Fluphenazine, depot

Across the sites, an average of 15% of inpatients received depot antipsychotic drugs (Sim etal, 2004b). This was most common in Singapore (75%) followed by Taiwan (20%), Japan and China (6%). The depot antipsychotic drugs used were fluphenazine decanoate, flupenthixol decanoate, zuclopenthixol decanoate, haloperidol decanoate, pipothiazine palmitate, and fluphenazine enanthate. 

Intramuscular (IM) Into skeletal muscle. This route is used to deliver depot antipsychotic drugs like fluphenazine and haloperidol decanoate, which are used in the treatment of schizophrenia. 

Depot antipsychotics (e.g., haloperidol decanoate, fluphenazine decanoate, and risperidone long-acting injection) can be used for maintenance therapy of bipolar disorder with noncompliance or treatment resistance. 

If partial or poor adherence is an issue, a long-acting or depot injectable antipsychotic should be considered (e.g., risperidone microspheres, halo-peridol decanoate, fluphenazine decanoate). 

Fluphenazine (Prolixin). Fluphenazine is another high potency antipsychotic. It is widely used to treat psychosis and comes in oral, injectable, and long-acting injectable (depot) forms. Its side effect profile is typical of the other high potency antipsychotics. 

Fluphenazine should be initiated at 5 mg/day to treat schizophrenia and increased as needed. The depot form is administered every 2 weeks in doses from 6.25 to 50mg per dose. The depot form is generally believed to cause less EPS however, some physicians have raised the concern that depot fluphenazine may be prone to dose dumping. Dose dumping means that a significant portion of the depot dose might be prematurely released into the bloodstream. 

Like fluphenazine, haloperidol is available in oral, injectable, and depot forms. In schizophrenia, haloperidol is begun at doses of 5 mg daily and increased as needed. Lower doses are used for most other indications. The depot form of haloperidol is initiated by administration of a 50mg test dose. Depot haloperidol is given monthly at about 20 times the daily dose of the oral form. The maximum depot dose is 200 mg per month. Dose dumping does not seem to be a problem with depot haloperidol. 

For patients in whom treatment noncompliance is a recurring problem, the snccess of maintenance therapy can greatly be enhanced by administering a depot formnlation of the antipsychotic. Depot formulations are currently available for haloperidol (which must be administered once every 4 weeks) and risperidone or fluphenazine (each of which must be administered once every 2 weeks). 

When esterified with a fatty acid, both fluphenazine and haloperidol can be applied intramuscularly as depot preparations. 

Huphenazine is a short acting agent. Eor the management of agitated and potentially violent patients its hydrochloride formulation is frequently used for parenteral administration. Fluphenazine decanoate is a widely used depot preparation. Although its principal pharmacological activities are similar to those of the other phenothiazines fluphenazine displays only weak sedative action and it shows little anticholinergic and hypotensive effect. 

Among the difficulties in pharmacological treatment is the frequent non-compliance. The biggest determinant of compliance is the quality of a patient s relationship with his doctor. But a further way to handle the issue has involved the development of long acting products (depot neuroleptics), even though their effectiveness in the absolute or compared to oral preparations has not been adequately explored. The most commonly used depot agents are fluphenazine and haloperidol decanoate (see David et al., 2004). 

David A, Adams CE, Eisenbruch M, Quraishi S, Rath-bone J. Depot fluphenazine decanoate and enanthate for schizophrenia. Cochrane Database Syst Rev 2004. Issue 2. 

A high risk of relapse is inherent to schizophrenic psychoses. A relapse is often triggered by emotional stress. It is very important to prevent a relapse by either maintaining low-dose oral medication or by switching to a depot antipsychotic. In some cases, this cannot be avoided. Especially when compliance is a problem, a depot medication may help to keep the patient free of psychotic symptoms. Frequently used depot antipsy-chotics are haloperidol-decanoate, fluphenazine-decanoate, and fluspirilene, which are given in relatively low dosages (see Table 41.4). In EOS, relapse prevention is more important than in adulthood, as the majority of patients have not yet finished school or started a professional career. 

