Current Indications and Uses of Thorazine (Chlorpromazine)
Thorazine (chlorpromazine) is still used today, with primary indications including management of psychotic disorders, severe nausea/vomiting, intractable hiccups, acute agitation, and delirium, though it has largely been replaced by newer antipsychotics with better side effect profiles for many indications.
Primary Indications for Chlorpromazine
Psychotic Disorders
- Schizophrenia and acute psychotic states: FDA-approved for acute and maintenance treatment of schizophrenia 1
- Dosing typically starts at 25 mg three times daily with gradual increases until symptoms are controlled
- Maintenance dosage typically ranges from 200-400 mg daily
- For hospitalized patients with acute schizophrenic or manic states, higher doses may be needed (up to 1000 mg daily)
Non-Psychiatric Indications
- Nausea and vomiting: 10-25 mg every 4-6 hours as needed 1
- Intractable hiccups: 25-50 mg three or four times daily 1, 2
- Pre-surgical apprehension: 25-50 mg, 2-3 hours before surgery 1
- Acute intermittent porphyria: 25-50 mg three or four times daily 1
Emergency/Acute Settings
- Chemical restraint for acute agitation: Used in emergency settings for severe agitation when other interventions have failed 2
- Delirium management: Used for moderate to severe delirium, particularly in palliative care settings 2
- Dosing typically 12.5-25 mg orally or per rectum, with scheduled dosing every 6-12 hours if needed
Current Status in Clinical Practice
While still available and used, chlorpromazine has largely been supplanted by newer antipsychotics for many indications due to:
- Side effect profile: Higher risk of extrapyramidal symptoms (EPS) compared to atypical antipsychotics 3, 4
- Cardiac concerns: QT interval prolongation and risk of ventricular arrhythmias 5
- Availability of alternatives: Newer atypical antipsychotics generally have better tolerability 3
Special Considerations and Cautions
Side Effects Requiring Monitoring
- Extrapyramidal symptoms (dystonic reactions)
- Orthostatic hypotension
- Sedation and anticholinergic effects
- QTc interval prolongation
- Sinus tachycardia and other dysrhythmias 2, 5
Contraindications/Use with Caution
- Patients with renal or hepatic impairment
- Cardiovascular disease
- History of seizures
- Parkinson's disease or dementia with Lewy bodies 5
- Patients taking other QT-prolonging medications 2
Specific Populations
- Elderly patients: Lower dosages recommended due to increased susceptibility to hypotension and neuromuscular reactions 1
- Pediatric patients: Generally not recommended for children under 6 months except in potentially life-saving situations 1
- Dementia: Should not be used as first-line management for behavioral and psychological symptoms of dementia 2
Historical Context
Chlorpromazine was one of the first antipsychotic medications and revolutionized the treatment of schizophrenia in the 1950s 6. Despite being an older medication, it remains on the World Health Organization's list of essential drugs 7, indicating its continued importance in global healthcare.
Comparison with Newer Antipsychotics
Studies comparing chlorpromazine to atypical antipsychotics show:
- Olanzapine may have better clinical response rates 3
- Risperidone shows similar clinical response but better quality of life scores 3
- Quetiapine has similar efficacy but significantly fewer extrapyramidal side effects 3
In summary, while newer antipsychotics have largely replaced chlorpromazine as first-line treatments for many conditions, it remains a valuable medication in specific clinical scenarios, particularly in resource-limited settings, for acute management of agitation, and for non-psychiatric indications like intractable hiccups and severe nausea.