Ziprasidone (Geodon)

Second generation antipsychotic (dopamine, serotonin receptor antagonist (D2, 5-HT2))

Dosing

In schizophrenia and mania, Start 40 mg bid and raise to target (60-80 mg bid) by day 3. You can also give all at night, but must take with full meal (500 kcal). Surprisingly, ziprasidone is better tolerated when titrated quickly.

Absorption drops 50% if taken on an empty stomach.

INTERACTIONS: Raise by 1.5-2x if using with carbamazepine. Lower with strong CYP2D6 inhibitors (bupropion, duloxetine, fluoxetine, paroxetine, sertraline ≥150 mg/day, tricyclics, cannabidiol, clozapine, risperidone, asenapine, some first-generation antipsychotics).

Management

Some side effects improve at higher doses (>120 mg/d).

TOLERABILITY: Sedation, GI distress, EPS (dystonia, stiffness), anticholinergic.

RISKS: Tardive dyskinesia (25% over 10 years, higher in elderly), prolactinemia (can lead to breast cancer, osteopenia, sexual dysfunction), orthostasis (falls), QTc prolongation, temperature imbalance in elderly, NMS (muscle rigidity, fever, tachycardia).

Largely free of metabolic risks and akathisia.

EMR Text