Haldol dec dosing q14 days instead of q28

[annoyedpsychiatrist]

Is there any evidence that dosing it every two weeks rather than four weeks offers superior efficacy? I have a patient coming to me and I noticed they're getting it every 14 days rather than monthly. Typically ive always dosed it monthly once on a stable oral dose, with slow reduction of the oral dose by month 2 or 3.

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[ObsequiousAplomb]

Some people dose Haldol dec on shorter intervals for several reasons:

- to give a monthly dose higher than the equivalent of 350 mg (e.g., 200 q14 days vs 400 q28 days)
- as a short-term strategy while loading the dec (e.g., 200 mg q14 days x several weeks, then stretched to 2-300 q28 days)
- a pattern of clinical response for the first two weeks that fades by the third week in that patient, as in a rapid metabolizer or when taken alongside inducers of metabolism
- a pattern of adverse effects from dosing q28 days that isn't present when dosing q14 days in that patient
- patient refuses to have more than one injection at a time and the volume necessary for the dose would require two injections


Hopefully there is documentation that indicates one of the above (or another) justifications or the patient is a reliable enough historian.

 

[annoyedpsychiatrist]

true hard to say. For some people that i suspect are metabolizing it quickly i just continue a little oral overlap, but obviously noncompliance can be a factor hence why they may be on an LAI. Is there any benefit to doses higher than 350mg? That would be around 35mg give or take of the oral which seems pretty high.

This patient is on seroquel 300mg and haldol dec 100mg q14 days so im wondering how we arrived at that strategy...

 

[ObsequiousAplomb]

true hard to say. For some people that i suspect are metabolizing it quickly i just continue a little oral overlap, but obviously noncompliance can be a factor hence why they may be on an LAI. Is there any benefit to doses higher than 350mg? That would be around 35mg give or take of the oral which seems pretty high.

This patient is on seroquel 300mg and haldol dec 100mg q14 days so im wondering how we arrived at that strategy...

Statistically, it is unlikely that a patient who didn't respond to 350 mg will respond to higher doses, just like statistically patients who don't respond to 20 mg aren't very likely to respond to 40 mg. Patients are much more likely to develop an adverse effect than respond to doses higher than 20 mg / day.

For the patients who do respond to the higher doses (but not the lower ones) these types of strategies are frequently used, oftentimes in an effort to ensure the patient really does in fact take and need those higher doses. Some people claim that there is a decreased likelihood of acute EPS if you were to give 400 mg of Haldol Dec / month vs 40 mg of Haldol orally a day. I haven't seen any literature to prove one way or the other, I just acknowledge that some people use that logic.

Without more information, it isn't entirely clear why they're taking that combination of Seroquel 300 and Haldol dec 100 mg q14 days. Possibilities that immediately spring to mind:
- It could be that regarding the Haldol dec they didn't tolerate 200 mg q28 days but they do happen to tolerate 100 mg q14 days. Sometimes this happens. It's unusual to discover this since it's not typically done, but when it's what has helped then sometimes people continue it, but then again not that unusual since I've seen this exact regimen several times before in state hospital and CMHC settings
- It could be that the plan is to stretch them out to 150-200 mg q28 days but this is the early phase of that process
- It could be antipsychotic polypharmacy by an expert
- It could be antipsychotic polypharmacy by an amateur
- It could be a cross-taper (in either direction, for either drug, tbh)
- It could be that the Seroquel might have been titrated just for sleep and the Haldol dec is the real maintenance drug
- It could be that the patient was previously taking Seroquel in the community, was incarcerated and since the correctional setting didn't have Seroquel they were treated with Haldol Dec, then they were discharged and either want the Seroquel to resume or their initial OP provider restarted the Seroquel. This one's really stretching the imagination, but honestly I've seen this exact scenario more frequently than I'd care to admit.

 

[annoyedpsychiatrist]

Statistically, it is unlikely that a patient who didn't respond to 350 mg will respond to higher doses, just like statistically patients who don't respond to 20 mg aren't very likely to respond to 40 mg. Patients are much more likely to develop an adverse effect than respond to doses higher than 20 mg / day.

