What is the recommended dose of ziprasidone (Geodon) for a 69-year-old female with schizoaffective disorder, bipolar type, and metabolic syndrome?

Recommended Ziprasidone Dosing for 69-Year-Old Female with Schizoaffective Disorder, Bipolar Type and Metabolic Syndrome

Start ziprasidone at 40 mg twice daily with food, then increase to 60-80 mg twice daily based on tolerance and efficacy, with a target dose of approximately 120 mg/day (60 mg twice daily). 1

Initial Dosing Strategy

• Begin with 40 mg twice daily with food as recommended by the FDA for bipolar disorder (which includes the bipolar type of schizoaffective disorder), rather than the 20 mg twice daily starting dose used for schizophrenia 1
• The dose may be increased to 60 mg or 80 mg twice daily on the second day of treatment, then adjusted based on tolerance and efficacy within the range of 40-80 mg twice daily 1
• In flexible-dose clinical trials for bipolar disorder, the mean daily dose administered was approximately 120 mg 1

Critical Administration Requirement

• Ziprasidone MUST be administered with a 500 kcal meal to ensure adequate absorption 2
• Without food, absorption is substantially reduced and cannot be compensated for by increasing the dose 2
• Capsules must be swallowed whole and not opened, crushed, or chewed 1

Rationale for This Patient

Ziprasidone is particularly advantageous for this 69-year-old patient with metabolic syndrome because:

• Ziprasidone is one of the most weight-neutral antipsychotics with minimal metabolic effects 3
• It has minimal impact on cholesterol, triglycerides, or glycemic control 3
• It is not associated with clinically significant weight gain or adverse changes in metabolic parameters 2, 4
• Patients may experience moderate improvement in metabolic measures when switching to ziprasidone from other antipsychotics 2

Dose Optimization

• Target the 120-160 mg/day range for optimal symptom control 2
• Only doses between 120-160 mg/day have consistently demonstrated superiority to placebo in clinical trials 5
• The rate of dose titration and final dose achieved have important bearing on ziprasidone's efficacy profile 2
• Dosage adjustments should occur at intervals of not less than 2 days, as steady-state is achieved within 1-3 days 1

Safety Monitoring in Elderly Patients

Important considerations for this 69-year-old patient:

• Monitor for QTc prolongation: obtain baseline ECG and follow-up ECGs as ziprasidone prolongs the QT interval more than several other antipsychotics 1, 5
• Ziprasidone causes an average QTc prolongation of approximately 20 msec, though this does not appear to pose substantial clinical problems in most patients 2, 5
• Before starting treatment, obtain: BMI, waist circumference, blood pressure, HbA1c, glucose, lipids, liver function tests, renal function, and ECG 6
• Check fasting glucose at 4 weeks following initiation 6
• Monitor BMI, waist circumference, and blood pressure weekly for 6 weeks 6

Tolerability Profile

• Ziprasidone has low extrapyramidal symptom liability 4, 7
• It is not anticholinergic, which is beneficial for elderly patients 2
• Common side effects include headache, nausea, and somnolence 5
• It lacks significant persistent effects on prolactin levels 2
• Only infrequently causes postural hypotension, though monitoring is still warranted in elderly patients 2

Maintenance Treatment

• Continue treatment at the same dose on which the patient was initially stabilized, within the range of 40-80 mg twice daily with food 1
• Patients should be periodically reassessed to determine the need for continued maintenance treatment 1
• For maintenance in bipolar disorder, ziprasidone is used as an adjunct to lithium or valproate, though it can be used as monotherapy for acute episodes 1