What is the recommended dosage and treatment guidelines for Latuda (lurasidone) in patients with schizophrenia or bipolar depression?

Lurasidone (Latuda) Dosage and Treatment Guidelines for Schizophrenia and Bipolar Depression

For patients with schizophrenia, lurasidone should be started at 40 mg once daily with food (at least 350 calories), with a recommended dose range of 40-160 mg/day, while for bipolar depression, the recommended starting dose is 20 mg once daily with food, with an effective dose range of 20-120 mg/day for adults and 20-80 mg/day for pediatric patients (10-17 years). 1

Dosing Guidelines for Schizophrenia

• Initial dosing: 40 mg once daily with food
• Effective dose range: 40-160 mg/day
• Titration: Initial dose titration is not required, but dose adjustments can be made based on clinical response 1, 2
• Administration: Must be taken with food (at least 350 calories) as this increases absorption approximately 2-fold and peak concentration 3-fold 1

Dosing Guidelines for Bipolar Depression

Adults

• Initial dosing: 20 mg once daily with food
• Effective dose range: 20-120 mg/day (monotherapy or adjunctive with lithium or valproate)
• Maximum dose: 120 mg/day
• Note: Higher dose range (80-120 mg/day) did not provide additional efficacy compared to lower dose range (20-60 mg/day) in monotherapy studies 1

Pediatric Patients (10-17 years)

• Initial dosing: 20 mg once daily with food
• Effective dose range: 20-80 mg/day (monotherapy)
• Maximum dose: 80 mg/day
• Note: Most pediatric patients (67%) received 20-40 mg/day in clinical studies 1

Special Population Considerations

Renal Impairment

• Moderate impairment (CrCl 30-<50 mL/min): Start at 20 mg/day, maximum 80 mg/day
• Severe impairment (CrCl <30 mL/min): Start at 20 mg/day, maximum 80 mg/day 1

Hepatic Impairment

• Moderate impairment (Child-Pugh Score 7-9): Start at 20 mg/day, maximum 80 mg/day
• Severe impairment (Child-Pugh Score 10-15): Start at 20 mg/day, maximum 40 mg/day 1

Drug Interactions

• Strong CYP3A4 inhibitors (ketoconazole, clarithromycin, ritonavir, etc.): Contraindicated
• Moderate CYP3A4 inhibitors (diltiazem, atazanavir, erythromycin, etc.): Reduce lurasidone dose to half of original dose
• When adding lurasidone to moderate CYP3A4 inhibitor therapy: Start at 20 mg/day, maximum 80 mg/day 1, 3

Duration of Treatment

• For schizophrenia, antipsychotic treatment should be continued for at least 12 months after the beginning of remission 4
• The effectiveness of lurasidone for longer-term use (>6 weeks) has not been established in controlled studies, so periodic re-evaluation is recommended for extended treatment 1

Monitoring and Follow-up

• Assess treatment effectiveness early and use a proactive approach when commencing, switching, or augmenting treatment 4
• Monitor for common side effects including:
  • Somnolence
  • Akathisia (most common adverse effect)
  • Nausea
  • Parkinsonism 2, 5
• Advantage: Lurasidone has minimal weight gain and no clinically meaningful alterations in glucose, lipids, or ECG QT interval 2, 6, 7

Switching Strategies

When switching from another antipsychotic to lurasidone:

• Use gradual cross-titration informed by the half-life and receptor profile of each medication
• Monitor for sedation, orthostatic hypotension, and extrapyramidal symptoms, particularly in the first 24-48 hours 4, 8

Treatment Algorithm for Inadequate Response

1. First antipsychotic trial: Give at therapeutic dose for at least 4 weeks
2. If inadequate response: Switch to an alternative antipsychotic with different pharmacodynamic profile
3. If still inadequate after second 4-week trial: Reassess diagnosis and consider clozapine 4

Important Clinical Considerations

• Lurasidone is primarily metabolized by CYP3A4 and should not be coadministered with strong CYP3A4 inducers or inhibitors 3
• The medication has a distinctive pharmacodynamic profile with antagonist activity at dopamine D2 and serotonin 5-HT2A receptors, as well as 5-HT7 antagonistic activity and partial agonism at 5-HT1A receptors 3, 6
• Lurasidone is devoid of antihistaminic and anticholinergic activities, contributing to its favorable side effect profile 3

Remember that treatment decisions should be made collaboratively with the patient based on side-effect and efficacy profiles, with careful monitoring for response and adverse effects.