Ziprasidone (Geodon) Dosage and Usage for Schizophrenia and Bipolar Disorder
For schizophrenia and bipolar disorder, ziprasidone should be administered at an initial dose of 20 mg twice daily with food, with titration up to 80 mg twice daily based on clinical response. 1
Dosing for Schizophrenia
Initial Dosing and Titration
- Start with 20 mg twice daily with food
- Adjust dose based on clinical response at intervals of not less than 2 days (steady-state is achieved within 1-3 days)
- Observe patients for several weeks before upward dose adjustment to ensure use of lowest effective dose
- Effective dose range: 20-80 mg twice daily (40-160 mg/day)
- Target dose range for optimal symptom control: 120-160 mg/day 2
- Maximum recommended dose: 80 mg twice daily (160 mg/day) 1
Maintenance Treatment
- Continue effective dose for maintenance therapy
- Clinical trials demonstrated delay in time to relapse for patients maintained on ziprasidone compared to placebo 1
- For stable chronic schizophrenia, 40 mg/day may be an effective maintenance dose 3
Dosing for Bipolar Disorder
Acute Manic or Mixed Episodes
- Initial dose: 40 mg twice daily with food
- Increase to 60 or 80 mg twice daily on the second day of treatment
- Adjust dose based on tolerance and efficacy within the range of 40-80 mg twice daily
- Maintenance dose: 40-80 mg twice daily 1
Adjunctive Maintenance Treatment
- When used as adjunct to lithium or valproate for maintenance treatment of bipolar I disorder:
- Dose range: 40-80 mg twice daily
- Continue treatment at the same dose on which the patient was initially stabilized 1
Administration Requirements
Food Effect
- Critical administration requirement: Must be taken with food (≥500 kcal meal)
- Absorption is substantially reduced when taken without food (up to 60% decrease in bioavailability)
- This reduced absorption cannot be compensated for by increasing the dose 2
- Taking ziprasidone with a meal ensures proper absorption and efficacy
Safety Considerations
Cardiovascular Monitoring
- QT interval prolongation is a concern with ziprasidone
- Consider alternative treatments in patients with risk factors for QT prolongation
- Ziprasidone has greater capacity to prolong QT/QTc interval compared to several other antipsychotics 1
- All antipsychotics increase QTc to some degree (from olanzapine 1.7 ms to thioridazine 30.1 ms) 4
Metabolic Advantages
- Ziprasidone has important advantages regarding metabolic parameters:
- Not associated with clinically significant weight gain
- No adverse changes in cholesterol, triglycerides, or glycemic control
- Patients may experience moderate improvement in these measures when switching from other antipsychotics 2
Other Safety Considerations
- Low propensity for extrapyramidal side effects
- No significant persistent effects on prolactin levels
- Not anticholinergic
- May cause somnolence 2
- Contraindicated in elderly patients with dementia-related psychosis due to increased mortality risk 1
Clinical Pearls
- Efficacy is comparable to other atypical antipsychotics but requires proper dosing and administration
- For acute agitation in schizophrenia, intramuscular ziprasidone (not covered in this response) is available at doses of 10-20 mg IM 4
- When switching from another antipsychotic, cross-titration is recommended to minimize risk of relapse
- The 20 mg twice daily dose may be suboptimal for many patients; clinical trials show better response at higher doses within the recommended range 2
Monitoring Recommendations
- Baseline and periodic ECG monitoring for QTc prolongation
- Monitor for extrapyramidal symptoms, though incidence is low
- Regular assessment of therapeutic response and tolerability
- Unlike other atypical antipsychotics, routine monitoring of weight and metabolic parameters may be less critical, though still recommended as standard practice