Quetiapine Titration Schedule
For adults with schizophrenia or bipolar mania, start quetiapine at 25 mg twice daily on Day 1, increase to 50 mg twice daily on Day 2, then 100 mg twice daily on Day 3, reaching 150-200 mg twice daily by Day 4, with a target dose of 300-400 mg/day by Days 4-5. 1
Standard Titration for Adults
Schizophrenia
- Day 1: 25 mg twice daily 1
- Day 2: Increase by 25-50 mg in divided doses (2-3 times daily) 1
- Day 3: Continue increments of 25-50 mg 1
- Day 4: Target range of 300-400 mg/day 1
- Further adjustments: Can increase in increments of 25-50 mg twice daily at intervals of no less than 2 days 1
- Effective dose range: 150-750 mg/day 1
- Maximum dose: 750 mg/day 1
Bipolar Mania (Adults)
- Day 1: 100 mg/day in divided doses (twice daily) 1
- Day 2: 200 mg/day in divided doses 1
- Day 3: 300 mg/day in divided doses 1
- Day 4: 400 mg/day in divided doses 1
- Further adjustments: Up to 800 mg/day by Day 6 in increments no greater than 200 mg/day 1
- Target dose range: 400-800 mg/day 1
- Maximum dose: 800 mg/day 1
Bipolar Depression
- Administer once daily at bedtime 1
- Day 1: 50 mg 1
- Day 2: 100 mg 1
- Day 3: 200 mg 1
- Day 4: 300 mg 1
- Target and maximum dose: 300 mg/day 1
Adolescent Dosing (13-17 years for Schizophrenia; 10-17 years for Bipolar Mania)
Schizophrenia (Ages 13-17)
- Day 1: 25 mg twice daily 1
- Day 2: 100 mg/day in divided doses 1
- Day 3: 200 mg/day in divided doses 1
- Day 4: 300 mg/day in divided doses 1
- Day 5: 400 mg/day in divided doses 1
- Further adjustments: Increments no greater than 100 mg/day 1
- Target dose range: 400-800 mg/day 1
- Maximum dose: 800 mg/day 1
Bipolar Mania (Ages 10-17)
- Day 1: 25 mg twice daily 1
- Day 2: 100 mg/day in divided doses 1
- Day 3: 200 mg/day in divided doses 1
- Day 4: 300 mg/day in divided doses 1
- Day 5: 400 mg/day in divided doses 1
- Target dose range: 400-600 mg/day 1
- Maximum dose: 600 mg/day 1
Special Population Modifications
Elderly Patients
Start at 50 mg/day and increase in increments of 50 mg/day based on clinical response and tolerability. 1 The American Academy of Family Physicians recommends an even more conservative approach with 12.5 mg twice daily initially, with a maximum of 200 mg twice daily. 2 Elderly patients are at higher risk for transient orthostatic hypotension and sedation, requiring careful monitoring during dose escalation. 2
Hepatic Impairment
- Start at 25 mg/day 1
- Increase daily in increments of 25-50 mg/day to an effective dose based on clinical response and tolerability 1
Drug Interactions
With CYP3A4 Inhibitors (ketoconazole, itraconazole, ritonavir):
- Reduce quetiapine dose to one-sixth of the original dose 1
- When the inhibitor is discontinued, increase quetiapine by 6-fold 1
With CYP3A4 Inducers (phenytoin, carbamazepine, rifampin):
- Increase quetiapine dose up to 5-fold of the original dose when used chronically (>7-14 days) 1
- Titrate based on clinical response and tolerability 1
- When the inducer is discontinued, reduce quetiapine to the original level within 7-14 days 1
Rapid Titration in Acute Settings
Research evidence supports that in hospitalized patients with acute schizophrenia or mania, quetiapine can be safely titrated to 400 mg/day in as little as 2-3 days rather than the standard 5 days. 3, 4 This rapid escalation was well tolerated with minimal adverse events in acutely ill patients. 3, 4 However, the FDA-approved labeling remains the standard recommendation for most clinical scenarios. 1
Reinitiation After Discontinuation
- Off medication >1 week: Follow the initial dosing schedule 1
- Off medication <1 week: Gradual dose escalation may not be required; can reinitiate at maintenance dose 1
Key Clinical Considerations
Common adverse effects during titration include headache (19.4%), somnolence (17.5%), and dizziness (9.6%). 5 Monitor for orthostatic hypotension, particularly in elderly patients and during initial dose escalation. 2, 1 Quetiapine has a placebo-level incidence of extrapyramidal symptoms across all doses, allowing confident dose increases without increased EPS risk. 5, 6