Haloperidol

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Haloperidol
Haloperidol2DACS2.svg
Haloperidol3DanJ.gif
Systematic (IUPAC) name
4-[4-(4-Chlorophenyl)-4-hydroxy-1-piperidyl]-1-(4-fluorophenyl)-butan-1-one
Clinical data
Trade names Haldol
AHFS/Drugs.com monograph
MedlinePlus a682180
Pregnancy cat. C (AU) C (US)
Legal status Prescription Only (S4) (AU) -only (CA) POM (UK) -only (US)
Routes Oral, IM, IV, depot (as decanoate ester)
Pharmacokinetic data
Bioavailability 60-70% (Oral)[1]
Protein binding ~90%[1]
Metabolism Liver-mediated[1]
Half-life 14-26 hours (IV), 20.7 hours (IM), 14-37 hours (oral)[1]
Excretion Biliary (hence in faeces) and in urine[1][2]
Identifiers
CAS number 52-86-8 YesY
ATC code N05AD01
PubChem CID 3559
IUPHAR ligand 86
DrugBank DB00502
ChemSpider 3438 YesY
UNII J6292F8L3D YesY
KEGG D00136 YesY
ChEBI CHEBI:5613 YesY
ChEMBL CHEMBL54 YesY
Chemical data
Formula C21H23ClFNO2 
Mol. mass 375.9 g/mol
 YesY (what is this?)  (verify)

Haloperidol /hælpɛridɒl/ (INN, BAN, USAN, AAN; most common brand names: Haldol, Serenace) is an antipsychotic medication used in the treatment of schizophrenia, acute psychosis, mania, delirium, tics in Tourette syndrome, choreas, nausea and vomiting in palliative care, intractable hiccups, agitation and severe anxiety.[3][4][5] Haloperidol is a butyrophenone derivative and functions as an inverse agonist of dopamine. It is classified as a typical antipsychotic and has pharmacological effects similar to the phenothiazines.[4]

A long-acting decanoate ester of haloperidol is used as an injection given every four weeks to people with schizophrenia or related illnesses who have poor adherence to medication regimens (most commonly due to them forgetting to take their medication, or due to poor insight into their illness) and suffer frequent relapses of illness, or to overcome the drawbacks inherent to its orally administered counterpart.[6]

It is on the World Health Organization's List of Essential Medicines, a list of the most important medication needed in a basic health system.[7]

Medical uses[edit]

Haloperidol is used in the control of the symptoms of:

Haloperidol was considered indispensable for treating psychiatric emergency situations,[11][12] although the newer atypical drugs have gained greater role in a number of situations as outlined in a series of consensus reviews published between 2001 and 2005.[13][14][15][16] It is enrolled in the World Health Organization list of Essential Medicines.

A multiple-year study suggested this drug and other neuroleptic antipsychotic drugs commonly given to Alzheimer's patients with mild behavioural problems often make their condition worse that its withdrawal was even beneficial for some cognitive and functional measures.[17]

Pregnancy and lactation[edit]

Data from animal experiments indicate haloperidol is not teratogenic, but is embryotoxic in high doses. In humans, no controlled studies exist. Unconfirmed studies in pregnant women revealed possible damage to the fetus, although most of the women were exposed to multiple drugs during pregnancy. In addition, there have been reports that neonates exposed to antipsychotic drugs are at risk for extrapyramidal and/or withdrawal symptoms following delivery such as agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorder. Following accepted general principles, haloperidol should be given during pregnancy only if the benefit to the mother clearly outweighs the potential fetal risk.[18]

Haloperidol, when given to lactating women, is found in significant amounts in their milk. Breastfed children sometimes show extrapyramidal symptoms. If the use of haloperidol during lactation seems indicated, the benefit for the mother should clearly outweigh the risk for the child, or breastfeeding should be stopped.[citation needed]

Other considerations[edit]

Skeletal formula of haloperidol decanoate: The decanoate group is highlighted in blue.

