Renal Replacement Therapy for Risperidone Overdose
RRT or extracorporeal treatment is NOT required for risperidone overdose and should not be performed. 1
Rationale for Not Using Extracorporeal Treatment
Risperidone is not amenable to removal by dialysis or hemoperfusion due to its pharmacokinetic properties. The drug has a large volume of distribution (1-2 L/kg) and high protein binding (90%), both of which make extracorporeal removal ineffective 2. Drugs with protein binding above 95% can sometimes be removed by charcoal hemoperfusion, but risperidone's large volume of distribution remains the primary limiting factor 2.
Standard Management Approach
The FDA-approved management for risperidone overdose consists entirely of supportive care 1:
- Provide close medical supervision and monitoring with continuous cardiac rhythm and vital sign assessment 1
- Ensure adequate airway, oxygenation, and ventilation as drowsiness and sedation are the most common manifestations 1
- Monitor for cardiovascular effects including tachycardia, hypotension, and QT prolongation 1
- Treat extrapyramidal symptoms if they develop, which may require diphenhydramine 3
- Consider multiple drug overdose as coingestants are common and may require specific interventions 3
Clinical Course and Prognosis
Risperidone overdose typically resolves with supportive care alone within 24-72 hours. 3 In a prospective case series of 31 patients with risperidone overdose (doses ranging from 1-180 mg as sole ingestant), symptoms resolved within 24 hours in the majority of patients, with all patients asymptomatic by 72 hours 3. The most common effects were lethargy, tachycardia, extrapyramidal symptoms, and hypotension—all manageable with supportive measures 3.
Critical Pitfalls to Avoid
- Do not pursue dialysis or hemoperfusion as these modalities will not enhance drug elimination and expose the patient to unnecessary procedural risks 1, 2
- Do not delay supportive care while considering extracorporeal options—the priority is airway protection, hemodynamic support, and monitoring 1
- Do not overlook coingestants that may actually benefit from extracorporeal removal (such as lithium or certain cardiovascular medications if co-ingested) 3
When Extracorporeal Support Might Be Considered
VA-ECMO (venoarterial extracorporeal membrane oxygenation) may be considered only for refractory cardiovascular collapse, not for drug removal but for hemodynamic support until the drug is metabolized 4. This would be an extremely rare scenario with risperidone alone, as severe cardiovascular toxicity is uncommon 3.