject variability (coefficient of variation, %) in haloperidol clearance was estimated to be 44% in a population pharmacokinetic analysis in patients with schizophrenia. After intravenous haloperidol administration, 21% of the dose was eliminated in the faeces and 33% in the urine. Less than 3% of the dose is excreted unchanged in the urine.
Linearity/non-linearity
A linear relationship exists between haloperidol dose and plasma concentrations in adults.
Special populations
Elderly
Haloperidol plasma concentrations in elderly patients were higher than in younger adults administered the same dose. Results from small clinical studies suggest a lower clearance and a longer elimination half-life of haloperidol in elderly patients. The results are within the observed variability in haloperidol pharmacokinetics. Dose adjustment is recommended in elderly patients.
Renal impairment
The influence of renal impairment on the pharmacokinetics of haloperidol has not been evaluated. About one-third of a haloperidol dose is excreted in urine, mostly as metabolites. Less than 3% of administered haloperidol is eliminated unchanged in the urine. Haloperidol metabolites are not considered to make a significant contribution to its activity, although for the reduced metabolite of haloperidol, back-conversion to haloperidol cannot be fully ruled out. Even though impairment of renal function is not expected to affect haloperidol elimination to a clinically relevant extent, caution is advised in patients with renal impairment, and especially those with severe impairment, due to the long half-life of haloperidol and its reduced metabolite, and the possibility of accumulation.
Because of the high haloperidol distribution volume and its high protein binding, only very small amounts are removed by dialysis.
Hepatic impairment
The influence of hepatic impairment on the pharmacokinetics of haloperidol has not been evaluated. However, hepatic impairment may have significant effects on the pharmacokinetics of haloperidol because it is extensively metabolised in the liver. Therefore, dose adjustment and caution is advised in patients with hepatic impairment.
Paediatric population
Limited plasma concentration data were established in paediatric studies including 78 patients with various disorders (schizophrenia, psychotic disorder, Tourette's syndrome, autism) who received oral haloperidol doses up to a maximum of 30 mg/day. These studies included mainly children and adolescents aged between 2 and 17 years. Plasma concentrations measured at various time points and after various durations of treatment, were either undetectable or ranged up to a maximum of 44.3 ng/ml. As in adults, high inter-subject variability in plasma concentrations was observed. There was a trend toward shorter half-lives in children compared to adults.
In 2 studies in children receiving haloperidol treatment for tics and Tourette's syndrome, a positive response was associated with plasma concentrations of 1 to 4 ng/ml
Pharmacokinetic/pharmacodynamics relationships
Therapeutic concentrations
Based on published data from multiple clinical studies, therapeutic response is obtained in most patients with acute or chronic schizophrenia at plasma concentrations of 1 to 10 ng/ml. A subset of patients may require higher concentrations as a consequence of a high inter-subject variability in haloperidol pharmacokinetics.
In patients with first-episode schizophrenia, therapeutic response may be obtained at concentrations as low as 0.6 to 3.2 ng/ml, as estimated based on measurements of D2 receptor occupancy and assuming that a D2 receptor occupancy level of 60 to 80% is most appropriate for obtaining therapeutic response and limiting extrapyramidal symptoms. On average, concentrations in this range would be obtained with doses of 1 to 4 mg daily.
Due to the high inter-subject variability in haloperidol pharmacokinetics and the concentration-effect relationship, it is recommended to adjust the individual haloperidol dose based on the patient's response, taking into account data suggesting a lag time of 5 days to reach half of the maximal therapeutic response. Measurement of haloperidol blood concentrations may be considered in individual cases.
Cardiovascular effects
The risk of QTc prolongation increases with haloperidol dose and with haloperidol plasma concentrations.
Extrapyramidal symptoms
Extrapyramidal symptoms can occur within the therapeutic range, although the frequency is usually higher with doses producing higher than therapeutic concentrations.
Non-clinical data reveal no special hazards for humans based on conventional studies of repeat dose toxicity and genotoxicity. In rodents, haloperidol administration showed a decrease in fertility, limited teratogenicity as well as embryo-toxic effects.
In a carcinogenicity study of haloperidol, dose-dependent increases in pituitary gland adenomas and mammary gland carcinomas were seen in female mice. These tumours may be caused by prolonged dopamine D2 antagonism and hyperprolactinaemia. The relevance of these tumour findings in rodents in terms of human risk is unknown.
Haloperidol has been shown to block the cardiac hERG channel in several published studies in vitro. In a number of in vivo studies, intravenous administration of haloperidol in some animal models has caused significant QTc prolongation at doses around 0.3 mg/kg, producing Cmax plasma levels at least 7 to 14 times higher than the therapeutic plasma concentrations of 1 to 10 ng/ml that were effective in the majority of patients in clinical studies. These intravenous doses, which prolonged QTc, did not cause arrhythmias. In some animal studies, higher intravenous haloperidol doses of 1 mg/kg or greater caused QTc prolongation and/or ventricular arrhythmias at Cmax plasma levels at least 38 to 137 times higher than the therapeutic plasma concentrations that were effective in the majority of patients in clinical studies.
None known.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