During long-term treatment of chronic psychiatric disorders, the daily dose should be reduced to the lowest level needed for maintenance of remission. Sometimes, it may be indicated to terminate haloperidol treatment gradually.[19] In addition, during long-term use, routine monitoring including measurement of BMI, blood pressure, fasting blood sugar, and lipids, is recommended due to the risk of side-effects. [20]

Other forms of therapy (psychotherapy, occupational therapy/ergotherapy, or social rehabilitation) should be instituted properly.[citation needed] PET imaging studies have suggested low doses are preferable. Clinical response was associated with at least 65% occupancy of D2 receptors, while greater than 72% was likely to cause hyperprolactinaemia and over 78% associated with extrapyramidal side effects. Doses of haloperidol greater than 5 mg increased the risk of side effects without improving efficacy.[21] Patients responded with doses under even 2 mg in first episode psychosis.[22] For maintenance treatment of schizophrenia, an international consensus conference recommended a reduction dosage by about 20% every 6 months until a minimal maintenance dose is established.[20]

  • Depot forms are also available; these are injected deeply IM at regular intervals. The depot forms are not suitable for initial treatment, but are suitable for patients who have demonstrated inconsistency with oral dosages.[citation needed]

The decanoate ester of haloperidol (haloperidol decanoate, trade names Haldol decanoate, Halomonth, Neoperidole) has a much longer duration of action, so is often used in people known to be noncompliant with oral medication. A dose is given by intramuscular injection once every two to four weeks.[23] The IUPAC name of haloperidol decanoate is 4-(4-chlorophenyl)-1-1[4-(4-fluorophenyl)-4-oxobutyl]-4 piperidinyl decanoate.

Topical formulations of haloperidol should not be used as treatment for nausea because research does not indicate that this therapy is more effective than alternatives.[24]

Adverse effects[edit]

Sources for the following lists of adverse effects[25][26][27][28]

Common (>1% incidence)
  • Extrapyramidal side effects such as: (as haloperidol is a high potency typical antipsychotic it tends to produce significant extrapyramidal side effects. According to a recent meta-analysis of the comparative efficacy and tolerability of 15 antipsychotic drugs it was the most prone of the 15 for causing extrapyramidal side effects.[29])
- Dystonia
- Muscle rigidity
- Akathisia
- Parkinsonism
  • Hypotension
  • Anticholinergic side effects such as: (Note: these adverse effects are less common than with lower potency typical antipsychotics)
- Constipation
- Dry mouth
- Blurred vision
  • Somnolence (which is not a particularly prominent side effect, as is supported by the results of the aforementioned meta-analysis.[29])
Unknown frequency
Rare (<1% incidence)
  • Jaundice
  • Hepatitis
  • Cholestasis
  • Acute hepatic failure
  • Liver function test abnormal
  • Hypoglycaemia
  • Hyperglycaemia
  • Hyponatraemia
  • Anaphylactic reaction
  • Hypersensitivity
  • Agranulocytosis
  • Neutropaenia
  • Leukopaenia
  • Thrombocytopaenia
  • Pancytopaenia
  • Psychotic disorder
  • Agitation
  • Confusional state
  • Depression
  • Insomnia
  • Seizure
  • Torsades de pointes
  • Ventricular fibrillation
  • Ventricular tachycardia
  • Extrasystoles
  • Bronchospasm
  • Laryngospasm
  • Laryngeal oedema
  • Dyspnoea
  • Nausea
  • Vomiting
  • Leukocytoclastic vasculitis
  • Dermatitis exfoliative
  • Urticaria
  • Photosensitivity reaction
  • Rash
  • Pruritis
  • Hyperhidrosis
  • Urinary retention
  • Priapism
  • Gynaecomastia
  • Sudden death
  • Face oedema
  • Oedema
  • Hypothermia
  • Hyperthermia
  • Injection site abscess
  • Anorexia
  • Pulmonary embolism
  • Tardive dyskinesia
  • Cataracts
  • Retinopathy
  • Neuroleptic malignant syndrome

Haloperidol has been shown to dramatically increase dopamine activity, up to 98%, in test subjects after two weeks on a "moderate to high" dose compared to chronic schizophrenics.[30] In another study, a live survey of a patient showed the person has 90% more dopamine receptors, of the D2 subtype, than before treatment with haloperidol.[30] The long-term effect of this is unknown, but the first study concludes this upregulation is positively associated with severe dyskinesias (more upregulation, more dyskinesia).

