Thorazine: Effective Management of Severe Psychiatric and Medical Conditions
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Synonyms | |||
Thorazine (chlorpromazine hydrochloride) is a first-generation typical antipsychotic medication belonging to the phenothiazine class. It is primarily indicated for the management of manifestations of psychotic disorders, including schizophrenia, and for the treatment of severe behavioral problems in children. Additionally, it is used as an antiemetic to control nausea and vomiting, and for the treatment of intractable hiccups. Its mechanism of action involves antagonism of postsynaptic mesolimbic dopaminergic D1 and D2 receptors in the brain, though it also exhibits antagonistic effects on alpha-adrenergic, histaminic H1, muscarinic, and serotonergic receptors. This broad receptor profile contributes to both its therapeutic efficacy and its side effect spectrum. Thorazine represents a foundational agent in psychopharmacology, with a well-established efficacy and safety profile when used appropriately under medical supervision.
Features
- Contains chlorpromazine hydrochloride as the active ingredient
- Available in multiple formulations: oral tablets, oral concentrate solution, and injectable forms (IM/IV)
- Exhibits potent antipsychotic, antiemetic, and sedative properties
- Demonstrates broad receptor binding affinity including dopamine D2, histamine H1, and alpha-adrenergic receptors
- Features established pharmacokinetics with hepatic metabolism and renal excretion
- Possesses a well-documented efficacy profile spanning decades of clinical use
Benefits
- Effectively reduces positive symptoms of psychosis including hallucinations, delusions, and thought disorder
- Provides rapid control of acute agitation and psychotic exacerbations through parenteral administration
- Offers reliable antiemetic action for chemotherapy-induced and postoperative nausea and vomiting
- Manages treatment-resistant hiccups through central nervous system modulation
- Facilitates behavioral stabilization in severe cases where other interventions have proven inadequate
- Serves as a cost-effective therapeutic option within formulary considerations
Common use
Thorazine is primarily employed in the management of psychotic disorders, particularly schizophrenia, where it addresses both acute exacerbations and maintenance therapy. It demonstrates efficacy in controlling manic episodes associated with bipolar disorder before the development of mood stabilizers. The medication is frequently utilized in emergency psychiatric settings for rapid tranquilization of severely agitated patients. Beyond psychiatric applications, it serves as a potent antiemetic for chemotherapy-induced nausea and vomiting, postoperative nausea, and various gastroenterological conditions. Additionally, it finds application in the treatment of intractable hiccups that have proven refractory to other interventions. Off-label uses include adjunctive management of tetanus, treatment of severe behavioral problems in children with conduct disorders, and as a second-line agent for migraine headaches.
Dosage and direction
Dosage must be individualized based on diagnosis, severity of condition, patient response, and tolerance to side effects. For psychiatric indications in adults: initial dosage typically ranges from 25-100 mg orally two to three times daily, gradually increased over several days to weeks. Maintenance doses generally range from 200-800 mg daily divided into two to four doses, though some patients may require higher doses under close supervision. For control of severe nausea and vomiting: 10-25 mg orally every 4-6 hours as needed. Intramuscular administration for acute agitation: 25-50 mg, which may be repeated in one hour if necessary. Elderly patients typically require lower initial doses (approximately one-third to one-half the usual adult dose) with gradual titration. Pediatric dosing for severe behavioral problems: 0.25 mg/lb every 4-6 hours as needed orally or IM. Always administer with food or milk to minimize gastrointestinal upset.
Precautions
Thorazine requires careful monitoring due to its extensive side effect profile. Regular assessment of complete blood count, liver function tests, and ophthalmological examinations are recommended during prolonged therapy. Patients should be cautioned about potential orthostatic hypotension, particularly during initial dose titration. Sedation may impair mental and physical abilities required for hazardous tasks such as driving or operating machinery. Neuroleptic malignant syndrome, characterized by hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability, represents a potentially fatal complication requiring immediate discontinuation and medical intervention. Tardive dyskinesia may develop with chronic treatment and appears to be irreversible in some cases. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death compared to placebo.
Contraindications
Thorazine is contraindicated in patients with known hypersensitivity to chlorpromazine or other phenothiazines. It should not be used in comatose states or significant central nervous system depression due to alcohol, barbiturates, opioids, or other CNS depressants. Contraindications include bone marrow suppression, severe hepatic impairment, and suspected subcortical brain damage. It is contraindicated in patients with a history of blood dyscrasias or pre-existing severe cardiovascular disease. The drug should not be administered to patients experiencing large amounts of CNS depressants. Cross-sensitivity between phenothiazine derivatives may occur, necessitating caution in patients with known hypersensitivity reactions to related compounds.
