Quetiapine (Seroquel) Titration Schedule
The recommended titration schedule for quetiapine (Seroquel) varies by indication, with initial doses starting at 25-50 mg and gradually increasing to therapeutic ranges of 300-800 mg/day, depending on the condition being treated. 1
Standard Titration Schedules by Indication
For Schizophrenia
Adults:
- Day 1: 25 mg twice daily (50 mg total)
- Days 2-3: Increase in increments of 25-50 mg divided two or three times daily
- Day 4: Target range of 300-400 mg/day
- Further adjustments can be made in increments of 25-50 mg twice daily, at intervals of not less than 2 days
- Recommended dose range: 150-750 mg/day
- Maximum dose: 750 mg/day 1
Adolescents (13-17 years):
- Day 1: 25 mg twice daily (50 mg total)
- Day 2: 50 mg twice daily (100 mg total)
- Day 3: 100 mg twice daily (200 mg total)
- Day 4: 150 mg twice daily (300 mg total)
- Day 5: 200 mg twice daily (400 mg total)
- Further adjustments should be in increments no greater than 100 mg/day
- Recommended dose range: 400-800 mg/day
- Maximum dose: 800 mg/day 1
For Bipolar Mania
- Adults:
- Day 1: 50 mg twice daily (100 mg total)
- Day 2: 100 mg twice daily (200 mg total)
- Day 3: 150 mg twice daily (300 mg total)
- Day 4: 200 mg twice daily (400 mg total)
- Further dosage adjustments up to 800 mg/day by Day 6 should be in increments of no greater than 200 mg/day
- Recommended dose range: 400-800 mg/day
- Maximum dose: 800 mg/day 1
For Bipolar Depression
- Adults:
- Day 1: 50 mg once daily at bedtime
- Day 2: 100 mg once daily at bedtime
- Day 3: 200 mg once daily at bedtime
- Day 4: 300 mg once daily at bedtime
- Recommended and maximum dose: 300 mg/day 1
Special Population Considerations
Elderly Patients
- Start at 50 mg/day
- Increase in increments of 50 mg/day
- Use slower titration rate and lower target doses
- Monitor closely for hypotensive reactions 1
Hepatically Impaired Patients
- Start at 25 mg/day
- Increase daily in increments of 25-50 mg/day
- Titrate based on clinical response and tolerability 1
Drug Interaction Considerations
With CYP3A4 Inhibitors
- Reduce quetiapine dose to one-sixth of original dose when co-administered with potent CYP3A4 inhibitors (e.g., ketoconazole, itraconazole)
- When the CYP3A4 inhibitor is discontinued, increase quetiapine dose by 6-fold 1
With CYP3A4 Inducers
- Increase quetiapine dose up to 5-fold of original dose when used with chronic treatment of potent CYP3A4 inducers (e.g., phenytoin, carbamazepine)
- When the CYP3A4 inducer is discontinued, reduce quetiapine dose to original level within 7-14 days 1
Practical Titration Tips
- Quetiapine can be taken with or without food 1
- For most patients, twice-daily dosing is as effective as three-times-daily dosing 2
- When restarting therapy after more than one week off medication, follow the initial titration schedule 1
- When restarting after less than one week off medication, gradual dose escalation may not be required 1
Monitoring During Titration
- Monitor for sedation, which is common, especially during initial titration 3, 4
- Watch for orthostatic hypotension, particularly during rapid titration 3
- Unlike typical antipsychotics, quetiapine has a placebo-level incidence of extrapyramidal symptoms (EPS) at all doses 5
- Quetiapine does not significantly increase prolactin levels 5, 2
Caution
While some studies suggest that rapid dose escalation of quetiapine may be well-tolerated in acutely ill patients 4, the FDA-approved titration schedule should generally be followed to minimize adverse effects and optimize tolerability. Individualized titration based on response and side effects is essential for achieving optimal outcomes.