Seranace (Haloperidol) Dosage for Psychotic Disorders
For first-episode psychosis, start haloperidol at 2 mg/day and increase gradually only if needed, with a maximum of 4-6 mg/day to minimize extrapyramidal side effects while maintaining efficacy. 1
Initial Dosing Strategy
Adults with First-Episode or Moderate Psychosis
- Begin with 2 mg/day of haloperidol, as this dose produces optimal response in many patients with first-episode psychosis. 2
- For moderate symptomatology, the FDA-approved range is 0.5-2 mg twice or three times daily (1-6 mg/day total). 3
- For severe symptomatology, start with 3-5 mg twice or three times daily (6-15 mg/day total). 3
Geriatric or Debilitated Patients
- Start at 0.5-2 mg twice or three times daily (1-6 mg/day total). 3
- Use lower doses to minimize risk of dizziness and extrapyramidal symptoms. 1
Pediatric Patients (Ages 3-12)
- Start at 0.5 mg/day, the lowest possible dose. 3
- For psychotic disorders: 0.05-0.15 mg/kg/day. 3
- For nonpsychotic behavior disorders and Tourette's: 0.05-0.075 mg/kg/day. 3
- Increase by 0.5 mg increments at 5-7 day intervals if needed. 3
- Maximum effective dose rarely exceeds 6 mg/day in children. 3
Dose Titration Guidelines
Critical principle: Increase doses only at widely spaced intervals of 14-21 days after initial titration if response is inadequate. 1, 4
Evidence-Based Dose Ceiling
- The maximum recommended dose for first-episode psychosis is 4-6 mg haloperidol equivalent to avoid extrapyramidal side effects. 1
- Research demonstrates that 2 mg/day produces optimal response in 42% of first-episode patients, with 75% responding to ≤5 mg/day. 2
- Studies show no clinically relevant advantage of 10 mg/day or 40 mg/day over 4 mg/day. 5
- Among responders in first-episode psychosis, 74% had plasma haloperidol levels below 5 ng/ml, achieved with low doses. 2
When Higher Doses May Be Considered
- Chronic or treatment-resistant patients may require 3-5 mg twice or three times daily initially. 3
- Daily doses up to 100 mg may be necessary in some severely resistant cases, though safety of prolonged high-dose administration is not well-established. 3
- For acute and transient psychotic disorders, both 5 mg/day and 20 mg/day show equivalent efficacy with no significant difference in improvement rates. 6
Alternative First-Line Options
WHO guidelines recommend haloperidol or chlorpromazine as routine first-line agents, with second-generation antipsychotics as alternatives if cost and availability permit. 1
- Atypical antipsychotics are better tolerated than typical antipsychotics even at low doses, reducing extrapyramidal side effects. 1
- Initial target doses for atypicals: risperidone 2 mg/day or olanzapine 7.5-10 mg/day. 1
- Maximum doses in first-episode: risperidone 4 mg/day or olanzapine 20 mg/day. 1
Maintenance Treatment
- Continue antipsychotic treatment for at least 12 months after beginning of remission. 1
- Once stable, gradually reduce to the lowest effective maintenance level. 3
- For patients stable for several years, withdrawal may be considered with awareness of increased relapse risk. 1
Critical Monitoring and Pitfalls
Extrapyramidal Side Effects
- Avoid extrapyramidal side effects to encourage future medication adherence. 1
- Do not use anticholinergics routinely for prevention; reserve for significant acute or severe symptoms when dose reduction fails. 1
- Extrapyramidal symptoms are the most common side effect requiring gradual dose titration. 7
Common Dosing Errors to Avoid
- Do not increase doses too rapidly—wait 14-21 days between increases after initial titration. 1, 4
- Do not assume higher doses work faster or better; evidence shows equivalent efficacy at lower doses with fewer side effects. 2, 6, 5
- Do not use typical antipsychotics as first-line when atypicals are available, due to higher extrapyramidal side effect rates. 1