What is the next dose increase for a patient on Seroquel (quetiapine) 100 mg qhs (every night)?

Quetiapine Dose Escalation from 100 mg QHS

Increase to 150-200 mg at bedtime, with the option to split into twice-daily dosing (100 mg BID) if sedation is problematic or higher total daily doses are needed.

FDA-Approved Titration Schedule

The FDA label provides clear guidance for quetiapine dose escalation in schizophrenia, which serves as the foundation for dosing across indications 1:

• Standard titration: Starting from Day 1 at 25 mg twice daily, doses increase by 25-50 mg increments every 2+ days until reaching 300-400 mg/day by Day 4 1
• Target therapeutic range: 150-750 mg/day, with most patients responding to 400 mg/day or above 1
• Increment size: Adjustments should be made in 25-50 mg increments, with intervals of at least 2 days between increases 1

Practical Next Step from 100 mg QHS

Since your patient is currently on 100 mg at bedtime (below the typical therapeutic range):

• Increase to 150-200 mg QHS as the next logical step, maintaining once-daily bedtime dosing if tolerated 1, 2
• Alternatively, split to 100 mg BID (total 200 mg/day) to reduce peak sedation while increasing total daily dose 1, 2
• The 50-100 mg increment from current dose aligns with FDA recommendations for dose adjustments 1

Rationale for Higher Doses

• Clinical trials demonstrate that doses ≥400 mg/day are often required for optimal antipsychotic efficacy in schizophrenia 3, 4
• Patients who don't fully respond to lower doses should be titrated to 400 mg or above 3
• The therapeutic range of 150-750 mg/day means 100 mg is subtherapeutic for most indications 1

Titration Speed Considerations

Standard approach (recommended for most patients):

• Increase by 50-100 mg every 2-3 days until reaching 300-400 mg/day 1, 2
• This schedule balances efficacy with tolerability monitoring 2

Rapid titration (for acute psychosis/mania):

• Can escalate more quickly (e.g., 100 mg increases daily) to reach therapeutic doses within 3-5 days 5
• Requires close monitoring for orthostatic hypotension and sedation 5
• Case series support safety of rapid escalation in acute settings, though this is off-label 5

Special Population Adjustments

Elderly or debilitated patients:

• Start at 50 mg/day and increase by 50 mg increments 1
• Use slower titration with lower target doses 1
• Your patient at 100 mg could increase to 150 mg, then 200 mg over 4-6 days 1

Hepatic impairment:

• Start at 25 mg/day with 25-50 mg daily increments 1
• More cautious escalation needed due to variable clearance 6

Monitoring During Titration

• Orthostatic vital signs: Check blood pressure sitting and standing, especially during first week of dose increases 7
• Sedation assessment: Peak sedation occurs 1-2 hours post-dose; consider splitting doses if excessive 2
• Clinical response: Assess symptom improvement at each dose level before further escalation 2

Common Pitfalls to Avoid

• Stopping at subtherapeutic doses: Don't remain at 100-200 mg/day if symptoms persist; most patients need 400+ mg/day 3, 4
• Too-rapid escalation in elderly: Maintain 2-3 day intervals between increases to assess tolerability 1
• Ignoring twice-daily dosing option: If sedation limits dose escalation with QHS dosing, split to BID to reach therapeutic total daily dose 1, 2
• Abrupt discontinuation: When stopping or significantly reducing dose, taper gradually to avoid withdrawal symptoms 7