Using the tool

This is the most up-to-date version (v5) of the tool.
Updated 1 February 2022. View update notification
Updated 16 June 2021. View update notification.
Updated 3 August 2020. View update notification.
Updated 29 October 2019. View update notification.

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This tool aims to assist prescribers when changing a patient’s antipsychotic treatment. For more information, see Stopping and switching antipsychotic drugs.

Select whether the change is from an oral to another oral formulation, or from a depot to another depot formulation. Then select the antipsychotic that the patient will switch from, and the antipsychotic that the patient will switch to. Click ‘Switch’ for the specific guidelines. Click ‘Reset’ for a new switching combination.

Formulation
Switch from
Switch to

Caution: While this tool gives guidelines, individual patient circumstances must be assessed. A slower cross titration may be necessary in some high-risk patients, especially in community settings.
Source: Psychotropic Drug Directory 2018, Maudsley Prescribing Guidelines in Psychiatry, and the authors’ own clinical experience.

Error: No combination found

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Cariprazine to aripiprazole

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Start aripiprazole at 10 mg on day 1. Slowly increase aripiprazole over the next four weeks to the desired therapeutic dose during the period of cariprazine elimination. Dose range of aripiprazole for psychosis is 10–30 mg taken in the morning.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to brexpiprazole

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Brexpiprazole has a long half-life and will take 10–12 days to reach steady-state concentrations. Start brexpiprazole 1 mg in the morning on day 1 and slowly increase the dose in steps during the period of cariprazine elimination. The dose range of brexpiprazole is 1–4 mg daily.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to amisulpride

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Start amisulpride on day 1 at 200 mg to avoid acute dystonia and increase slowly to the target dose, over the period of cariprazine elimination. Increase the dose of amisulpride slowly to a therapeutic dose during the period of cariprazine elimination. For positive symptoms of psychosis, the target dose of amisulpride is 200–800 mg daily.

Amisulpride is more likely to increase prolactin and cause sexual dysfunction than cariprazine. As amisulpride has an elevated risk of QTc prolongation, it is recommended to check serum magnesium, potassium and an ECG before administration.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to asenapine

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Start asenapine at 5 mg twice a day on day 1 and slowly increase the dose in steps as required, during the period of cariprazine elimination. The therapeutic dose of asenapine is 10–20 mg daily.

Expect asenapine to be more sedating than cariprazine and more likely to cause postural hypotension. The risk of weight gain is higher with asenapine than with cariprazine.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to chlorpromazine

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

If the target dose of chlorpromazine is known, slowly increase the dose in steps to reduce the anticholinergic and hypotensive adverse effects, during the period of cariprazine elimination.

If the target dose is not known, be guided by the patient’s previous drug history to estimate the chlorpromazine dose. The dose range of chlorpromazine is 200–800 mg daily.

Chlorpromazine is more likely to cause anticholinergic adverse effects, postural hypotension, sedation and increased prolactin than cariprazine.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to clozapine

Formulation: oral to oral
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Direct switch

The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Stop cariprazine. Start clozapine immediately according to standard titration schedules (from 12.5 mg or 25 mg), and increase the dose slowly as required during the period of cariprazine elimination. (An effective dose of clozapine is generally from 200 mg daily or when clozapine plasma concentrations have reached 350 microgram/L, and the patient has shown significant clinical effect.)

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to haloperidol

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Start haloperidol on day 1 at 1 mg in order to minimise effects such as dystonia. Slowly increase haloperidol in steps during the period of cariprazine elimination. The therapeutic dose range of haloperidol is 1–5 mg daily.

Haloperidol is more likely to cause extrapyramidal effects and increase prolactin than cariprazine. It is also likely to have some dysphoric effect, particularly after the use of partial dopamine agonists.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to lurasidone

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Start lurasidone at 40 mg once daily on day 1. This may be an effective dose for some patients. Dose titration can be undertaken if clinically indicated over the period of cariprazine elimination. For most patients, optimal clinical response and tolerability with lurasidone is expected at 40 or 80 mg once daily, doses up to 160 mg a day may be needed.

Lurasidone should be taken with food.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to olanzapine

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Olanzapine should be started at night on day 1 at a low dose (e.g. 5 mg). Olanzapine should then be increased slowly in steps over the period of cariprazine elimination. The dose range of olanzapine is 5–20 mg daily, and the dose should be adjusted according to clinical response and adverse effects.