Some research studies have suggested effects of haloperidol on brain tissue. In a 2005 placebo-compared study of six macaques receiving haloperidol for up to 27 months, a significant brain volume change of about 10% and weight decreases were detected.[31] In later studies (2008) of the stored samples, the previously reported changes were attributed primarily to astrocyte and oligodendrocyte loss, with the neuron loss at about 5%, which was not statistically significant.[32] A study in 2011 of rats given haloperidol in doses comparable to clinical use for eight weeks found a reduction in brain cortex volume of 10–12%.[33]

In other studies, the use of potent antipsychotics has been associated with cognitive decline and permanent brain damage.[34]

Psychosis and general morbidity[edit]

Several studies have explored the possibility that psychosis and/or its pharmacological treatment with anti-psychotics such as haloperidol may enhance patients' risk of developing cancers, particularly breast cancer among women, tobacco-related cancers among men, and obesity-related cancers, as well as many other non-psychiatric disorders, among them metabolic, cardiovascular, and respiratory, some or all of which may be due to decreased access to healthcare and treatment and behaviors associated with maladjusted behavior, such as smoking, alcoholism, drug abuse, and eating disorders, rather than to specific pharmacological side effects. A link between atypical anti-psychotics, such as risperidone and quetiapine, and pituitary tumor growth has been generally reported.[35][36][37][38][39][40][41]

Contraindications[edit]

  • Pre-existing coma, acute stroke[citation needed]
  • Severe intoxication with alcohol or other central depressant drugs[citation needed]
  • Known allergy against haloperidol or other butyrophenones or other drug ingredients[citation needed]
  • Known heart disease, when combined will tend towards cardiac arrest[citation needed]

Special cautions[edit]

  • Pre-existing Parkinson's disease[42] or dementia with Lewy bodies
  • Patients at special risk for the development of QT prolongation (hypokalemia, concomitant use of other drugs causing QT prolongation)[citation needed]
  • Compromised liver function (as haloperidol is metabolized and eliminated mainly by the liver)[citation needed]
  • In patients with hyperthyreosis, the action of haloperidol is intensified and side effects are more likely.[citation needed]
  • IV injections: risk of hypotension or orthostatic collapse[citation needed]
  • Patients with a history of leukopenia: a complete blood count should be monitored frequently during the first few months of therapy and discontinuation of the drug should be considered at the first sign of a clinically significant decline in white blood cells.[18]
  • Elderly patients with dementia-related psychosis: analysis of 17 trials showed the risk of death in this group of patients was 1.6 to 1.7 times that of placebo-treated patients. Most of the causes of death were either cardiovascular or infectious in nature. It is not clear to what extent this observation is attributed to antipsychotic drugs rather than the characteristics of the patients. The drug bears a boxed warning about this risk.[18]

Interactions[edit]

[citation needed]

  • Other central depressants (alcohol, tranquilizers, narcotics): actions and side effects of these drugs (sedation, respiratory depression) are increased. In particular, the doses of concomitantly used opioids for chronic pain can be reduced by 50%.
  • Methyldopa: increased risk of extrapyramidal side effects and other unwanted central effects
  • Levodopa: decreased action of levodopa
  • Tricyclic antidepressants: metabolism and elimination of tricyclics significantly decreased, increased toxicity noted (anticholinergic and cardiovascular side effects, lowering of seizure threshold)
  • lithium: rare cases of the following symptoms have been noted: encephalopathy, early and late extrapyramidal side effects, other neurologic symptoms, and coma.[43]
  • Guanethidine: antihypertensive action antagonized
  • Epinephrine: action antagonized, paradoxical decrease in blood pressure may result
  • Amphetamine and methylphenidate: counteracts increased action of norepinephrine and dopamine in patients with narcolepsy or ADD/ADHD
  • Amiodarone: Q-Tc interval prolongation (potentially dangerous change in heart rhythm).[44]
  • Other drugs metabolized by the CYP3A4 enzyme system: inducers such as carbamazepine, phenobarbital, and rifampicin decrease plasma levels and inhibitors such as quinidine, buspirone, and fluoxetine increase plasma levels [18]

Neurotoxic metabolites[edit]

Haloperidol has been shown to metabolize in rat[45] and human[46] hepatocytes via CYP-3A4 to the neurotoxic pyridinium metabolites 4-(4-chlorophenyl)-1-(4-fluorophenyl)-4-oxobutylpyridinium(HPP+)and 4-(4-chlorophenyl)-1-(4-fluorophenyl)-4-hydroxybutylpyridinium (RHPP+).[47] HPP+ and RHPP+ are lipophilic and have elimination half lives of 67.3 hrs and 63.3 hrs, respectively.[48] HPP+ is a structural analog of the more widely known Parkinson’s producing neurotoxin MPP+ and its precursor MPTP. Unlike MPP+, HPP+ is not dependent on MAO-B for metabolism to toxic species and does not require functional dopamine transporter protein for intracellular uptake.[49]

