What are the doses of Haloperidol (antipsychotic medication)?

From the Guidelines

Haloperidol dosing should start at 0.5-1 mg orally at night and every 2 hours when required, with a maximum daily dose of 10 mg, or 5 mg daily in elderly patients, as recommended by the most recent guidelines 1. When managing delirium or agitation, it's crucial to consider the patient's age, condition, and potential interactions with other medications.

• For patients who are severely distressed or causing immediate danger to others, a higher starting oral dose of 1.5-3 mg may be considered 1.
• The dose can be increased in 0.5-1 mg increments as required, and the same dose of haloperidol may be administered subcutaneously as required rather than orally 1.
• Alternatively, a subcutaneous infusion of 2.5-10 mg over 24 hours can be used 1.
• It's also important to consider adding a benzodiazepine such as lorazepam or midazolam if the patient remains agitated, as suggested by the guidelines 1.
• Another study suggests starting with 0.5–1 mg p.o. or s.c. stat, with a PRN dose of 0.5 or 1 mg p.o. or s.c. q1h PRN, and using lower doses in older or frail patients, e.g., 0.25–0.5 mg, and titrating gradually 1. However, the most recent and highest quality study should be prioritized, which in this case is the 2020 guideline from the BMJ 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION There is considerable variation from patient to patient in the amount of medication required for treatment. Clinical experience suggests the following recommendations: Oral Administration Initial Dosage Range Adults Moderate Symptomatology - 0.5 mg to 2 mg b.i.d. or t.i.d. Severe Symptomatology - 3 mg to 5 mg b.i.d. or t.i. d. To achieve prompt control, higher doses may be required in some cases. Geriatric or Debilitated Patients - 0.5 mg to 2 mg b.i.d. or t.i.d. Chronic or Resistant Patients - 3 mg to 5 mg b.i.d. or t.i. d. Patients who remain severely disturbed or inadequately controlled may require dosage adjustment. Daily dosages up to 100 mg may be necessary in some cases to achieve an optimal response. Infrequently, haloperidol has been used in doses above 100 mg for severely resistant patients; however, the limited clinical usage has not demonstrated the safety of prolonged administration of such doses Children The following recommendations apply to children between the ages of 3 and 12 years (weight range 15 kg to 40 kg). Haloperidol is not intended for children under 3 years old. Therapy should begin at the lowest dose possible (0.5 mg per day). If required, the dose should be increased by an increment of 0. 5 mg at 5 to 7 day intervals until the desired therapeutic effect is obtained.

The recommended haloperidol doses are:

• Adults:
  • Moderate symptomatology: 0.5 mg to 2 mg b.i.d. or t.i.d.
  • Severe symptomatology: 3 mg to 5 mg b.i.d. or t.i.d.
  • Geriatric or debilitated patients: 0.5 mg to 2 mg b.i.d. or t.i.d.
  • Chronic or resistant patients: 3 mg to 5 mg b.i.d. or t.i.d.
• Children (ages 3-12):
  • Initial dose: 0.5 mg per day
  • Increment: 0.5 mg at 5 to 7 day intervals
  • Psychotic disorders: 0.05 mg/kg/day to 0.15 mg/kg/day
  • Nonpsychotic behavior disorders and Tourette’s disorder: 0.05 mg/kg/day to 0.075 mg/kg/day 2

From the Research

Haloperidol Doses

• The optimal dose of haloperidol for the treatment of acute schizophrenia is not well established, but studies suggest that lower doses may be effective and have a lower risk of extrapyramidal side effects 3.
• A study comparing different dose ranges of haloperidol found that doses between 3 to 7.5 mg/day had a lower rate of development of clinically significant extrapyramidal adverse effects than higher doses 3.
• Another study found that risperidone and haloperidol had similar efficacy in first-episode psychosis patients, but risperidone had a lower risk of extrapyramidal side effects and was more effective in preventing relapse 4.
• The use of haloperidol has been compared to other antipsychotics, such as olanzapine, which has been found to have a lower extrapyramidal symptom profile 5.
• High doses of haloperidol (> 7.5 mg/day) may be associated with a higher risk of extrapyramidal side effects, and clinicians should be cautious when prescribing these doses 3, 6.

Extrapyramidal Side Effects

• Extrapyramidal side effects, such as dystonia and parkinsonism, are a common adverse effect of haloperidol, particularly at high doses 3, 6, 5.
• The risk of extrapyramidal side effects can be reduced by using lower doses of haloperidol or by switching to an alternative antipsychotic with a lower risk of these side effects 3, 4, 5.
• Clinicians should be aware of the potential for patients to misuse haloperidol, such as by smoking it, which can increase the risk of extrapyramidal side effects 6.