What is the recommended dosing for Seroquel (quetiapine)?

Quetiapine (Seroquel) Dosing Guidelines

The recommended initial dose of quetiapine depends on the indication, with schizophrenia requiring 25 mg twice daily on day 1, titrated to 300-400 mg by day 4, with a maximum dose of 750 mg/day for adults. 1

Dosing by Indication

Schizophrenia

• Adults:

  • Initial: Day 1: 25 mg twice daily
  • Titration: Increase in increments of 25-50 mg divided two or three times daily on Days 2 and 3
  • Target: 300-400 mg by Day 4
  • Recommended range: 150-750 mg/day
  • Maximum: 750 mg/day 1

• Adolescents (13-17 years):

  • Initial: Day 1: 25 mg twice daily
  • Titration: Day 2: 100 mg/day; Day 3: 200 mg/day; Day 4: 300 mg/day; Day 5: 400 mg/day
  • Recommended range: 400-800 mg/day
  • Maximum: 800 mg/day 1

Bipolar Mania

• Adults (monotherapy or adjunct):

  • Initial: Day 1: 100 mg/day in divided doses
  • Titration: Day 2: 200 mg/day; Day 3: 300 mg/day; Day 4: 400 mg/day
  • Further adjustments up to 800 mg/day by Day 6 in increments ≤200 mg/day
  • Recommended range: 400-800 mg/day
  • Maximum: 800 mg/day 1

• Children/Adolescents (10-17 years):

  • Initial: Day 1: 25 mg twice daily
  • Titration: Day 2: 100 mg/day; Day 3: 200 mg/day; Day 4: 300 mg/day; Day 5: 400 mg/day
  • Recommended range: 400-600 mg/day
  • Maximum: 600 mg/day 1

Bipolar Depression

• Adults:
  • Initial: Day 1: 50 mg at bedtime
  • Titration: Day 2: 100 mg; Day 3: 200 mg; Day 4: 300 mg
  • Recommended dose: 300 mg/day
  • Maximum: 300 mg/day 1

Administration Considerations

• Can be taken with or without food 1
• Dosing frequency:
  • Twice daily dosing (BID) is as effective as three times daily (TID) at the same total daily dose 2
  • For bipolar depression, administer once daily at bedtime 1

Special Populations

Elderly Patients

• Start at lower dose: 50 mg/day
• Titrate more slowly in increments of 50 mg/day
• Monitor closely for hypotensive reactions 1

Hepatically Impaired Patients

• Start at 25 mg/day
• Increase daily in increments of 25-50 mg/day based on clinical response and tolerability 1

Rapid Dose Escalation

• Research suggests that escalation to 400 mg/day can be safely accomplished in 2-3 days rather than the standard 5-day titration in acutely ill hospitalized patients 3
• However, standard titration is preferred for outpatients and those at risk for hypotension

Dose-Response Relationship

• Fixed-dose studies suggest that 150-450 mg/day is more effective than placebo and no less effective than 600-750 mg/day for most patients with schizophrenia 4
• Doses of 400 mg/day or higher should be used in patients who do not fully respond to lower doses 5
• Extended-release formulation studies suggest 600-800 mg/day may be more effective than 400 mg/day 4

Maintenance Treatment

• For schizophrenia and bipolar disorder maintenance: 400-800 mg/day
• Patients should be periodically reassessed to determine the need for continued maintenance treatment 1

Common Pitfalls and Caveats

1. Underdosing: Doses below 150 mg/day are generally subtherapeutic for most indications
2. Excessive sedation: May require dividing the dose or administering a larger portion at bedtime
3. Orthostatic hypotension: Monitor blood pressure during initial titration, especially in elderly
4. Metabolic effects: Monitor weight, blood glucose, and lipid profiles regularly
5. Discontinuation: Avoid abrupt discontinuation; taper gradually over 1-2 weeks

Monitoring Recommendations

• Baseline: Complete blood count, metabolic panel, lipid profile, weight, blood pressure
• Follow-up: Weight at each visit; metabolic parameters at 3 months and then annually
• Efficacy assessment: Allow 2-4 weeks at therapeutic dose before determining response

Quetiapine has the advantage of placebo-level incidence of extrapyramidal symptoms (EPS) and minimal effect on prolactin levels at all doses, making it well-tolerated across its dosing range 5.