Microdialysis studies were performed in the striatum, substantia nigra and cortex of conscious rats to compare the neurotoxic potential of 1-methyl-4-phenylpyridinium (MPP+) and HPP+ to dopaminergic and serotonergic neurons. HPP+ was a less potent neurotoxin than MPP+ to dopaminergic neurons and displayed equipotent serotonergic neurotoxicity.[50] Impairment of cortico-striatal mitochondrial complex I is pathognomic of MPP+ neurotoxicity and Parkinson's cellular dysfunction.[51][52] HPP+ is more potent than MPP+ at inhibiting murine mitochondrial complex I with an IC50 of 12mMol for HPP+ and 160mMol for MPP+.[50] Prolonged, high dose (2 & 5 mg\kg) administration of haloperidol in a murine model elevates striatal nitric oxide, TNF-a, and caspase-3.[53]

HPP+ and RHPP+ have been found in the brains of patients taking Haldol at autopsy.[54] A short term 6 week trial failed to find statistically significant correlation between HPP+, RHPP+ and extrapyramidal symptoms.[55] A long term retrospective study found a significant positive correlation between levels of HPP+ and severity of tardive dyskinesia.[56]

Overdose[edit]

Experimental evidence from animal studies indicates the doses needed for acute poisoning are quite high in relation to therapeutic doses. Overdoses with depot injections are uncommon, because only certified personnel are legally permitted to administer them to patients.[citation needed]

Symptoms[edit]

Symptoms are usually due to exaggerated side effects. Most often encountered are:

Treatment[edit]

Treatment is merely symptomatic and involves intensive care with stabilization of vital functions. In early detected cases of oral overdose, induction of emesis, gastric lavage, and the use of activated charcoal can all be tried. Epinephrine is avoided for treatment of hypotension and shock, because its action might be reversed. In the case of a severe overdose, antidotes such as bromocryptine or ropinirole may be used to treat the extrapyramidal effects caused by haloperidol, acting as dopamine receptor agonists.[citation needed] ECG and vital signs should be monitored especially for QT prolongation and severe arrhythmias should be treated with anti-arrhythmic measures.[18]

Prognosis[edit]

In general, the prognosis of overdose is good, and lasting damage is not known, provided the patient has survived the initial phase. An overdose of haloperidol can be fatal.[57]

Pharmacology[edit]

Haloperidol, 10mg oral tablet

Haloperidol is a typical butyrophenone type antipsychotic that exhibits high affinity dopamine D2 receptor antagonism and slow receptor dissociation kinetics.[58] The drug binds preferentially to D2 and Alpha 1 receptors at low dose (ED50 = 0.13 and 0.42 mg/kg, respectively), and 5-HT2 receptors at a higher dose (ED50 = 2.6 mg/kg). Given that antagonism of D2 receptors is more beneficial on the positive symptoms of schizophrenia and 5-HT2 receptors on the negative symptoms, this characteristic underlies haloperidol's greater effect on delusions, hallucinations and other manifestations of psychosis. [59] Haloperidol's negligible affinity for histamine H1 receptors and muscarinic M1 acetylcholine receptors yields an antipsychotic with a lower incidence of sedation, weight gain, and orthostatic hypotension though having higher rates of treatment emergent extrapyramidal symptoms.

Haloperidol acts on the following receptors: (Ki)

Dopamine D1 (Silent antagonist) Unknown efficiency[citation needed]

Dopamine D5 (Silent antagonist) Unknown efficiency[citation needed]

Dopamine D2 (inverse agonist) 1.55nM[60]

Dopamine D3 (Inverse agonist) 0.74nM[61]

Dopamine D4 (inverse agonist) 5-9nM[62]

Sigma 1(Irreversible inactivation by HPP+): 3nM[63]

Sigma 2 agonist: 54nM[64]

5HT1A receptor agonist: 1927nM[65]

5HT2A (Silent antagonist) 53nM[65]

5HT2C (Silent antagonist) 10,000nM[65]

5HT6 (Silent antagonist) 3666nM[65]

5HT7 (Irreversible silent antagonist) 377.2nM[65]

Histamine H1 (Silent antagonist) 1800nM[65]

Muscarinic M1 (Silent antagonist) 10,000nM[65]

Alpha Adrenergic 1a (Silent antagonist) 12nM[65]

Alpha Adrenergic 2a (Silent antagonist) 1130nM[65]

Alpha Adrenergic 2b (Silent antagonist) 480nM[65]

Alpha Adrenergic 2c (Silent antagonist) 550nM[65]

NR1\NR2B Subunit containing NMDA receptor antagonist (Ifenprodil site): IC50 2,000 nM[66]

