Initial Dosing of Quetiapine for Bipolar Disorder
For bipolar mania in adults, start quetiapine at 100 mg/day divided into two doses (50 mg twice daily) on Day 1, then rapidly escalate to 400 mg/day by Day 4. 1
Acute Mania Dosing Protocol
The FDA-approved titration schedule for bipolar mania follows a structured escalation:
- Day 1: 100 mg total (divided into two doses)
- Day 2: 200 mg total (divided into two doses)
- Day 3: 300 mg total (divided into two doses)
- Day 4: 400 mg total (divided into two doses)
- Days 5-6: May increase up to 800 mg/day in increments of no greater than 200 mg/day 1
The therapeutic dose range is 400-800 mg/day, with 800 mg/day as the maximum dose. 1
Bipolar Depression Dosing Protocol
For bipolar depression, the dosing differs significantly—start at 50 mg once daily at bedtime on Day 1, then escalate to the target dose of 300 mg/day by Day 4. 1
- Day 1: 50 mg at bedtime
- Day 2: 100 mg at bedtime
- Day 3: 200 mg at bedtime
- Day 4: 300 mg at bedtime (target dose) 1
The maximum dose for bipolar depression is 300 mg/day, which is notably lower than for mania. 1 This lower dosing for depression has been validated in multiple controlled trials showing efficacy at 300 mg/day. 2, 3, 4
Pediatric and Adolescent Dosing
For children and adolescents (ages 10-17) with bipolar mania, start at 25 mg twice daily on Day 1, then escalate to 400 mg/day by Day 5. 1
- Day 1: 25 mg twice daily (50 mg total)
- Day 2: 100 mg total (divided doses)
- Day 3: 200 mg total (divided doses)
- Day 4: 300 mg total (divided doses)
- Day 5: 400 mg total (divided doses) 1
The therapeutic range is 400-600 mg/day (maximum 600 mg/day) for pediatric bipolar mania. 1 Note that lithium remains the only FDA-approved agent for bipolar disorder in youth aged 12 and older, though quetiapine and other atypicals are commonly used in clinical practice. 5
Special Population Modifications
Elderly Patients
Start at 50 mg/day and increase in 50 mg/day increments based on response and tolerability. 1 The slower titration accounts for increased risk of orthostatic hypotension and sedation in this population. 6
Hepatic Impairment
Start at 25 mg/day and increase daily in 25-50 mg/day increments to reach an effective dose. 1 This conservative approach is necessary due to altered drug metabolism.
Critical Monitoring Considerations
Orthostatic hypotension is most problematic during initial dose titration, particularly in the first 3-5 days. 6 Monitor blood pressure during dose escalation.
Sedation intensity peaks 1-3 hours post-dose during the escalation phase. 7 The extended-release formulation (quetiapine XR) produces significantly lower sedation intensity during this window compared to immediate-release. 7
Weight gain and metabolic changes can occur, with some patients experiencing clinically relevant increases in glucose and lipid parameters. 2 Baseline and periodic monitoring of weight, glucose, and lipids is warranted.
Common Pitfalls to Avoid
Do not use the bipolar depression dosing schedule for mania—the mania protocol requires much faster escalation to higher doses (400-800 mg/day vs. 300 mg/day). 1
Do not routinely start at 25 mg/day in adults unless they are elderly or hepatically impaired—the standard adult starting dose for mania is 100 mg/day divided into two doses. 1
Avoid combining with strong CYP3A4 inhibitors without dose adjustment—reduce quetiapine dose to one-sixth when co-administered with ketoconazole, ritonavir, or similar agents. 1
Do not assume 600 mg/day is superior to 300 mg/day for depression—trials show no difference in treatment outcomes between these doses for bipolar depression. 2