quetiapine

ROUTE	ONSET	PEAK	DURATION
PO	unknown	unknown	8–12 hr
PO-XR	unknown	unknown	unknown

Contraindicated in:

Hypersensitivity;
Concurrent use of agents that prolong the QT interval (↑ risk of serious arrhythmias);
History of arrhythmias, including bradycardia;
Hypokalemia or hypomagnesemia (↑ risk of serious arrhythmias);
Congenital long QT syndrome (↑ risk of serious arrhythmias).

Use Cautiously in:

Cardiovascular disease, cerebrovascular disease, dehydration, or hypovolemia (↑ risk of hypotension);
History of seizures or Alzheimer dementia;
Diabetes (may ↑ risk of hyperglycemia);
Patients at risk for aspiration pneumonia or falls;
Hepatic impairment (dose ↓ may be necessary);
Hypothyroidism (may be exacerbated);
May ↑ risk of suicide attempt/ideation especially during early treatment or dose adjustment; this risk appears to be greater in adolescents or children
;
Low white blood cell count or history of drug-induced leukopenia/neutropenia (↑ risk of leukopenia/neutropenia);
Urinary retention, prostatic hypertrophy, constipation, or ↑ intraocular pressure;
History of breast cancer;
OB: Neonates at ↑ risk for extrapyramidal symptoms and withdrawal after delivery when exposed during the 3rd trimester; use only if potential maternal benefit justifies potential fetal risk;
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant;
Pedi: Safety and effectiveness not established in children <18 yr (extended release) or <10 yr (immediate release);
Geri:
Appears on Beers list. ↑ risk of stroke, cognitive decline, and mortality in older adults with dementia. Avoid use in older adults, except for schizophrenia, bipolar disorder, adjunctive treatment of major depressive disorder, or psychosis in Parkinson disease
.

Adv. Reactions/Side Effects ⬆ ⬇

CV: ↑BP (children), palpitations, peripheral edema, postural hypotension

Derm: ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS, DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-JOHNSON SYNDROME (SJS), sweating

EENT: ear pain, pharyngitis, rhinitis

Endo: hyperglycemia, hyperprolactinemia, hypothyroidism

GI: anorexia, constipation, dry mouth, dyspepsia, GI OBSTRUCTION, PANCREATITIS

GU: ↓fertility (women)

Hemat: ↓hemoglobin, AGRANULOCYTOSIS, leukopenia, neutropenia

Metab: weight gain, hyperlipidemia, hypertriglyceridemia

MS: rhabdomyolysis

Neuro: dizziness, cognitive impairment, extrapyramidal symptoms, NEUROLEPTIC MALIGNANT SYNDROME, sedation, SEIZURES, SUICIDAL THOUGHTS/BEHAVIORS, tardive dyskinesia

Resp: cough, dyspnea

Misc: flu-like syndrome

Interactions ⬆ ⬇

Drug-drug:

QT interval prolonging medications, including macrolide antibiotics (erythromycin, clarithromycin), dofetilide, sotalol, quinidine, disopyramide, procainamide, thioridazine, chlorpromazine, droperidol, moxifloxacin, mefloquine, pentamidine, arsenic trioxide, citalopram, escitalopram, tacrolimus, and ziprasidone, may ↑ risk of serious ventricular arrhythmias and should be avoided.
↑CNS depression may occur with alcohol, antihistamines, opioid analgesics, and sedative/hypnotics.
↑risk of hypotension with acute ingestion of alcohol or antihypertensives.
CYP3A inducers, including phenytoin, carbamazepine, barbiturates, rifampin, or corticosteroids, may ↓ levels and effectiveness.
CYP3A inhibitors, including ketoconazole, itraconazole, fluconazole, protease inhibitors, or erythromycin, may ↑ levels and risk of toxicity.
Concurrent use of anticholinergic medications may ↑ risk of anticholinergic adverse reactions.