Pharmacokinetics[edit]

Oral[edit]

The bioavailability of oral haloperidol ranges from 60-70%. However, there is a wide variance in reported mean Tmax and T1/2 in different studies, ranging from 1.7 to 6.1 hours and 14.5 to 36.7 hours respectively.[1]

Intramuscular injections[edit]

The drug is well and rapidly absorbed with a high bioavailability when injected intramuscularly. The Tmax is 20 minutes in healthy individuals and 33.8 minutes in patients with schizophrenia. The mean T1/2 is 20.7 hours.[1] The decanoate injectable formulation is for intramuscular administration only and is not intended to be used intravenously. The plasma concentrations of haloperidol decanoate reach a peak at about six days after the injection, falling thereafter, with an approximate half-life of three weeks.[67]

Intravenous injections[edit]

The bioavailability is 100% in intravenous (IV) injection, and the very rapid onset of action is seen within seconds. The T1/2 is 14.1 to 26.2 hours. The apparent volume of distribution is between 9.5 to 21.7 L/kg.[1] The duration of action is four to six hours. If haloperidol is given as a slow IV infusion, the onset of action is slowed, and the duration of action is prolonged.[citation needed]

Haloperidol for injection

Therapeutic concentrations[edit]

Plasma levels of four to 25 micrograms per liter are required for therapeutic action. The determination of plasma levels can be used to calculate dose adjustments and to check compliance, particularly in long-term patients. Plasma levels in excess of the therapeutic range may lead to a higher incidence of side effects or even pose the risk of haloperidol intoxication.[citation needed]

The concentration of haloperidol in brain tissue is about 20-fold higher compared to blood levels. It is slowly eliminated from brain tissue,[68] which may explain the slow disappearance of side effects when the medication is stopped.[68][69]

Distribution and metabolism[edit]

Haloperidol is heavily protein bound in human plasma, with a free fraction of only 7.5 to 11.6%. It is also extensively metabolized in the liver with only about 1% of the administered dose excreted unchanged in the urine. The greatest proportion of the hepatic clearance is by glucuronidation, followed by reduction and CYP-mediated oxidation, primarily by CYP3A4. [1]

History[edit]

Haloperidol was discovered by Paul Janssen.[70] It was developed in 1958 at the Belgian company Janssen Pharmaceutica and submitted to the first of clinical trials in Belgium later that year.[71]

Haloperidol was approved by the U.S. Food and Drug Administration (FDA) on April 12, 1967; it was later marketed in the U.S. and other countries under the brand name Haldol by McNeil Laboratories.[citation needed]

Society and culture[edit]

Coincident with civil unrest in the United States in the 1960s and 1970s, schizophrenia was racialized to match the behavior of angry/violent black men. Haldol was promoted as a way to pacify them, and was marketed to appeal to feelings of racial unease. (cf. Metzl 2010. The Protest Psychosis)

Soviet dissidents, including medical staff, have reported several times on the use of haloperidol in the Soviet Union for punitive purposes or simply to break the prisoners' will.[72][73][74] Notable dissidents who were administered haloperidol as part of their court-ordered treatment were Sergei Kovalev and Leonid Plyushch.[75] The accounts Plyushch gave in the West, after he was allowed to leave the Soviet Union in 1976, were instrumental in triggering Western condemnation of Soviet practices at the World Psychiatric Association's 1977 meeting.[76] The use of haloperidol in the Soviet Union's psychiatric system was prevalent because it was one of the few psychotropic drugs produced in quantity in the USSR.[77]

Haloperidol has been used for its sedating effects during the deportations of immigrants by the United States Immigration and Customs Enforcement (ICE). During 2002-2008, federal immigration personnel used haloperidol to sedate 356 deportees. By 2008, following court challenges over the practice, it was given to only three detainees. Following lawsuits, U.S. officials changed the procedure so the drug is administered only by the recommendation of medical personnel and under court order.[78][79]

Brand names[edit]

Haloperidol is sold under the tradenames Aloperidin, Bioperidolo, Brotopon, Dozic, Duraperidol (Germany), Einalon S, Eukystol, Haldol (common tradename in the US and UK), Halosten, Keselan, Linton, Peluces, Serenace and Sigaperidol.[citation needed]

Veterinary use[edit]

Haloperidol is also used on many different kinds of animals. It appears to be particularly successful when given to birds, e.g., a parrot that will otherwise continuously pluck its feathers out.[80]

References[edit]

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