Geodon (Ziprasidone) Dosing
For schizophrenia, start ziprasidone at 20 mg twice daily with food and titrate to 40-80 mg twice daily; for bipolar mania, start at 40 mg twice daily with food and adjust to 60-80 mg twice daily based on response. 1
Critical Administration Requirement
- Ziprasidone MUST be administered with food (at least 500 kcal meal) to ensure adequate absorption 1, 2
- Without food, absorption is reduced by approximately 50%, and this cannot be compensated by increasing the dose 2
- Capsules must be swallowed whole—do not open, crush, or chew 1
Schizophrenia Dosing
Initial Treatment
- Starting dose: 20 mg twice daily with food 1
- Titrate upward based on clinical response, with adjustments at intervals of at least 2 days (steady-state achieved in 1-3 days) 1
- Target therapeutic range: 40-80 mg twice daily 1, 3
- Maximum studied dose: 100 mg twice daily 1
Optimal Dosing Strategy
- Target dose range of 120-160 mg/day (60-80 mg twice daily) is associated with optimal symptom control and greater treatment persistence 2, 4
- The 160 mg/day dose group showed significantly lower discontinuation rates (26.9%) compared to lower doses (40.9% for 40 mg/day, 45.5% for 80 mg/day) 4
- Number needed to treat (NNT) to avoid one additional discontinuation: 4 for 160 mg/day versus 12 for 40 mg/day 4
Maintenance Treatment
- Continue at the dose that achieved symptom stabilization 1
- No additional benefit demonstrated for doses above 20 mg twice daily in maintenance studies, though higher doses may be needed for individual patients 1
- Periodically reassess the need for continued treatment 1
Bipolar I Disorder Dosing
Acute Manic or Mixed Episodes
- Starting dose: 40 mg twice daily with food 1
- Increase to 60 mg or 80 mg twice daily on day 2 of treatment 1
- Therapeutic range: 40-80 mg twice daily 1
- Mean daily dose in clinical trials: approximately 120 mg/day 1
Maintenance Treatment (Adjunct to Lithium or Valproate)
- Continue at the stabilization dose within the range of 40-80 mg twice daily with food 1
- Periodically reassess need for maintenance treatment 1
Pediatric Considerations
- Ziprasidone is FDA-approved only for adults 1
- For adolescents age 12 and older with bipolar disorder, ziprasidone is approved for acute mania in adults but not specifically studied in this age group 5
- Lithium remains the only FDA-approved agent for bipolar disorder in youth age 12 and older 5
Important Safety Considerations
QTc Prolongation
- Ziprasidone has greater capacity to prolong QT/QTc interval compared to several other antipsychotics 1
- Consider alternative treatments first unless clinical situation warrants ziprasidone use 1
- Baseline ECG recommended before initiating treatment 1
Contraindications and Cautions
- Avoid in patients with recent myocardial infarction, uncompensated heart failure, or history of QT prolongation 1
- Use caution with concomitant medications that prolong QTc interval 1
- Monitor for extrapyramidal symptoms, though incidence is low 3, 6
Advantages of Ziprasidone
- Neutral effect on body weight—no clinically significant weight gain 3, 2, 6
- No adverse changes in cholesterol, triglycerides, or glycemic control 2
- Low extrapyramidal symptom liability 3, 6
- No persistent prolactin elevation 3, 6
- Not anticholinergic 2
- Available in intramuscular formulation for acute agitation 3, 6
Common Pitfalls to Avoid
- Failing to administer with adequate food (500 kcal)—this is the most critical error that undermines efficacy 2
- Using doses below 120 mg/day in acute schizophrenia, which may result in suboptimal response and higher discontinuation rates 2, 4
- Titrating too rapidly without allowing 2-day intervals between dose adjustments 1
- Discontinuing prematurely due to lack of response when adequate dose with food has not been achieved 2