Route/Dosage ⬆ ⬇

Schizophrenia

PO (Adults ): Immediate release: 25 mg twice daily on Day 1; ↑ by 25–50 mg 2–3 times daily on Days 2 and 3, up to 300–400 mg/day in 2–3 divided doses by Day 4 (not to exceed 800 mg/day); Extended release: 300 mg once daily; ↑ by 300 mg/day (not to exceed 800 mg/day); older adults or patients with hepatic impairment should be started on immediate-release product and converted to extended-release product once effective dose is reached.
PO (Children 13–17 yr): Immediate release: 25 mg twice daily on Day 1; ↑ to 50 mg twice daily on Day 2; then ↑ to 100 mg twice daily on Day 3; then ↑ to 150 mg twice daily on Day 4; then ↑ to 200 mg twice daily on Day 5; may then ↑ by no more than 100 mg/day (not to exceed 800 mg/day).

Acute Manic Episodes Associated With Bipolar I Disorder

PO (Adults ): Immediate release: 50 mg twice daily on Day 1; then ↑ to 100 mg twice daily on Day 2; then ↑ to 150 mg twice daily on Day 3; then ↑ to 200 mg twice daily on Day 4; may then ↑ by no more than 200 mg/day up to 400 mg twice daily on Day 6 if needed; Extended release: 300 mg once daily on Day 1, then 600 mg once daily on Day 2, then 400–800 mg once daily starting on Day 3.
PO (Children 10–17 yr): Immediate release: 25 mg twice daily on Day 1; then ↑ to 50 mg twice daily on Day 2; then ↑ to 100 mg twice daily on Day 3; then ↑ to 150 mg twice daily on Day 4; then ↑ to 200 mg twice daily on Day 5; may then ↑ by no more than 100 mg/day (not to exceed 600 mg/day).

Acute Depressive Episodes Associated With Bipolar Disorder

PO (Adults ): Immediate release or extended release: 50 mg once daily at bedtime on Day 1; then ↑ to 100 mg daily at bedtime on Day 2; then ↑ to 200 mg daily at bedtime on Day 3; then ↑ to 300 mg daily at bedtime thereafter.

Maintenance Treatment of Bipolar I Disorder

PO (Adults ): Continue at the dose required to maintain symptom remission (usual dosage: 400–800 mg/day given as once daily dose [extended release] or in two divided doses [immediate release]).
PO (Children 10–17 yr): Continue at the lowest dose required to maintain symptom remission.

Depression

PO (Adults ): Extended release: 50 mg once daily on Days 1 and 2; then ↑ to 150 mg once daily starting on Day 3 (not to exceed 300 mg/day).

Availability ⬆ ⬇

(Generic available)

Immediate-release tablets: 25 mg; 50 mg; 100 mg; 200 mg; 300 mg; 400 mg
Extended-release tablets: 50 mg; 150 mg; 200 mg; 300 mg; 400 mg

Assessment ⬆ ⬇

Monitor mental status (mood, orientation, behavior) before and periodically during therapy.
Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be ↑ in children, adolescents, and adults ≤24 yr. After starting therapy, young adults should be seen by health care provider face-to-face at least weekly for 4 wk, then every other wk for next 4 wk, then at 12 wk, and then on advice of health care provider thereafter.
Assess weight and BMI initially; then at Wk 4, Wk 8, and Wk 12; and then every 4 mo during therapy. Refer as appropriate for nutritional/weight management and medical management.
Assess orthostatic vitals (HR and BP lying, sitting, standing) frequently during initial dosage adjustment and periodically throughout therapy. Titrate slowly and monitor closely; may cause orthostatic hypotension, bradycardia, and syncope. If hypotension occurs during dose titration, return to the previous dose.
Observe patient carefully to ensure medication is swallowed and not hoarded or cheeked.
Monitor for onset of akathisia (restlessness or desire to keep moving) and extrapyramidal side effects (parkinsonian: difficulty speaking or swallowing, loss of balance control, pill-rolling motion of hands, masklike face, shuffling gait, rigidity, tremors and dystonic muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs) every 2 mo during therapy and 8–12 wk after therapy has been discontinued. Notify health care provider if these symptoms occur; ↓ in dose or discontinuation of medication may be necessary. Trihexyphenidyl or benztropine may be used to control these symptoms.
Monitor for possible tardive dyskinesia (uncontrolled rhythmic movement of mouth, face, and extremities; lip smacking or puckering; puffing of cheeks; uncontrolled chewing; rapid or worm-like movements of tongue). Report these symptoms immediately; may be irreversible.
Monitor frequency and consistency of bowel movements and assess for symptoms of hypomotility (nausea, vomiting, abdominal distension, abdominal pain). Symptoms range from constipation to paralytic ileus; ↑ risk with use of other anticholinergic medications. ↑ fiber and fluids in the diet and laxatives may help to minimize constipation. Prophylactic laxatives may be used for high-risk patients.
Monitor for signs and symptoms of neuroleptic malignant syndrome (hyperpyrexia, muscle rigidity, seizures altered mental status, evidence of autonomic instability [irregular HR or BP, tachycardia, diaphoresis, cardiac arrhythmia]). Notify health care provider immediately if these symptoms occur.
Assess for rash or signs and symptoms of SJS frequently during therapy (fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, eosinophilia). Discontinue and provide supportive care; may be life-threatening.
Monitor for signs of pancreatitis (nausea, vomiting, anorexia, persistent severe abdominal pain sometimes radiating to the back) during therapy.
Quetiapine ↓ the seizure threshold. Institute seizure precautions for patients with history of seizure disorder.
Monitor for symptoms related to hyperprolactinemia (menstrual abnormalities, galactorrhea, sexual dysfunction).
Assess for falls risk. Drowsiness, orthostatic hypotension, and motor and sensory instability ↑ risk. Institute prevention if indicated.
Monitor for signs and symptoms of DRESS (fever, rash, lymphadenopathy, facial swelling), associated with involvement of other organ systems (hepatitis, nephritis, hematologic abnormalities, myocarditis, myositis) during therapy. May resemble an acute viral infection. Eosinophilia is often present. Discontinue therapy if signs occur.

