From the Guidelines
The administration of high doses of antipsychotics, including Latuda (lurasidone) and Zyprexa (olanzapine), combined with Haldol (haloperidol) and Benadryl (diphenhydramine), to a patient with Attention Deficit Hyperactivity Disorder (ADHD) and genetically confirmed resistance to psychosis, without evidence of psychotic symptoms, is a potentially harmful and regulatory non-compliant practice.
Key Points
- The use of multiple high-dose antipsychotic medications increases the risk of adverse effects, including severe sedation, respiratory depression, and extrapyramidal symptoms 1.
- The combination of antipsychotics with different side-effect profiles may lead to a wider variety of side effects, and drug-drug interactions can have additive or reductive effects on plasma concentrations and side effects 1.
- The patient's reported symptoms of coordination impairment, slurred speech, dry mouth, confusion, and cognitive impairment are consistent with anticholinergic toxicity and excessive sedation.
- The use of antipsychotics in patients with ADHD may exacerbate symptoms, and alternative treatments should be considered 1.
- The practice parameter on the use of psychotropic medication in children and adolescents emphasizes the need for a clear rationale for using medication combinations and careful monitoring of patients 1.
Recommendations
- Avoid the use of multiple high-dose antipsychotic medications in patients with ADHD and genetically confirmed resistance to psychosis.
- Consider alternative treatments for ADHD, such as stimulants or non-stimulants, and carefully monitor patients for adverse effects 1.
- Be aware of potential drug-drug interactions and adjust treatment plans accordingly 1.
- Follow established practice parameters for the use of psychotropic medication in children and adolescents 1.
From the FDA Drug Label
Haloperidol tablets are indicated for use in the management of manifestations of psychotic disorders. Haloperidol tablets should be reserved for these two groups of children only after failure to respond to psychotherapy or medications other than antipsychotics.
The administration of high doses of antipsychotics, including Latuda (lurasidone) and Zyprexa (olanzapine), combined with Haldol (haloperidol) and Benadryl (diphenhydramine), to a patient with Attention Deficit Hyperactivity Disorder (ADHD) and genetically confirmed resistance to psychosis, without evidence of psychotic symptoms, is a potentially harmful practice.
- The use of haloperidol is indicated for the management of psychotic disorders, which is not present in this patient.
- The patient has ADHD, but haloperidol is only indicated for severe behavior problems in children with hyperactivity and conduct disorders after failure to respond to other treatments.
- The combination of high doses of antipsychotics with other medications like Benadryl (diphenhydramine) may increase the risk of adverse effects.
- This practice may be regulatory non-compliant as it goes against the recommended use of haloperidol as stated in the drug label 2.
From the Research
Administration of High Doses of Antipsychotics
- The administration of high doses of antipsychotics, including Latuda (lurasidone) and Zyprexa (olanzapine), combined with Haldol (haloperidol) and Benadryl (diphenhydramine), to a patient with Attention Deficit Hyperactivity Disorder (ADHD) and genetically confirmed resistance to psychosis, without evidence of psychotic symptoms, may be considered a potentially harmful practice 3, 4, 5.
- Antipsychotic polypharmacy, which refers to the co-prescription of more than one antipsychotic drug, is a common practice in some clinical settings, but its benefits and risks are still debated 4, 6.
- High-dose antipsychotic therapy is associated with an increased risk of adverse effects, including extrapyramidal side effects (EPS), hypotension, and other serious side effects 3, 5.
Regulatory Compliance
- The use of antipsychotic polypharmacy and high-dose monotherapy is not generally recommended in clinical practice guidelines, which prefer monotherapy and discourage antipsychotic polypharmacy unless other evidence-based treatments have been exhausted 4, 6.
- However, some studies suggest that a certain proportion of select patients can benefit from antipsychotic polypharmacy without further negative consequences, and that guidelines regarding the use of antipsychotic polypharmacy in clinical practice should be revised 6.
- The development of online tools for calculating and interpreting total daily doses of antipsychotics may help clinicians to review their prescribing practice and improve patient safety outcomes 5.
Specific Patient Population
- The administration of high doses of antipsychotics to a patient with ADHD and genetically confirmed resistance to psychosis, without evidence of psychotic symptoms, may be considered a potentially harmful and regulatory non-compliant practice, as it may expose the patient to unnecessary risks of adverse effects without a clear therapeutic benefit 3, 4, 5.
- The use of antipsychotic polypharmacy and high-dose monotherapy in this patient population should be carefully evaluated and monitored, taking into account the potential risks and benefits, as well as the availability of alternative treatment options 4, 6, 7.