What is the next dose increase for Quetiapine (Seroquel) 300 mg qhs (every night)?

Quetiapine Dose Escalation from 300 mg QHS

For a patient currently on quetiapine 300 mg at bedtime, the next dose increase should be to 400 mg at bedtime, with subsequent increases in 50-100 mg increments every 2-3 days as tolerated, targeting a therapeutic range of 400-800 mg/day for most psychiatric indications. 1

FDA-Approved Titration Guidelines

The FDA label provides clear guidance on dose escalation beyond 300 mg depending on the indication 1:

For Schizophrenia (Adults)

• Current dose: 300 mg/day (you are at Day 3 of standard titration)
• Next step: Increase to 400 mg/day (target for Day 4)
• Further adjustments can be made in increments of 25-50 mg twice daily (50-100 mg total daily dose), with intervals of not less than 2 days 1
• Therapeutic range: 150-750 mg/day; maximum dose: 750 mg/day 1

For Bipolar Mania (Adults)

• Current dose: 300 mg/day (Day 3 of standard titration)
• Next step: Increase to 400 mg/day (Day 4 target)
• Further dosage adjustments up to 800 mg/day by Day 6 should be in increments no greater than 200 mg/day 1
• Therapeutic range: 400-800 mg/day; maximum dose: 800 mg/day 1

For Bipolar Depression (Adults)

• If treating bipolar depression specifically, the target dose is 300 mg/day at bedtime (you are already at target) 1
• Maximum dose for bipolar depression: 300 mg/day 1
• Do not increase further for this indication 1

Practical Dosing Algorithm

The specific next step depends on the indication:

1. If treating schizophrenia or bipolar mania: Increase to 400 mg at bedtime (or split to 200 mg twice daily if daytime sedation is problematic) 1

2. If treating bipolar depression: Remain at 300 mg at bedtime—this is the maximum effective dose 1

3. After reaching 400 mg/day: Wait at least 2 days before further increases 1

4. Subsequent titration: Increase by 50-100 mg every 2-3 days based on response and tolerability 1

5. Target therapeutic dose: Most patients respond to 400-600 mg/day, though some require up to 750-800 mg/day depending on indication 1, 2, 3

Special Population Considerations

Elderly Patients

• Do not follow standard titration 1
• Should have been started at 50 mg/day with increases of 50 mg/day 1
• If already at 300 mg, increase by 50 mg increments only with slower titration intervals 1
• Use lower target doses due to increased risk of orthostatic hypotension 4

Hepatic Impairment

• Should have been started at 25 mg/day with 25-50 mg daily increments 1
• If already at 300 mg, proceed cautiously with 25-50 mg increments 1

Patients on CYP3A4 Inhibitors

• If starting a potent CYP3A4 inhibitor (ketoconazole, ritonavir, nefazodone), reduce dose to 50 mg (one-sixth of 300 mg) 1
• When inhibitor discontinued, increase back to 300 mg 1

Patients on CYP3A4 Inducers

• If on chronic CYP3A4 inducer (phenytoin, carbamazepine, rifampin), may need to increase up to 1500 mg/day (5-fold increase) 1
• Titrate based on clinical response 1

Clinical Response Monitoring

Assess the following before increasing dose:

• Efficacy: Insufficient improvement in target symptoms (psychosis, mania, depression) after 2-3 days at current dose 2, 3
• Tolerability: Absence of dose-limiting side effects (sedation, orthostatic hypotension, dizziness) 4, 5
• Sedation profile: If excessive daytime sedation at 300 mg qhs, consider splitting to twice-daily dosing (150 mg BID) before increasing total daily dose 1, 5

Common Pitfalls to Avoid

• Do not increase too rapidly: Intervals of less than 2 days increase risk of orthostatic hypotension and sedation 1
• Do not exceed indication-specific maximums: 300 mg/day for bipolar depression, 750 mg/day for schizophrenia, 800 mg/day for bipolar mania 1
• Do not ignore metabolic monitoring: Check weight, glucose, and lipids regularly as quetiapine causes dose-related metabolic effects 6, 3
• Do not combine with benzodiazepines at high doses: Risk of oversedation and respiratory depression, particularly with olanzapine but caution applies to all atypicals 4
• Do not use standard titration in elderly: They require 50% lower starting doses and slower titration 1

Evidence Quality Note

The dosing recommendations are derived directly from FDA-approved labeling 1, which represents the highest quality prescribing guidance. Clinical trial data support efficacy at 300-600 mg/day for most indications 2, 3, 5, with the 300 mg dose being the established target for bipolar depression specifically 6, 3.