What is the recommended dose and frequency for administering Haloperidol (Haldol)?

Haloperidol Dosing and Frequency

For acute agitation in adults, start with 5-10 mg orally or intramuscularly, repeatable every 30-60 minutes as needed, with a maximum daily dose of 40 mg; however, for elderly patients (≥65 years), initiate with 0.5-1 mg and do not exceed 5 mg daily. 1, 2

Adult Dosing (Non-Elderly)

Initial Dose

• Standard starting dose: 5-10 mg (oral or intramuscular) 1, 2
• For severe agitation or immediate danger: Consider 10-20 mg for rapid tranquilization 1, 2
• Can use higher initial dose (1.5-3 mg) if severely distressed 1

Frequency and Repeat Dosing

• Repeat every 30-60 minutes as needed for ongoing agitation 1, 2
• For severe cases: May repeat every 20-30 minutes until controlled 1, 2
• Maximum daily dose: 40 mg 1, 2

Pharmacokinetics to Guide Timing

• Onset: 20-30 minutes (oral), 10-20 minutes (IM), 5-15 minutes (IV) 1, 2
• Peak effect: 4-5 hours (oral), 60 minutes (IM), 20 minutes (IV) 1, 2
• Duration: 6-8 hours (oral), up to 24 hours (IM) 1, 2

Elderly Patients (≥65 Years) - Critical Dose Reduction Required

Initial Dose

• Start with 0.5-1 mg orally OR 0.25-0.5 mg intramuscularly 1, 3
• Preferably administer at night 3

Frequency and Repeat Dosing

• Repeat every 1-2 hours as needed for IM route 3
• Repeat every 2 hours as needed for oral route 1, 3
• Increase in 0.5-1 mg increments only if necessary 1
• Maximum daily dose: 5 mg (not 40 mg as in younger adults) 1, 3

Evidence Supporting Low-Dose Approach in Elderly

• Higher doses show no benefit in decreasing agitation duration but significantly increase sedation risk 3
• Low-dose haloperidol results in shorter hospital stays, less restraint use, and better discharge outcomes 3, 4, 5
• In a 2023 study, elderly patients receiving ≤0.5 mg required no additional doses within 4 hours and had better outcomes than higher-dose groups 4

Pediatric Dosing

Children (6-12 years)

• Initial dose: 0.5-2 mg or 2.5 mg 1, 2
• Weight-based: 0.05-0.1 mg/kg (oral/IM) 1
• Maximum daily dose: 30 mg 1, 2

Adolescents (12-16 years)

• Initial dose: 10 mg 1, 2
• May repeat every 2 hours as needed 1

Older Adolescents (>16 years)

• Initial dose: 5-10 mg 1, 2
• Maximum daily dose: 40 mg 1, 2

For Acute Agitation in Pediatrics

• 0.05-0.15 mg/kg IV/IM, maximum 5 mg per dose 2, 6
• May repeat hourly as needed 2, 6

Special Clinical Contexts

Delirium Management

• Able to swallow: 0.5-1 mg orally at night and every 2 hours PRN 1
• Increase in 0.5-1 mg increments as required 1
• Maximum: 10 mg daily (5 mg daily in elderly) 1
• Unable to swallow: Consider levomepromazine instead (12.5-25 mg subcutaneously) 1

Palliative Care/End-of-Life

• Start with 0.5-1 mg PO or subcutaneously 2
• PRN dosing: 0.5-1 mg every hour as needed 2
• Use lower doses (0.25-0.5 mg) for older or frail patients 2

First-Episode Psychosis

• Start with 2 mg daily - many patients respond to this low dose 7, 8
• Increase weekly to 5 mg, then 10 mg, then 20 mg only if inadequate response 7
• Optimal plasma levels typically below 5 ng/mL 7
• Low dose (2 mg) equally effective as high dose (8 mg) but better tolerated 8

Critical Monitoring and Safety Considerations

Extrapyramidal Symptoms (EPS)

• Higher doses significantly increase EPS risk 1, 9
• Doses >7.5 mg/day have substantially higher EPS rates compared to 3-7.5 mg/day 9
• If EPS develop, reduce next dose 2
• Consider adding benzodiazepine rather than increasing haloperidol 1

QTc Prolongation Risk

• Risk increases with doses above 7.5 mg/day 2
• Monitor ECG with repeated doses 2

When NOT to Use Haloperidol

• Intoxication-related agitation: Use benzodiazepines first-line 1, 2
• Severe neutropenia (ANC <1000/mm³): Discontinue 10
• Severe cardiovascular disorders: Use cautiously due to hypotension risk 10

Combination Therapy

• For severe agitation unresponsive to haloperidol alone: Add benzodiazepine (lorazepam 0.5-1 mg or midazolam 2.5-5 mg) rather than escalating haloperidol dose 1, 2
• Older adolescents (>16 years): Haloperidol + lorazepam or midazolam is recommended combination 1

Common Pitfalls to Avoid

1. Overdosing elderly patients: The 40 mg maximum applies to adults, NOT elderly patients (5 mg max) 1, 3
2. Using depot formulations acutely: Depot haloperidol is NOT for acute agitation - requires 12 months of stability first 6
3. Escalating doses unnecessarily: Evidence shows doses >7.5 mg/day offer no additional efficacy but increase adverse effects 9, 5
4. Ignoring non-pharmacological interventions first: Especially in elderly, attempt orientation, adequate lighting, and communication before medication 1, 3
5. Using haloperidol for substance-induced agitation: Benzodiazepines are preferred 1