Olanzapine will be more sedating than cariprazine and is likely to cause significantly more weight gain.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to paliperidone

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Paliperidone should be started at a low dose on day 1 and increased slowly (at intervals of at least 5 days), as necessary, during the period of cariprazine elimination. The dose range of paliperidone is 3–12 mg daily.

The patient should be advised to take paliperidone at the same time in relation to food intake and should not be concerned if they occasionally notice something in their stools that looks like a tablet.

Paliperidone is more likely to increase prolactin than cariprazine.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to periciazine

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Periciazine may be started at a low dose on day 1 and increased slowly as required over the period of cariprazine elimination. The dose of periciazine depends on the indication ranging from 2.5 mg to 75 mg daily in divided doses.

Periciazine is likely to be more sedating, have more anticholinergic effects, and possibly cause more extrapyramidal adverse effects, than cariprazine.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to quetiapine

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Start quetiapine at a low dose on day 1 (e.g. 50 mg extended-release or 25 mg twice-daily immediate release). Quetiapine should then be gradually increased in steps depending on response over the period of cariprazine elimination.

The usual effective daily dose of quetiapine is 300–450 mg. Lower doses are generally used for bipolar depression than for mania and schizophrenia. Depending on the clinical response and tolerability, the daily dose of quetiapine may be adjusted within a range of 200–800 mg.

Quetiapine will be more sedating and is likely to have more anticholinergic effects than cariprazine.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to risperidone

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Start risperidone on day 1 at a low dose, such as 1 mg daily, then increase gradually to the target dose during the period of cariprazine elimination. If the target dose is unknown, slowly increase the dose from 1 mg daily depending on the response. The dose of risperidone is 1–6 mg daily, given in one or two doses.

Risperidone is more likely to increase prolactin than cariprazine.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to ziprasidone

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Ziprasidone should be commenced at a low dose (e.g. 40 mg) on day 1 and increased gradually to the target dose during the period of cariprazine elimination. If the target dose is not known, it is recommended to start ziprasidone at 40 mg daily and slowly adjust the dose depending on clinical effects. The recommended dose range of ziprasidone is 80–160 mg daily, given in one or two doses.

Ziprasidone has a higher risk of QTc prolongation than cariprazine. It is recommended to check serum magnesium, potassium and an ECG before administration.

Ziprasidone should be taken with food.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Cariprazine to zuclopenthixol

Formulation: oral to oral
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Direct switch

Cariprazine can be stopped on day 1. The long effective half-life of cariprazine (about 7 days) means withdrawal effects are unlikely. It may take 3–4 weeks for most of the cariprazine to be eliminated.

Zuclopenthixol should be started at a low dose on day 1 (e.g. 10 mg) and increased slowly to the target dose during the period of cariprazine elimination.

If the target dose is not known, start zuclopenthixol at 10 mg daily and adjust the dose slowly based on clinical effects. The dose range of zuclopenthixol is 10–75 mg daily, depending on the indication.

Zuclopenthixol is more likely to cause extrapyramidal effects and increase prolactin than cariprazine.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Amisulpride to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

Start cariprazine and simultaneously commence reduction of amisulpride gradually in steps over about 4 weeks during the period of cariprazine initiation. If the original dose of amisulpride is 200 mg or less, it is advisable not to start reducing it for at least the first 3 weeks after starting cariprazine.

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Aripiprazole to cariprazine

Formulation: oral to oral
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Direct switch or cross titration

The half-life of aripiprazole is long (approximately 75 hours). Most of the drug is eliminated two weeks after stopping. It can be stopped immediately with little risk of withdrawal effects. When switching to cariprazine, cross titration may be used if there is concern about maintaining adequate antipsychotic treatment.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

Start cariprazine on day 1 and at the same time cease or reduce aripiprazole over the period of cariprazine titration. The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose of cariprazine can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability, to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Asenapine to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

Start cariprazine and simultaneously commence reduction of asenapine gradually in steps over about 4 weeks during the period of cariprazine initiation. If the original dose of asenapine is 5 mg, it is advisable not to start reducing it for at least the first 3 weeks after starting cariprazine.

