Dosage of Quetiapine for acutely manic patients?

[Iparksiako]

Almost every guidelines I read, suggest that if you want to start Quetiapine for Acutely Ill Manic (or Psychotic in general) patients who have severe behaviour disturbance, you start 200-300mg on day 1, and you move upwards for day 2.

I have a feeling that 200 or 300mg will not be enough for a manic patient and he will be very agitated in the clinic.

What is you experience with it? Are 200 -300 mg enough?

Can you start it on higher doses?

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Other than that, whats your go-to drug scheme you use in acutely ill patients?

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[Bartelby]

For acute mania I prefer something like olanzapine that can be very rapidly increased to a therapeutic dose (and can be a great PRN and emergency IM). It is always possible to cross-titrate later to another option, ideally something with less risk for weight gain and sedation for most patients.

 

[calvnandhobbs68]

1) Acutely manic or psychotic patients that are a danger to themselves or others in any way are probably best managed in an inpatient setting

2) Yes seroquel is going to be pretty difficult to titrate quickly outpatient, sedation and orthostatic hypotension tend to be your limiting factors there. Also yes, you’re going to be in the 300+ range to have good mood stabilization and antipsychotic properties, I wouldn’t usually start at higher doses (although I don’t do any inpatient anymore) but you can titrate quickly inpatient by 100-200mg every few days.

3) I was going to say the same thing as above. Zyprexa is going to give you decent sedation, gets to a therapeutic dose quickly and doesn’t have as much of an acute side effect profile as seroquel. Risperdal is also a good acute option and easily convertible to IM Invega later on down the line. Abilify can be not quite as strong acutely but also easily convertible to IM for maintenance later if needed. It does matter if we’re talking about mania or psychosis because with mania you can also do things like load with Depakote rapidly to get things under control more quickly.

 

[Crayola227]

Are these patients neuroleptic naive? Is there any dose dependency to reactions like NMS and therefore an advantage that way to starting at that introductory dose rather than higher? I'm curious if any of this is a consideration for starting dose? And is this risk expected to be lower for people who have not reacted in that way in the past? I apologize I'm piggybacking off your question to ask a few of my own, but I do wonder if what I'm thinking plays a role in those guidelines.

My impression was that plenty of people even when very agitated and "up" can still respond pretty snow-ily to say a standard dose like 300 mg, just as you or I or someone not agitated, psychotic, or manic might. Meaning that I'm not sure how much the sedation effect is really counterbalanced by starting agitation level? Which isn't to say that sometimes it isn't as you might expect, and they need significantly higher doses to combat how wound up they are.

What I'm trying to say, is I've seen people be off the walls and still a normal dose of a sedating med can sedate them and snow them to a level that you wouldn't have expected for where they seemed to start. It seems to depend on a number of factors, one being that you're reasonably sure it's mania or the like, and not say agitated delirium (I will assume that is the case here), size, age, how exhausted the patient otherwise is, etc etc.

I saw a case with a patient that was slim, young, definitely a psychotic break, took like 7 full grown male police officers to subdue, was tased like 11 times, but I think it may have tired them out in all reality even though they never quit until they were medicated, and they were given what probably seemed like a dose appropriate, as in proportional to all this, to subdue them, and they were basically out for days and days despite lowering the dose. Ultimately it seemed to take only a whiff of neuroleptic to get them under control.

I've seen other patients similar, including mania. Medication response was not proportional to how manic they were, ie they were very very manic but it still only took anything from a standard dose to a whiff to get them calmed down. I don't have enough experience to say how common that is.

Some of these patients seem to almost collapse under a reasonable dose of chemical restraint. I wonder if this is why the recommended starting dose?

Obviously you have to consider if you're getting the patient under control enough to not be a continuing danger to themselves or others in dosing. But also has to be balanced with the dangers of getting snowed, as that can be quite dangerous as well.

I think sometimes we can get into a mindset of thinking we always need to dose proportionally for the amount of subjective problem there is, and that isn't always true. I'm not talking about titration here, just starting doses. You can be surprised sometimes by response is all I'm saying.

I don't know how much that is the case with mania and seroquel, so I am curious.

I'm not an expert so this may not be that useful. Apologies if so.

 

[forchinet121]

I wouldn’t start seroquel at 300, I’d start at 100 and increase by 100 each day and provide prn medications to control breakthrough agitation/mania

 

[Candidate2017]

Almost every guidelines I read, suggest that if you want to start Quetiapine for Acutely Ill Manic (or Psychotic in general) patients who have severe behaviour disturbance, you start 200-300mg on day 1, and you move upwards for day 2.

I have a feeling that 200 or 300mg will not be enough for a manic patient and he will be very agitated in the clinic.

What is you experience with it? Are 200 -300 mg enough?

Can you start it on higher doses?

---

Other than that, whats your go-to drug scheme you use in acutely ill patients?

I really hope you're a PCP, rather than an NP. Because these questions...

 

[clausewitz2]

Echoing some of the commenters upthread, the correct dose of quetiapine for an acutely manic patient is 10 mg of Zyprexa.

 

[deleted1100659]

For acute mania I prefer something like olanzapine that can be very rapidly increased to a therapeutic dose (and can be a great PRN and emergency IM). It is always possible to cross-titrate later to another option, ideally something with less risk for weight gain and sedation for most patients.

exactly this. Heck I even use haldol sometimes, depending on the setting. Though i would prefer to use zyprexa. There is no way I would use seroquel in acute mania.