For patients with chronic psychotic symptoms who do not comply with a daily medication regimen, a long-acting depot preparation should be considered after stabilization with oral medication. Fluphenazine, haloperidol, and risperidone are the only long-acting injectable antipsychotic medications currently available in the United States. 

The intramuscular administration of antipsychotics acting for weeks prevents this independent action and improves compliance on the other hand, only highly potent antipsychotics such as fluphenazine, flupenthixol and haloperidol are suitable for depot administration and it is precisely these medicines that lead more frequently to EPS and dysphoric mood (van Putten et al, 1984). 

Several longitudinal studies have also found that patients stabilized on depot fluphenazine relapsed when switched to an oral antipsychotic preparation ( 264). Mirror-image studies also found depot fluphenazine (decanoate or enanthate) reduced the incidence of relapse, as well as the number of days hospitalized, when compared with oral therapy. These open, crossover studies switched patients from oral to depot forms, and the outcome with each approach was evaluated. 

Kane et al. (266) point out that some studies may not have effectively evaluated the potential benefit of depot fluphenazine. Thus, patients volunteering for such studies are those who might be compliant whether they took oral or depot medications therefore, these studies may underrepresent the noncompliant population. In addition, inasmuch as relapse may not occur for 3 to 7 months after medications have been completely discontinued, a 1-year study period may not be long enough to evaluate the relative effectiveness of a depot versus oral antipsychotic. 

Flaloperidol decanoate is an effective depot agent comparable with standard oral preparations ( 268, 269, 270 and 261). It can be given monthly, and has a marginally lower incidence of EPS compared with the fluphenazine formulations. 

Is as effective in controlling psychotic symptoms in chronic schizophrenic patients as oral haloperidol, other oral antipsychotics, or depot fluphenazine. 

Fluphenazine decanoate may cause more acute EPS than haloperidol decanoate due to a phenomenon known as dose dumping. Here, a small amount of depot formulation is released into the systemic circulation shortly after an injection. There may be a tendency for haloperidol to be more effective for a subset of schizophrenic symptoms, less depressogenic, and slightly less likely to exacerbate extrapyramidal symptoms. These effects, however, are not large, may not be clinically significant, and are not consistently evident in all studies. 

Crawford R, Forrest A. Controlled trial of depot fluphenazine in out-patient schizophrenics. Br J Psychiatry 1974 124 385-391. 

Schooler NR, Levine J, Severe JB. NIMH-PRB collaborative fluphenazine study group. Depot fluphenazine in the prevention of relapse in schizophrenia evaluation of a treatment regimen. Psychopharmacol Bull 1979 15 44-47. 

Wistedt B. A depot neuroleptic withdrawal study. A controlled study of the clinical effects of the withdrawal of depot fluphenazine decanoate and depot flupenthixol decanoate in chronic schizophrenic patients. Acta Psychiatr Scand 1981 64(l) 65-84. 

Fluphenazine Available as slow release depot form ... 

Ayd, F. J. (1975). The depot fluphenazines A reappraisal after 10 years clinical experience. American Journal of Psychiatry, 132, 491-500. 

A 38-year-old woman was admitted to hospital in the third week after conception and acute schizophrenia was diagnosed. She was given oral haloperidol 1.5 mg at 12-hourly intervals. In the fourth week after conception, intramuscular depot fluphenazine 12.5 was added every 15 days. At 8 weeks of gestation, after the pregnancy had been diagnosed, haloperidol and fluphenazine were withdrawn and trifluoperazine 5 mg was started and continued until 8 weeks before the baby was bom. The child was bom with phocomelia of the left arm, with an extremely short humerus and an absent forearm. 

Depot oil suspension Fluphenazine, haloperidol, risperidone Slow release allows for dosing every 2-4 weeks... 

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