Antipsychotics equivalent doses

Antipsychotic drugs vary greatly in potency (not the same as efficacy) and this is usually expressed as differences in neuroleptic or chlorpromazine equivalents. Some of the estimates relating to neuroleptic equivalents are based on early dopamine binding studies and some largely on clinical experience or even inspired guesswork. BNF maximum doses for antipsychotic drugs bear little relationship to their neuroleptic equivalents. The following table gives some approximate equivalent doses for conventional drugs1,2. Values given should be seen as a rough guide when transferring from one conventional drug to another. An early review of progress is essential.

Table
Drug

Equivalent doses
Equivalent dose (consensus) 100 mg/day 2 mg/day 5 mg/day 3 mg/day 25 mg/day 3 mg/day 200 mg/day 2 mg/day 10 mg/day 5 mg/week 10 mg/week 10 mg/week 100 mg/week 15 mg/week Range of values in literature 25 mg/day 2.55 mg/day 23 mg/day 2560 mg/day 1.55 mg/day 200270 mg/day 2 mg/day 1025 mg/day 112.5 mg/week 1012.5 mg/week 1020 mg/week 40100 mg/week 525 mg/week

Chlorpromazine Fluphenazine Trifluoperazine Flupentixol Zuclopenthixol Haloperidol Sulpiride Pimozide Loxapine Fluphenazine depot Pipotiazine depot Flupentixol depot Zuclopenthixol depot Haloperidol depot

It is inappropriate to convert SGA doses into equivalents since the doseresponse relationship is usually well-defined for these drugs. Dosage guidelines are discussed under each individual drug. Those readers eager to find chlorpromazine equivalents for the newer drugs are directed to the only published paper listing such data3. References
1. 2. 3. Foster P. Neuroleptic equivalence. Pharm J 1989; 243:431432. Atkins M et al. Chlorpromazine equivalents: a consensus of opinion for both clinical and research implications. Psychiatr Bull 1997; 21:224226. Woods SW. Chlorpromazine equivalent doses for the newer atypical antipsychotics. J Clin Psychiatry 2003; 64:663667.

Taylor, David; Paton, Carol; Kapur, Shitij: The South London and Maudsley NHS Foundation Trust & Oxleas NHS Foundation Trust prescribing guidelines, Informa Healthcare 2009

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Schizophrenia

Antipsychotics minimum effective doses

The table below suggests the minimum dose of antipsychotic likely to be effective in schizophrenia (first episode or relapse). At least some patients will respond to the dose suggested, although others may require higher doses. Given the variation in individual response, all doses should be considered approximate. Primary references are provided where available, but consensus opinion has also been used (as have standard texts such as the BNF and SPC). Only oral treatment with commonly used drugs is covered.

Schizophrenia

Table Minimum effective dose/day antipsychotics

Drug FGAs Chlorpromazine Haloperidol15 Sulpiride6 Trifluoperazine7 SGAs Amisulpride810 Aripiprazole11,12 Asenapine13 Bifeprunox13 Iloperidone14,15 Olanzapine5,16,17 Paliperidone18 Quetiapine1922 Risperidone4,2325 Sertindole26 Ziprasidone2729 Zotepine30,31
*Estimate too few data available.

First episode

Relapse

200 mg* 2 mg 400 mg* 10 mg*

300 mg >4 mg 800 mg 15 mg

400 mg* 10 mg* Not known Not known 4 mg* 5 mg 3 mg* 150 mg* 12 mg Not appropriate 80 mg* 75 mg*

800 mg 10 mg 10 mg* 20 mg* 8 mg* 10 mg 3 mg 300 mg 34 mg 12 mg 80 mg 150 mg

References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Oosthuizen P et al. Determining the optimal dose of haloperidol in first-episode psychosis. J Psychopharmacol 2001; 15:251255. McGorry PD. Recommended haloperidol and risperidone doses in first-episode psychosis. J Clin Psychiatry 1999; 60:794795. Waraich PS et al. Haloperidol dose for the acute phase of schizophrenia. Cochrane Database Syst Rev 2002; CD001951. Schooler N et al. Risperidone and haloperidol in first-episode psychosis: a long-term randomized trial. Am J Psychiatry 2005; 162:947953. Keefe RS et al. Long-term neurocognitive effects of olanzapine or low-dose haloperidol in first-episode psychosis. Biol Psychiatry 2006; 59:97105. Soares BG et al. Sulpiride for schizophrenia. Cochrane Database Syst Rev 2000; CD001162. Armenteros JL et al. Antipsychotics in early onset Schizophrenia: Systematic review and meta-analysis. Eur Child Adolesc Psychiatry 2006; 15:141148. Mota NE et al. Amisulpride for schizophrenia. Cochrane Database Syst Rev 2002; CD001357. Puech A et al. Amisulpride, and atypical antipsychotic, in the treatment of acute episodes of schizophrenia: a dose-ranging study vs. haloperidol. The Amisulpride Study Group. Acta Psychiatr Scand 1998; 98:6572. Moller HJ et al. Improvement of acute exacerbations of schizophrenia with amisulpride: a comparison with haloperidol. PROD-ASLP Study Group. Psychopharmacology 1997; 132:396401. Taylor D. Aripiprazole: a review of its pharmacology and clinical utility. Int J Clin Pract 2003; 57:4954. Cutler AJ et al. The efficacy and safety of lower doses of aripiprazole for the treatment of patients with acute exacerbation of schizophrenia. CNS Spectr 2006; 11:691702. Bishara D et al. Upcoming agents for the treatment of schizophrenia. Mechanism of action, efficacy and tolerability. Drugs 2008; 68:22692296. Kane JM et al. Long-term efficacy and safety of iloperidone: results from 3 clinical trials for the treatment of schizophrenia. J Clin Psychopharmacol 2008; 28:S29S35. Potkin SG et al. Efficacy of iloperidone in the treatment of schizophrenia: initial phase 3 studies. J Clin Psychopharmacol 2008; 28:S411. Sanger TM et al. Olanzapine versus haloperidol treatment in first-episode psychosis. Am J Psychiatry 1999; 156:7987.