Lab Test Considerations:

May cause asymptomatic ↑ in AST and ALT.
- Assess fasting lipid profile at baseline, Wk 12, and every 5 yr thereafter. May ↑ total cholesterol and triglycerides.
- Monitor fasting blood glucose at baseline, Wk 12, and annually; patients with diabetes should be monitored more frequently.
- May cause anemia, thrombocytopenia, leukocytosis, and leukopenia.
- Monitor serum prolactin prior to and periodically during therapy. May ↑ serum prolactin levels.

Implementation ⬆ ⬇

Do not confuse quetiapine with olanzapine. Do not confuse Seroquel with Seroquel XR.
If therapy is reinstituted after an interval of ≥1 wk off, follow initial titration schedule.
PO: Administer without regard to food; however, extended-release tablets are best absorbed on an empty stomach. DNC: Extended-release tablets should be swallowed whole; do not break, crush, or chew.

Patient/Family Teaching ⬆ ⬇

Explain the purpose and side effects of quetiapine. Instruct patient to take as directed. Take missed doses as soon as remembered unless almost time for next dose; do not double doses. Consult health care provider prior to stopping; should be discontinued gradually. Stopping abruptly may cause insomnia, nausea, and vomiting. Advise patient of need for continued medical follow-up for psychotherapy, eye exams, and laboratory tests. Advise patient to read Patient Information before starting and with each Rx refill in case of changes.
Instruct patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care provider before taking any other medications. Caution patient to avoid concurrent use of alcohol and other CNS depressants.
Inform patient of the possibility of extrapyramidal symptoms. Instruct patient to report symptoms immediately to health care provider.
Advise patient to change positions slowly to minimize orthostatic hypotension. Protect from falls.
May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient to avoid extremes in temperature; this drug impairs body temperature regulation.
Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care provider immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior.
Refer patient for nutritional, weight, or medical management of dyslipidemia as indicated.
Advise patient to notify health care provider of medication regimen before treatment or surgery.
Instruct patient to notify health care provider promptly of sore throat, fever, unusual bleeding or bruising, constipation, or rash.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding. May lead to temporary, reversible infertility in women. Consider early screening for gestational diabetes if used during pregnancy. Neonates exposed to antipsychotic drugs during 3rd trimester are at risk for extrapyramidal and/or withdrawal symptoms following delivery. Monitor neonates for symptoms of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, excessive sedation, and feeding difficulties. Monitor infants exposed to quetiapine through breast milk for excessive sedation. There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to atypical antipsychotics, during pregnancy. Health care providers are encouraged to advise patients to register by calling the National Pregnancy Registry for Atypical Antipsychotics at 1-866-961-2388 or visiting https://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