Haldol: Effective Management of Severe Psychiatric Disorders
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Synonyms
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Haldol (haloperidol) is a first-generation (typical) antipsychotic medication belonging to the butyrophenone class. It is primarily indicated for the management of manifestations of psychotic disorders, including schizophrenia, and is also used to control tics and vocal utterances of Tourette’s Syndrome. Its efficacy is attributed to its potent dopamine D2 receptor antagonism in the mesolimbic pathway of the brain. Haldol is available in multiple formulations, including immediate-release oral tablets, concentrate, and a long-acting injectable (decanoate) form, allowing for tailored treatment regimens to support patient adherence and long-term stability. It remains a cornerstone in psychiatric pharmacotherapy for acute agitation and maintenance treatment due to its well-established efficacy profile.
Features
- Active Ingredient: Haloperidol
- Drug Class: First-generation (typical) antipsychotic
- Available Formulations: Oral tablets (0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg), oral concentrate (2 mg/mL), and long-acting intramuscular injection (Haldol Decanoate 50 mg/mL, 100 mg/mL)
- Mechanism of Action: Potent antagonist of postsynaptic dopamine (D2) receptors in the brain
- Half-life: Approximately 20 hours for oral administration; Haldol Decanoate has an extended half-life of approximately 3 weeks
- Bioavailability: ~60% for oral administration
Benefits
- Provides rapid control of acute psychotic symptoms, including hallucinations, delusions, and thought disorder.
- Effective in reducing aggressive behavior and severe agitation in emergency psychiatric settings.
- Long-acting injectable formulation (Decanoate) ensures consistent drug delivery, improving adherence and reducing relapse rates in maintenance therapy.
- Proven efficacy in managing tics and vocalizations associated with Tourette’s Syndrome.
- Can be used as a second-line agent for severe nausea and vomiting, and intractable hiccups.
- Cost-effective compared to many second-generation antipsychotics, making it accessible for long-term treatment.
Common use
Haldol is primarily prescribed for the treatment of schizophrenia and related psychotic disorders. It is highly effective in managing positive symptoms such as hallucinations, delusions, and hostility. It is also FDA-approved for the control of tics and vocal utterances in Tourette’s Disorder. Off-label, it is sometimes used at lower doses for the management of severe agitation in dementia (though with caution due to black box warnings), chemotherapy-induced nausea and vomiting, and intractable hiccups. In acute care settings, the injectable form is frequently utilized for rapid tranquilization of agitated patients.
Dosage and direction
Dosage must be individualized based on severity of symptoms, patient response, and tolerability. For psychosis in adults, initial oral doses typically range from 0.5 mg to 5 mg two or three times daily. Dosage may be gradually increased until symptoms are controlled; maintenance doses are often between 5 mg and 20 mg daily, though some patients may require higher doses. For Haldol Decanoate, the initial dose is generally 10 to 15 times the previous daily oral dose, administered intramuscularly every 4 weeks. The injection must be administered via deep IM gluteal injection using a Z-track technique. Always titrate slowly to the lowest effective dose.
Precautions
Haldol carries a Black Box Warning for increased mortality in elderly patients with dementia-related psychosis. Use with extreme caution in patients with a history of seizures, cardiovascular disease, or Parkinson’s disease. It may cause sedation and impair mental or physical abilities required for hazardous tasks like driving. Neuroleptic Malignant Syndrome (NMS), a rare but life-threatening reaction, requires immediate medical attention. Tardive Dyskinesia (TD), a potentially irreversible involuntary movement disorder, may develop with chronic use. Regular monitoring for extrapyramidal symptoms (EPS) is essential. Avoid abrupt discontinuation.
Contraindications
Haldol is contraindicated in patients with known hypersensitivity to haloperidol or any component of the formulation. It is also contraindicated in patients with severe central nervous system depression or comatose states, and in those with Parkinson’s disease. Use is contraindicated in conditions where CNS depression is undesirable. The injectable form is contraindicated in patients with known QT prolongation or significant cardiac arrhythmias.
Possible side effect
Common side effects include extrapyramidal symptoms (dystonia, akathisia, parkinsonism), sedation, dry mouth, blurred vision, and constipation. Serious side effects require immediate medical attention and may include tardive dyskinesia, neuroleptic malignant syndrome (hyperthermia, muscle rigidity, autonomic instability), QT prolongation leading to torsades de pointes, seizures, and significant orthostatic hypotension. Hyperprolactinemia leading to galactorrhea and sexual dysfunction may also occur.
Drug interaction
Haldol has numerous significant drug interactions. Concurrent use with other CNS depressants (e.g., alcohol, benzodiazepines, opioids) can potentiate sedation and respiratory depression. It may enhance the hypotensive effects of antihypertensive drugs. QT-prolonging agents (e.g., certain antibiotics, antiarrhythmics, other antipsychotics) increase the risk of torsades de pointes. Carbamazepine may decrease haloperidol plasma levels. Haloperidol may inhibit the metabolism of tricyclic antidepressants, increasing their serum concentrations. Always review a patient’s full medication list.
Missed dose
If a dose is missed, it should be taken as soon as remembered. However, if it is almost time for the next scheduled dose, the missed dose should be skipped. Doubling the dose to make up for a missed one is not recommended. For patients on the long-acting Decanoate injection, maintain the regular injection schedule; do not administer a dose early if an appointment is missed. Consult the prescribing physician for guidance on rescheduling.
Overdose
Symptoms of overdose are primarily extensions of its pharmacological effects and include severe extrapyramidal reactions, hypotension, sedation, progression to coma, and respiratory depression. QT prolongation and arrhythmias are cardiac concerns. There is no specific antidote. Management involves immediate gastric lavage (if ingestion was recent) and activated charcoal, along with aggressive supportive care. Cardiovascular monitoring is essential. Treatment for EPS (e.g., benztropine, diphenhydramine) may be required. Dialysis is not effective.
Storage
Store at controlled room temperature (20°-25°C or 68°-77°F), protected from light and moisture. Keep the oral concentrate in its original bottle; do not transfer to another container. Keep all medications out of reach of children and pets. Do not freeze. For the Decanoate injection, ensure the vial is stored upright and protect from light. Do not use if the solution is discolored or contains particulate matter.
Disclaimer
This information is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or before starting any new treatment. Never disregard professional medical advice or delay in seeking it because of something you have read here. Dosage and indications may vary based on individual patient factors and latest clinical guidelines.
Reviews
Haldol has been extensively studied over decades and is considered a gold-standard treatment for acute psychosis in clinical guidelines. Expert consensus acknowledges its high efficacy for positive symptoms and agitation, though its side effect profile, particularly regarding extrapyramidal symptoms and tardive dyskinesia, necessitates careful patient selection and monitoring. Many clinicians value the long-acting injectable formulation for its role in improving adherence in patients with chronic schizophrenia. Reviews in clinical literature consistently emphasize the importance of using the lowest effective dose for the shortest duration necessary to minimize the risk of adverse effects while achieving therapeutic benefit.