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reduced The dose can be repeated every 3 4 hours; when the patient is less symptomatic, oral doses can replace parenteral administration in most cases In the elderly, both atypical (eg, risperidone 025 mg 05 mg daily or olanzapine 125 mg daily) and conventional (eg haloperidol 0,5 mg daily or perphenazine 2 mg daily) antipsychotics, often used effectively in small doses for behavioral control, have been linked to premature death in some cases Various factors play a role in the absorption of oral medications Of particular importance are previous gastrointestinal surgery and concomitant administration of other drugs There are racial differences in metabolizing the neuroleptic drugs eg, many Asians require only about half the usual dosage Bioavailability is influenced by other factors such as smoking or hepatic microsomal enzyme stimulation with alcohol or barbiturates and enzyme-altering drugs such as carbamazepine or methylphenidate Neuroleptic plasma drug level determinations are not currently of major clinical assistance Divided daily doses are not necessary after a maintenance dose has been established, and most patients can then be maintained on a single daily dose, usually taken at bedtime This is particularly appropriate in a case where the sedative effect of the drug is desired for nighttime sleep, and undesirable sedative effects can be avoided during the day Risperidone is an exception, being given twice daily First-episode patients especially should be tapered off medications after about 6 months of stability and carefully monitored; their rate of relapse is lower than that of multiple-episode patients Psychiatric patients particularly paranoid individuals often neglect to take their medication In these cases and in nonresponders to oral medication, the enanthate and decanoate (the latter is slightly longer-lasting and has fewer extrapyramidal side effects) forms of fluphenazine or the decanoate form of haloperidol may be given by deep subcutaneous injection or intramuscularly to achieve an effect that will usually last 7 28 days A patient who cannot be depended on to take oral medication (or who overdoses on minimal provocation) will generally agree to come to the clinician s office for a shot The usual dose of the fluphenazine longacting preparations is 25 mg every 2 weeks Dosage and frequency of administration vary from about 100 mg weekly to 125 mg monthly Use the smallest effective amount as infrequently as possible A monthly injection of 25 mg of fluphenazine decanoate is equivalent to about 15 20 mg of oral fluphenazine daily Risperidone is the first atypical neuroleptic now available in a long-acting injectable form (25 50 mg intramuscularly every 2 weeks) Concomitant use of a benzodiazepine (eg, lorazepam, 2 mg orally twice daily) may permit reduction of the required dosage of oral or parenteral antipsychotic drug Intravenous haloperidol, the neuroleptic most commonly used by this route, is often used in critical care units in the management of agitated, delirious patients Intravenous haloperidol should be given no faster than 1 mg/min to reduce cardiovascular side effects, such as torsades de pointes.

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may help decrease side effects More activating than sedating, aripiprazole is thought to impose a low risk of extrapyramidal symptoms, weight gain, hyperprolactinemia, and delayed QT interval None of the antipsychotics produce true physical dependency All decrease adrenergic responses Despite higher costs, atypical neuroleptics are often considered preferable to traditional antipsychotics because they are thought to be associated with reduced extrapyramidal symptoms and a lesser risk of tardive dyskinesia

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