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. Furthermore, it is employed for severe behavioral problems in children and for the short-term treatment of hyperactive children who show excessive motor activity with accompanying conduct disorders. Haldol works by blocking dopamine D2 receptors in the brain, which helps to reduce the symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking. Its long history of clinical use and extensive research support its role as a cornerstone in acute and maintenance treatment of severe mental health conditions.
Features
- Active Ingredient: Haloperidol
- Available Forms: Oral tablets, oral concentrate solution, and injectable formulations (including immediate-release and decanoate long-acting injection)
- Mechanism of Action: Potent dopamine D2 receptor antagonist
- Half-life: Approximately 20 hours for oral administration; Haldol Decanoate offers extended release with a half-life of approximately 3 weeks
- Bioavailability: Approximately 60-70% for oral administration
- Metabolism: Hepatic, primarily via CYP3A4 and CYP2D6 isoenzymes
- Excretion: Primarily renal and biliary
Benefits
- Provides rapid control of acute psychotic agitation and symptoms
- Effective long-term maintenance therapy for chronic psychotic disorders
- Reduces frequency and severity of tics in Tourette’s syndrome
- Available in long-acting injectable form to enhance adherence
- Well-established efficacy profile with decades of clinical use
- Cost-effective compared to many newer antipsychotic agents
Common use
Haldol is commonly prescribed for the treatment of schizophrenia, particularly for managing positive symptoms such as hallucinations, delusions, and thought disorder. It is also used in acute psychotic episodes, manic episodes associated with bipolar disorder, and for the control of tics and vocal utterances in Tourette’s disorder. Additionally, it may be employed off-label for severe agitation and aggression in dementia (with extreme caution due to black box warnings), intractable hiccups, and as an antiemetic in palliative care settings. Its use in children is generally restricted to severe cases of Tourette’s or disruptive behavior disorders after other interventions have failed.
Dosage and direction
Dosage must be individualized based on severity of symptoms, patient response, and tolerability. For psychosis in adults: initial oral dose is 0.5-5 mg 2-3 times daily; maintenance dose is typically 1-15 mg/day, though some patients may require up to 100 mg/day in divided doses. For IM administration: initial dose of 2-5 mg, repeat every 4-8 hours as needed. Haldol Decanoate: initial dose is 10-15 times the previous daily oral dose, administered IM every 4 weeks. For Tourette’s syndrome in children (3-12 years): initial dose of 0.5 mg daily, increased by 0.5 mg increments weekly; maintenance dose is usually 0.05-0.075 mg/kg/day. Always titrate slowly to the lowest effective dose.
Precautions
Use with caution in elderly patients with dementia-related psychosis due to increased mortality risk. Monitor for neuroleptic malignant syndrome (NMS), a potentially fatal reaction characterized by hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability. Tardive dyskinesia may develop and potentially become irreversible; discontinue if symptoms appear. May cause orthostatic hypotension; caution patients about rising slowly from sitting or lying positions. Use cautiously in patients with cardiovascular disease, seizure disorders, or Parkinson’s disease. May impair mental or physical abilities required for hazardous tasks; caution against driving or operating machinery until response is known. Periodic eye examinations recommended due to risk of lens opacities.
Contraindications
Hypersensitivity to haloperidol or any component of the formulation; severe CNS depression or comatose states; Parkinson’s disease; dementia with Lewy bodies; concomitant use with other QT-prolonging agents in patients with known QT prolongation or significant cardiac history. Contraindicated in patients with blood dyscrasias or bone marrow suppression.
Possible side effect
Common: Extrapyramidal symptoms (dystonia, akathisia, parkinsonism), sedation, dizziness, headache, insomnia, restlessness. Less common: Tardive dyskinesia, neuroleptic malignant syndrome, hyperprolactinemia, weight gain, blurred vision, constipation, dry mouth. Serious: QT prolongation, torsades de pointes, seizures, leukopenia, neutropenia, agranulocytosis, orthostatic hypotension, syncope, hepatic impairment, priapism. With long-term use: potential for metabolic changes including hyperglycemia and dyslipidemia.
Drug interaction
Strong CYP3A4 inhibitors (ketoconazole, itraconazole) increase haloperidol concentrations. CYP3A4 inducers (carbamazepine, rifampin) decrease haloperidol concentrations. Concomitant use with other CNS depressants (alcohol, benzodiazepines, opioids) may potentiate sedation. May enhance effects of antihypertensive medications. Concurrent use with other QT-prolonging agents (antiarrhythmics, certain antibiotics, antidepressants) may increase risk of serious arrhythmias. Lithium may increase risk of neurotoxicity. Anticholinergic agents may worsen constipation and reduce haloperidol efficacy.
Missed dose
If a dose is missed, take it as soon as remembered unless it is almost time for the next dose. Do not double the dose to make up for the missed one. For patients on once-daily dosing: if remembered within 12 hours of scheduled time, take missed dose; if beyond 12 hours, skip and resume regular schedule. For multiple daily dosing: take missed dose if within 4 hours of scheduled time; otherwise, skip and resume regular schedule. Contact healthcare provider with questions about missed doses.
Overdose
Symptoms may include severe extrapyramidal reactions, hypotension, sedation, coma, respiratory depression, and QT prolongation. Management is supportive and symptomatic: maintain airway, administer activated charcoal if recent ingestion, monitor ECG for QT prolongation and arrhythmias. Treat hypotension with IV fluids and vasopressors if needed. Extrapyramidal symptoms may be treated with anticholinergic agents such as benztropine. There is no specific antidote. Dialysis is not effective due to high protein binding and large volume of distribution.
Storage
Store at controlled room temperature (20-25°C or 68-77°F). Protect from light and moisture. Keep oral concentrate in original container; do not freeze. Keep all medications out of reach of children and pets. Do not use after expiration date. For institutional use: follow specific facility protocols for controlled medication storage.
Disclaimer
This information is for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional before starting, changing, or stopping any medication. The prescribing physician should be familiar with the complete prescribing information and monitor patients appropriately. Individual response to medication may vary. Not all possible uses, precautions, side effects, or interactions are listed here.
Reviews
Clinical studies and decades of use demonstrate Haldol’s efficacy in managing acute psychosis and maintaining symptom control. Many clinicians appreciate its rapid action in emergency situations and the availability of long-acting formulations for maintenance therapy. However, the high incidence of extrapyramidal side effects and risk of tardive dyskinesia have led to decreased first-line use in favor of newer atypical antipsychotics with better side effect profiles. Despite this, it remains valuable for treatment-resistant cases and situations where cost is a significant factor. Patient experiences vary widely, with some reporting significant symptom improvement while others describe challenging side effects that necessitate medication changes.