Taylor, David; Paton, Carol; Kapur, Shitij: The South London and Maudsley NHS Foundation Trust & Oxleas NHS Foundation Trust prescribing guidelines, Informa Healthcare 2009

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17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

Kasper S. Risperidone and olanzapine: optimal dosing for efficacy and tolerability in patients with schizophrenia. Int Clin Psychopharmacol 1998; 13:253262. Meltzer HY et al. Efficacy and tolerability of oral paliperidone extended-release tablets in the treatment of acute schizophrenia: pooled data from three 6-week, placebo-controlled studies. J Clin Psychiatry 2008; 69:817829. Small JG et al. Quetiapine in patients with schizophrenia. A high- and low-dose double-blind comparison with placebo. Seroquel Study Group. Arch Gen Psychiatry 1997; 54:549557. Peuskens J et al. A comparison of quetiapine and chlorpromazine in the treatment of schizophrenia. Acta Psychiatr Scand 1997; 96:265273. Arvanitis LA et al. Multiple fixed doses of "Seroquel" (quetiapine) in patients with acute exacerbation of schizophrenia: a comparison with haloperidol and placebo. Biol Psychiatry 1997; 42:233246. Kopala LC et al. Treatment of a first episode of psychotic illness with quetiapine: an analysis of 2 year outcomes. Schizophr Res 2006; 81:2939. Lane HY et al. Risperidone in acutely exacerbated schizophrenia: dosing strategies and plasma levels. J Clin Psychiatry 2000; 61:209214. Williams R. Optimal dosing with risperidone: updated recommendations. J Clin Psychiatry 2001; 62:282289. Ezewuzie N et al. Establishing a doseresponse relationship for oral risperidone in relapsed schizophrenia. J Psychopharmacol 2006; 20:8690. Lindstrom E et al. Sertindole: efficacy and safety in schizophrenia. Expert Opin Pharmacother 2006; 7:18251834. Bagnall A et al. Ziprasidone for schizophrenia and severe mental illness. Cochrane Database Syst Rev 2000; CD001945. Taylor D. Ziprasidone an atypical antipsychotic. Pharm J 2001; 266:396401. Joyce AT et al. Effect of initial ziprasidone dose on length of therapy in schizophrenia. Schizophr Res 2006; 83:285292. Petit M et al. A comparison of an atypical and typical antipsychotic, zotepine versus haloperidol in patients with acute exacerbation of schizophrenia: a parallel-group double-blind trial. Psychopharmacol Bull 1996; 32:8187. Palmgren K et al. The safety and efficacy of zotepine in the treatment of schizophrenia: results of a one-year naturalistic clinical trial. Int J Psychiatry Clin Pract 2000; 4:299306.

Further reading
Davis JM et al. Dose response and dose equivalence of antipsychotics. J Clin Psychopharmacol 2004; 24:192208.

Taylor, David; Paton, Carol; Kapur, Shitij: The South London and Maudsley NHS Foundation Trust & Oxleas NHS Foundation Trust prescribing guidelines, Informa Healthcare 2009

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Schizophrenia

Antipsychotics licensed maximum doses

The table below lists the UK licensed maximum doses of antipsychotics.
Schizophrenia Drug FGAs oral Chlorpromazine Flupentixol Haloperidol Levomepromazine Pericyazine Perphenazine Pimozide Sulpiride Trifluoperazine Zuclopenthixol SGAs oral Amisulpride Aripiprazole Clozapine Olanzapine Paliperidone Quetiapine Risperidone Sertindole Ziprasidone* Zotepine Depots Flupentixol depot Fluphenazine depot Haloperidol depot Pipotiazine depot Risperidone** Zuclopenthixol depot Maximum dose 1000 mg/day 18 mg/day 30 mg/day (See BNF) 1000 mg/day 300 mg/day 24 mg/day 20 mg/day 2400 mg/day None (suggest 30 mg/day) 150 mg/day 1200 mg/day 30 mg/day 900 mg/day 20 mg/day 12 mg/day 750/800 mg/day (see BNF) 16 mg/day (see BNF) 24 mg/day 160 mg/day 300 mg/day 400 mg/week 50 mg/week 300 mg every 4 weeks (see BNF) 50 mg/week 25 mg/week 600 mg/week

Note: Doses above these maxima should only be used in extreme circumstances: there is no evidence for improved efficacy. *Not available in the UK at time of publication, European labelling used. **May only be given two weekly.

Taylor, David; Paton, Carol; Kapur, Shitij: The South London and Maudsley NHS Foundation Trust & Oxleas NHS Foundation Trust prescribing guidelines, Informa Healthcare 2009

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