For the patients who do respond to the higher doses (but not the lower ones) these types of strategies are frequently used, oftentimes in an effort to ensure the patient really does in fact take and need those higher doses. Some people claim that there is a decreased likelihood of acute EPS if you were to give 400 mg of Haldol Dec / month vs 40 mg of Haldol orally a day. I haven't seen any literature to prove one way or the other, I just acknowledge that some people use that logic.

Without more information, it isn't entirely clear why they're taking that combination of Seroquel 300 and Haldol dec 100 mg q14 days. Possibilities that immediately spring to mind:
- It could be that regarding the Haldol dec they didn't tolerate 200 mg q28 days but they do happen to tolerate 100 mg q14 days. Sometimes this happens. It's unusual to discover this since it's not typically done, but when it's what has helped then sometimes people continue it, but then again not that unusual since I've seen this exact regimen several times before in state hospital and CMHC settings
- It could be that the plan is to stretch them out to 150-200 mg q28 days but this is the early phase of that process
- It could be antipsychotic polypharmacy by an expert
- It could be antipsychotic polypharmacy by an amateur
- It could be a cross-taper (in either direction, for either drug, tbh)
- It could be that the Seroquel might have been titrated just for sleep and the Haldol dec is the real maintenance drug
- It could be that the patient was previously taking Seroquel in the community, was incarcerated and since the correctional setting didn't have Seroquel they were treated with Haldol Dec, then they were discharged and either want the Seroquel to resume or their initial OP provider restarted the Seroquel. This one's really stretching the imagination, but honestly I've seen this exact scenario more frequently than I'd care to admit.

based upon some chart digging, pt had significant hx of IV drug use in past. My hunch is they treated him aggressively because SIMD doesnt respond well to maintenance antipsychotics. Or patient just kept endorsing symptoms and they just kept adding on. I know in theory though that seroquel can help EPS due to the dopamine masking effect. I think i typically see equal rates of EPS between the LAI and oral but with the oral i can at least back down if needed. I usually use haldol dec as a third or fourth line LAI though, i would much prefer invega or abilify maintenna

 

[ObsequiousAplomb]

based upon some chart digging, pt had significant hx of IV drug use in past. My hunch is they treated him aggressively because SIMD doesnt respond well to maintenance antipsychotics. Or patient just kept endorsing symptoms and they just kept adding on. I know in theory though that seroquel can help EPS due to the dopamine masking effect. I think i typically see equal rates of EPS between the LAI and oral but with the oral i can at least back down if needed. I usually use haldol dec as a third or fourth line LAI though, i would much prefer invega or abilify maintenna

I agree that under certain circumstances Haldol Dec isn't a great first line. It is by far the cheapest LAI though, and the only one I'd use when Haldol was the antipsychotic the patient responded well to. Since it's so cheap, it's favored extensively in correctional and state hospital settings (why I have more experience with it than Abilify Maintena).

The history of IV drug use makes me curious about the appropriateness of the Seroquel. Since the patient seems to be getting an unusual Haldol Dec regimen, I'd consider a serum Haldol level to be somewhat clinically meaningful to justify the continued odd regimen. Since I'm getting the haldol level, I'd probably order a Seroquel level too, just to make sure they're taking it and that the level is what's expected per dose (to rule out rapid metabolism as well as diversion).

 

[annoyedpsychiatrist]

I agree that under certain circumstances Haldol Dec isn't a great first line. It is by far the cheapest LAI though, and the only one I'd use when Haldol was the antipsychotic the patient responded well to. Since it's so cheap, it's favored extensively in correctional and state hospital settings (why I have more experience with it than Abilify Maintena).

The history of IV drug use makes me curious about the appropriateness of the Seroquel. Since the patient seems to be getting an unusual Haldol Dec regimen, I'd consider a serum Haldol level to be somewhat clinically meaningful to justify the continued odd regimen. Since I'm getting the haldol level, I'd probably order a Seroquel level too, just to make sure they're taking it and that the level is what's expected per dose (to rule out rapid metabolism as well as diversion).

oh and i just saw theyre on klonopin .5mg TID and have history of klonopin OD. lovely. Yes I absolutely hate seroquel in hx of drug use, seroquel is like currency in some settings