I only use seroquel in bipolar depression, dementia with significant agitation, sometimes ASD/ID with behavioral issues as my goal with that is to give sedation. Though with bipolar depression I personally prefer latuda or vraylar due to less metabolic effects.

 

[SpinDktr]

Yet another who rarely uses oral quetiapine for this purpose. I prefer oral olanzapine if they're actually willing to take medications. If not, I usually have to get the court order and then skip right to IM Haldol. It's pretty effective, and they almost always are more amenable to discussion about oral medications afterward. Lithium usually seems like the lesser of the evils both to them and me.

 

[brosa]

I never liked quetiapine for manic or psychotic patients, but my attendings in the US love it. They use it very often and I still don't see it working well. My anecdotal experience in Brazil is exactly the same as the colleagues above: best dose of quetiapine is olanza 10mg.

 

[MacDonaldTriad]

I admit that I have not read all of the input into this question. If you are asking what is the effective dose of Zeroquel, good luck. We have spent a couple of decades chasing this answer. It is sad that this molecule is popular with very little evidence it works. It is popular because it has few side effects, but it is chased by the fact that it has no effects. I know this is my opinion and that there are studies that say otherwise, but this is my experience. Not a fan.

 

[Celexa]

I admit that I have not read all of the input into this question. If you are asking what is the effective dose of Zeroquel, good luck. We have spent a couple of decades chasing this answer. It is sad that this molecule is popular with very little evidence it works. It is popular because it has few side effects, but it is chased by the fact that it has no effects. I know this is my opinion and that there are studies that say otherwise, but this is my experience. Not a fan.

FEW side effects? You mean othet than knocking pts out and giving them diabetes, something it's pretty great at? And let's not forget all the orthostatic hypotension in my tottering elderly folks, where strokes and falls duke it out to see who kills them first.

Joking aside I share your dislike of it. Despite seeing it used a ton I am skeptical that it actually does anything related to psychotic symptoms. If I'm going to pitch someone head first into metabolic syndrome I may as well use olanzapine, which actually works. And getting patients OFF seroquel is a frigging nightmare. There are times I'd rather be tapering a benzo.

Other than patients with hx of substance use who really need the sedating effects I don't like using seroquel long term for anyone. And as for acute mania, like everyone else, I would go with a wide variety of other things first.

 

[Merovinge]

I admit that I have not read all of the input into this question. If you are asking what is the effective dose of Zeroquel, good luck. We have spent a couple of decades chasing this answer. It is sad that this molecule is popular with very little evidence it works. It is popular because it has few side effects, but it is chased by the fact that it has no effects. I know this is my opinion and that there are studies that say otherwise, but this is my experience. Not a fan.

I used to feel this way as a med student and early resident, I attributed more Seroquel prescriptions with worse psychiatrists. I will say that more practice has shown me some pretty impressive results in bipolar disorder, particularly for patients not currently manic where it would not be my first or second choice on an IP unit. The consistent sleep, anxiolytic and antidepressant effects while also reducing manic symptoms in the long-term are tough to beat. I use a lot of Latuda as well, but taking it with food is a drag and it does not tend to improve anxiety like Seroquel does. I see quite sick adolescents in the PHP space where we treat comorbid SUDs (which greatly raises the rate of bipolar d/o patients) and think the medication is likely underused at this point in that population.

Definitely not a fan for psychosis, I completely agree with that.

 

[MacDonaldTriad]

So this is a drug who's primary indication has not worked out very well, but after it has bounced around for a quarter of a century, may have some legitimate use. I will pardon my impudent attitude, but any drug that needs a couple of decades to search for an illness is probably not high on my list of go to arrows in my quiver.

 

[Candidate2017]

I used to feel this way as a med student and early resident, I attributed more Seroquel prescriptions with worse psychiatrists. I will say that more practice has shown me some pretty impressive results in bipolar disorder, particularly for patients not currently manic where it would not be my first or second choice on an IP unit. The consistent sleep, anxiolytic and antidepressant effects while also reducing manic symptoms in the long-term are tough to beat.

Definitely not a fan for psychosis, I completely agree with that.

That has been my experience as well.

Seroquel IR qhs, for a 1-3 nights, is useful for sleep for manic or psychotic inpatients. Either IR or XR is a useful adjunct for bipolar outpatients who are already on decent doses of lithium or depakote but experiencing increased depression or hypomania. I have some patients with a seasonal component to their decompensation, and have learned from them to titrate Seroquel up or down depending on their seasonal pattern.

BTW, OP seems to have ghosted this thread, furthering my suspicion they are a psych NP. Oh well, probably too busy cranking out 10 ADHD patients an hour for a billion dollar telehealth startup, or billing a bunch of 5 minute visits at 99214-90833.

 

[Iparksiako]

That has been my experience as well.

Seroquel IR qhs, for a 1-3 nights, is useful for sleep for manic or psychotic inpatients. Either IR or XR is a useful adjunct for bipolar outpatients who are already on decent doses of lithium or depakote but experiencing increased depression or hypomania. I have some patients with a seasonal component to their decompensation, and have learned from them to titrate Seroquel up or down depending on their seasonal pattern.

BTW, OP seems to have ghosted this thread, furthering my suspicion they are a psych NP. Oh well, probably too busy cranking out 10 ADHD patients an hour for a billion dollar telehealth startup, or billing a bunch of 5 minute visits at 99214-90833.

I am here.

Thank you all for your replies. I got the answers I wanted.