THERAPEUTICS
Brands
Generic
Class and Mechanism of Action
- Neuroscience-based nomenclature: dopamine receptor antagonist (D-RAn)
- Conventional antipsychotic (neuroleptic, butyrophenone, dopamine 2 antagonist)
- Blocks dopamine 2 receptors in the mesolimbic pathway, reducing positive symptoms of psychosis and possibly combative, explosive, and hyperactive behaviors
- Blocks dopamine 2 receptors in the nigrostriatal pathway, improving tics and other symptoms in Tourette syndrome
US FDA Approved for Pediatric Use
- Tics and vocal utterances in Tourette syndrome (oral, age not specified)
- Effective for second-line treatment of severe behavior problems in children of combative, explosive hyperexcitability (oral, age not specified)
- Effective for second-line short-term treatment of hyperactive children (oral, age not specified)
Off-Label for Pediatric Use
- Approved in adults:
- Tics and vocal utterances in Tourette syndrome (immediate-release injection)
- Schizophrenia/manifestations of psychotic disorders (oral, immediate-release injection)
- Treatment of schizophrenic patients who require prolonged parenteral antipsychotic therapy (depot intramuscular decanoate)
- Other off-label uses:
- Bipolar disorder
- Delirium (with lorazepam)
Tests
- Before starting haloperidol:
- Plan to monitor weight and metabolic functions more closely than in adults because children and adolescents may be more prone to these side effects than adults
- Weigh all patients and monitor weight gain against that expected for normal growth, using the pediatric height/weight chart to monitor
- Get baseline personal and family history of diabetes, obesity, dyslipidemia, hypertension, and cardiovascular disease
- Get waist circumference (at umbilicus), blood pressure, fasting plasma glucose, and fasting lipid profile
- After starting haloperidol:
- Monitor weight and BMI
- Consider monitoring fasting triglycerides monthly for several months in patients at high risk for metabolic complications
- Patients with low white blood cell count (WBC) or history of drug-induced leukopenia/neutropenia should have complete blood count (CBC) monitored frequently during the first few months and haloperidol should be discontinued at the first sign of decline of WBC in the absence of other causative factors
- Monitoring elevated prolactin levels is of dubious clinical benefit
- Consider monitoring plasma drug levels if not responding, or questions about compliance or side effects
What to Tell Parents About Efficacy
- Haloperidol is now considered a second-line therapy
- Haloperidol was chosen because other options have been tried and failed
- For acute symptoms, it can work right away
- Intramuscular haloperidol can be given by a healthcare professional on an as-needed basis for some symptoms like agitation; oral haloperidol can be given by a parent under supervision by a healthcare professional off-label on an as-needed basis as well
- Oral haloperidol is usually given every day
- Explain which use haloperidol is being chosen for, how to tell if the drug is working by targeting specific symptoms, and why this is being done
- Once the child/adolescent calms down, at some point after one dose or after several days of dosing or after long-term dosing, we should all assess whether the medication should be continued
- While the medicine helps by reducing symptoms and improving function, it is not a cure and it therefore may be necessary to keep taking the medication long-term to sustain its therapeutic effects
- Because every treatment consideration depends on a risk/benefit analysis, parents should fully understand short- and long-term risks as well as benefits
- It is often a good idea to tell parents whether the medication chosen is specifically approved for the disorder being treated, or whether it is being given for “unapproved” or “off-label” reasons based on good clinical practice, expert consensus, and/or prudent extrapolation of controlled data from adults
What to Tell Children and Adolescents About Efficacy
- Be specific about the symptoms being targeted: we are trying to help you…
- Give the medication a try; if it’s not working very well, we can stop the medication and try something else
- A good try often takes many months
- If it does make you feel better, you cannot stop it right away or you may get sick again
- Medications don’t change who you are as a person; they give you the opportunity to be the best person you can be
What to Tell Teachers About the Medication (If Parents Consent)
- Haloperidol can make children/adolescents restless and have abnormal movements like tremor
- Haloperidol can make children/adolescents sedated
- It is not abusable
- Encourage dialogue with parents/guardians about any behavior or mood changes
