How to manage Seroquel (quetiapine) in patients with hypotension?

From the Guidelines

Managing Seroquel (quetiapine) in patients with hypotension requires careful dose adjustment and monitoring, prioritizing the patient's morbidity, mortality, and quality of life. When considering the management of quetiapine in patients with hypotension, it is essential to weigh the benefits of the medication against the potential risks of exacerbating hypotension.

Key Considerations

• Start with a lower initial dose of 25mg once daily and titrate slowly, increasing by 25-50mg every 2-3 days as tolerated while monitoring blood pressure 1.
• Administer doses at bedtime to minimize orthostatic effects, and advise patients to rise slowly from sitting or lying positions.
• For patients with significant hypotension (systolic BP <90 mmHg), consider temporarily holding the medication and consulting with a psychiatrist.
• Ensure adequate hydration and avoid concurrent use of other hypotension-inducing medications when possible.
• If hypotension persists, alternative antipsychotics with less hypotensive effect such as aripiprazole or ziprasidone may be considered.

Non-Pharmacologic Measures

Non-pharmacologic measures such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, or using compressive garments over the legs and abdomen can be beneficial in managing orthostatic hypotension 1.

Pharmacologic Interventions

Pharmacologic measures including midodrine and droxidopa, which are approved by the FDA for the treatment of orthostatic hypotension, may also be considered 1.

Patient Monitoring

Elderly patients and those with cardiovascular disease require particularly careful monitoring as they are at higher risk for hypotensive complications. The hypotensive effect of quetiapine occurs primarily through alpha-1 adrenergic receptor blockade, which causes peripheral vasodilation.

Additional Considerations

Physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance, and volume repletion with fluids and salt is critical 1.

From the FDA Drug Label

Quetiapine may induce orthostatic hypotension associated with dizziness, tachycardia and, in some patients, syncope, especially during the initial dose-titration period, probably reflecting its α 1-adrenergic antagonist properties. Quetiapine should be used with particular caution in patients with known cardiovascular disease (history of myocardial infarction or ischemic heart disease, heart failure, or conduction abnormalities), cerebrovascular disease or conditions which would predispose patients to hypotension (dehydration, hypovolemia, and treatment with antihypertensive medications) The risk of orthostatic hypotension and syncope may be minimized by limiting the initial dose to 25 mg twice daily [see DOSAGE AND ADMINISTRATION (2.2)] . If hypotension occurs during titration to the target dose, a return to the previous dose in the titration schedule is appropriate.

Management of Seroquel in patients with hypotension:

• Use caution when prescribing quetiapine to patients with hypotension.
• Limit the initial dose to 25 mg twice daily to minimize the risk of orthostatic hypotension and syncope.
• Monitor patients closely for signs of hypotension, dizziness, and syncope, especially during the initial dose-titration period.
• If hypotension occurs, consider returning to the previous dose in the titration schedule. 2

From the Research

Managing Seroquel in Patients with Hypotension

• Seroquel (quetiapine) is an antipsychotic medication that can cause orthostatic hypotension as a side effect 3, 4.
• In patients with pre-existing hypotension, the management of Seroquel requires careful consideration to avoid exacerbating the condition.
• The treatment of orthostatic hypotension in patients with hypertension is complex and requires a nuanced approach, taking into account the underlying pathophysiology and the potential interactions between antihypertensive agents and Seroquel 5.

Strategies for Managing Seroquel in Hypotensive Patients

• Removal of drugs that can worsen orthostatic hypotension, including Seroquel, should be considered 4.
• Optimization of the antihypertensive regimen to minimize the risk of orthostatic hypotension is crucial 5.
• Non-pharmacological interventions, such as abdominal binders and acarbose, can be used to prevent orthostatic hypotension and postprandial hypotension 4.
• If traditional pressor agents are needed, midodrine and droxidopa can be used, administered at the lowest dose and frequency that improves symptoms 4, 6, 7.

Monitoring and Adjustment

• Close monitoring of blood pressure and adjustment of the treatment regimen as needed is essential to manage Seroquel in patients with hypotension 3, 5.
• A thorough characterization of the patterns, triggers, and cause of orthostatic hypotension is necessary to develop an effective treatment strategy 5.