Possible side effect
The side effect profile of Thorazine is extensive due to its broad receptor activity. Neurological effects include extrapyramidal symptoms (parkinsonism, dystonia, akathisia), tardive dyskinesia, neuroleptic malignant syndrome, and seizures. Sedation and impaired cognitive function are common initially but often diminish with continued therapy. Autonomic effects comprise orthostatic hypotension, tachycardia, dry mouth, blurred vision, constipation, and urinary retention. Endocrine manifestations may include hyperprolactinemia, galactorrhea, menstrual irregularities, and weight gain. Dermatological reactions range from photosensitivity and skin pigmentation to contact dermatitis. Hematological effects include agranulocytosis, leukopenia, and eosinophilia. Ocular changes involving corneal and lenticular deposits may occur with long-term therapy. Cardiovascular effects include ECG changes such as QT prolongation and T-wave abnormalities.
Drug interaction
Thorazine exhibits numerous clinically significant drug interactions. It potentiates CNS depressants including alcohol, barbiturates, opioids, and anxiolytics, requiring dosage adjustments of concomitant agents. Antihypertensive agents may have their effects potentiated, particularly alpha-adrenergic blockers. Concurrent use with anticholinergic drugs may increase the risk of paralytic ileus and hyperthermia. Thorazine may antagonize the effects of dopamine agonists and levodopa. QT-prolonging agents (antiarrhythmics, macrolide antibiotics, antidepressants) may increase the risk of serious ventricular arrhythmias. It may reduce the efficacy of oral anticoagulants through enzyme induction. Lithium coadministration may increase the risk of extrapyramidal symptoms and neurotoxicity. Propranolol may increase chlorpromazine concentrations through metabolic inhibition.
Missed dose
If a dose is missed, it should be taken as soon as remembered unless it is nearly time for the next scheduled dose. In that case, the missed dose should be skipped and the regular dosing schedule resumed. Patients should not double the dose to make up for a missed administration. Consistent dosing is important for maintaining therapeutic effects, particularly in psychiatric conditions where medication adherence is crucial for symptom control. If multiple doses are missed, patients should contact their healthcare provider for guidance on resumption of therapy, as dose adjustment or gradual retitration may be necessary to minimize side effects.
Overdose
Thorazine overdose constitutes a medical emergency requiring immediate intervention. Symptoms include profound sedation, coma, hypotension, tachycardia, extrapyramidal symptoms, agitation, restlessness, convulsions, fever, and autonomic nervous system dysfunction. Cardiac manifestations may include QT prolongation, arrhythmias, and cardiac arrest. Management involves gastric lavage if presentation is early, followed by activated charcoal administration. Supportive measures include maintaining airway patency, ensuring adequate oxygenation, and managing hypotension with intravenous fluids and vasopressors if necessary. Extrapyramidal symptoms may be treated with anticholinergic agents. ECG monitoring is essential for at least 24 hours due to risk of delayed cardiac complications. There is no specific antidote; treatment remains supportive and symptomatic.
Storage
Store at controlled room temperature between 20°C to 25°C (68°F to 77°F), with excursions permitted between 15°C to 30°C (59°F to 86°F). Protect from light and moisture. Keep the oral concentrate in the original container and protect from freezing. The injection solution should be protected from light and should not be used if discolored or containing precipitate. Keep all medications out of reach of children and pets. Do not transfer the oral concentrate to other containers, as it may interact with plastic or other materials. Properly discard any unused medication after the expiration date or when treatment is discontinued.
Disclaimer
This information is provided for educational purposes only and does not constitute medical advice. Thorazine is a prescription medication that should be used only under the supervision of a qualified healthcare professional. The content presented here is not exhaustive and does not replace professional medical judgment. Patients should consult their healthcare provider for personalized medical advice, including information about indications, dosage, side effects, and precautions specific to their individual medical condition. The manufacturer’s prescribing information should be consulted for complete details regarding the safe and effective use of this medication.
Reviews
Clinical experience with Thorazine spans over six decades, establishing it as a foundational antipsychotic agent. Numerous studies demonstrate its efficacy in controlling positive symptoms of psychosis, with response rates typically ranging from 60-70% in treatment-naïve patients. The CATIE study (Clinical Antipsychotic Trials of Intervention Effectiveness) provided contemporary evidence regarding the comparative effectiveness of first-generation antipsychotics including chlorpromazine. While newer atypical antipsychotics offer improved side effect profiles regarding extrapyramidal symptoms, Thorazine remains a cost-effective alternative in resource-limited settings. Systematic reviews confirm its efficacy in treatment-resistant hiccups and as an antiemetic, though its use in these indications has diminished with the development of more selective agents. Long-term observational studies indicate that approximately 20-30% of patients develop tardive dyskinesia with chronic use, though this risk must be balanced against therapeutic benefits in severe psychiatric conditions.