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©2013 UpToDate ® Print Email Antipsychotics for initial management of the acutely agitated adult patient with psychosis Formulation Route Initial dose (mg) Frequency (hours) Maximum initial dose per 24 hours (mg) Time to peak plasma concentration (hours) Notes First-generation agents Haloperidol Short-acting lactate injection IM, IV 2-5 0.5-2* 30 0.5-1 Sedation, hypotension and prolongation of QTc interval more pronounced with injection. ↑ EPS risk. Oral solution PO 0.5-5 6 30 2 Droperidol Injection (short-acting) IM, IV 2.5-5 2-4* 40 0.5 Rapid onset of 3-10 minutes advantageous in severely agitated violent patients. Dose related QTc prolongation and risk of cardiac arrhythmias. ↑ EPS risk. Fluphenazine Short-acting hydrochloride injection IM 1.25 6 10 ND 1 mg short-acting IM injection is equivalent to ~2.5 mg oral. ↑ EPS risk. Oral solution PO 1-2.5 6 10 3 Chlorpromazine Injection (short-acting) IM, IV 25 1-4 200 0.5 Hypotension, sedation and injection site pain are limiting side effects. Not a first-line agent. Second-generation agents Aripiprazole Injection (short-acting) IM 9.75 2 30 1 Less sedating. Minimal prolongation of QTc interval or orthostatic hypotension. Disintegrating tablet, oral solution PO 10-15 2 30 3-5 Olanzapine Injection (short-acting) IM 5-10 2-4 30 0.25-0.75 Decreased clearance in female and/or non-smoking patients. Disintegrating tablet PO 5-10 0.5-2 20 5 Risperidone Disintegrating tablet, oral solution PO 1-2 0.5-2 4 1.5 Decreased clearance in renal and/or hepatic impairment. Ziprasidone Short-acting mesylate injection IM 10-20 2-4 40 0.5-1 Dose related QTc prolongation and risk of cardiac arrhythmias. Dose reduction necessary for older adults, debilitated patients and if used in combination with other sedation. See accompanying text for discussion of electrocardiograph and other monitoring for agents known to cause prolongation of the QTc interval. ND: no data; EPS: extrapyramidal symptoms. * It may be necessary to repeat initial dose or fraction thereof after 15 to 20 minutes in patients with severe agitation until desired level of sedation attained.