Risperidone (Risperdal)

Second generation antipsychotic (dopamine, serotonin, norepinephrine receptor antagonist (D2, 5-HT2, NE alpha-2))

  • Schizophrenia2 (13+)
  • Mania/mixed3 (10+)
  • Treatment resistant depression3
  • Autism (only treats aggression)3 (5-16)
  • PTSD augmentation3

Features

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Handout

Dosing

Mania/mixed (2-4 mg/d), antidepressant augmentation (1-2 mg/d), schizophrenia (2-6 mg/d), OCD (0.5-2 md/d, but may also worsen OCD), PTSD augmentation (1.5-4 mg/d).

INTERACTIONS: Metabolized by 3A4. Raise 1.5-2x with carbamazepine. Lower 2x with nefazodone and grapefruit juice. May need to lower a little with non-pram SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline ≥ 150 mg/day).

Management

Risperidone ranks with olanzapine as among most effective antipsychotics for schizophrenia. Also augments
antidepressants in unipolar (though off-label, it did perform better than other antipsychotics in meta-analyses). Main drawback is high risk of prolactinemia.

In PTSD and OCD, the risks usually outweigh the benefits unless there are psychotic symptoms.

TOLERABILITY: Weight gain, sedation, akathisia, EPS (dystonia, stiffness), anticholinergic.

RISKS: Tardive dyskinesia (25% over 10 years, higher in elderly), metabolic, prolactinemia (high risk, 75%, can lead to breast cancer, osteopenia, sexual dysfunction), orthostasis (falls), QTc prolongation, temperature imbalance in elderly, NMS (muscle rigidity, fever, tachycardia).

Side Effect Management

EMR Text

Bipolar

Risperidone use based on FDA approval in bipolar disorder.

Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.

Depression

Risperidone use based on controlled trials of antidepressant augmentation ((Zhou X et al, Int J Neuropsychopharmacol. 2015;18(11):pyv060).

Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.

Schizophrenia

Risperidone use based on FDA approval in schizophrenia.

Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.

PTSD

Risperidone use based on controlled augmentation trials in PTSD (Liu XH et al, Psychiatry Res. 2014;219(3):543-549).

Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.

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