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Brexpiprazole to cariprazine

Formulation: oral to oral
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Direct switch or cross titration

The half-life of brexpiprazole is long (approximately 91 hours). Most of the drug is eliminated 2.5 weeks after stopping. It can be stopped immediately with little risk of withdrawal effects. When switching to cariprazine, cross titration could be used if there is concern about maintaining adequate antipsychotic treatment.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

Start cariprazine on day 1. Cease or reduce brexpiprazole over the period of cariprazine titration. The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Chlorpromazine to cariprazine

Formulation: oral to oral
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Direct switch

A direct switch is not recommended because of the differences in adverse effect properties of the two drugs. Chlorpromazine should be stopped slowly to avoid anticholinergic withdrawal, possible blood pressure effects, and behavioural effects related to loss of sedation.

Cross titration

Reduce the chlorpromazine dose slowly in steps over a period of about 4 weeks while cariprazine is started on day 1. Cariprazine has no anticholinergic effects so there is some risk of cholinergic withdrawal after stopping chlorpromazine.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks). If the original dose of chlorpromazine is 200 mg or less, it is advisable not to start reducing it for at least the first 3 weeks after cariprazine therapy.

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Clozapine to cariprazine

Formulation: oral to oral
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Direct switch

Not recommended.

Cross titration

Always consult a psychiatrist when discontinuing clozapine. Abrupt stopping of clozapine carries a high risk of withdrawal psychosis and withdrawal anticholinergic symptoms. If withdrawal psychosis occurs, it can be severe and accompanied by physical and autonomic symptoms that resemble neuroleptic malignant syndrome. In severe cases, sometimes the only option is to restart clozapine. If this is not feasible because of adverse effects such as severe neutropenia, myocarditis or cardiomyopathy, specialist consultation is advised.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

Start cariprazine on day 1. If possible, reduce clozapine slowly over 6 weeks (very high-risk patients should stop clozapine over 3–6 months). The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. The dose of cariprazine can be titrated gradually during the period of clozapine withdrawal. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Haloperidol to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce haloperidol gradually in steps over a period of about 4 weeks while cariprazine is started on day 1. If the original dose of haloperidol is 2 mg or less, it is advisable not to start reducing it for at least the first 3 weeks after starting cariprazine.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Lurasidone to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce lurasidone gradually in steps over a period of about 4 weeks while cariprazine is started on day 1. If the original dose of lurasidone is 40 mg or less, it is advisable not to start reducing it for at least the first 3 weeks after starting cariprazine.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Olanzapine to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce olanzapine gradually in steps over a period of about 4 weeks while cariprazine is started on day 1. Slow reduction of olanzapine will minimise risk of anticholinergic withdrawal symptoms and insomnia.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Paliperidone to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce paliperidone gradually in steps over a period of about 4 weeks while cariprazine is started on day 1.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Periciazine to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce periciazine gradually in steps over a period of about 4 weeks while cariprazine is started on day 1.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Quetiapine to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce quetiapine (both immediate release and modified release) gradually in steps over a period of about 4 weeks while cariprazine is started on day 1. Slow reduction of quetiapine will minimise risk of anticholinergic withdrawal symptoms and insomnia.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Risperidone to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce risperidone gradually in steps over a period of 4 weeks while cariprazine is started on day 1.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Ziprasidone to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce ziprasidone gradually in steps over a period of about 4 weeks while cariprazine is started on day 1.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Zuclopenthixol to cariprazine

Formulation: oral to oral
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Direct switch

Due to differences in adverse-effect profiles and half-lives, a direct switch is not recommended.

Cross titration

Reduce zuclopenthixol gradually in steps over a period of about 4 weeks while cariprazine is started on day 1.

Cariprazine has a long effective half-life (about 7 days) and will take 4–5 weeks to reach steady-state concentrations (90% of steady state is achieved in 3 weeks).

The recommended starting dose of cariprazine is 1.5 mg once daily. Thereafter the dose can be increased (preferably slowly to reduce activation effects) in 1.5 mg increments according to efficacy and tolerability to a maximum daily dose of 6 mg, if needed. Technically the interval between cariprazine dose adjustments should be at least two weeks. When clinically necessary, adjustments can be made at shorter intervals such as weekly (observe for adverse effects).

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Olanzapine to amisulpride

Formulation: oral to oral
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Direct switch and cross titration

Low doses of olanzapine can be stopped on day 1. Higher doses (>10 mg) should be reduced by 50% on day 1 and stopped after 7 days.

Start amisulpride on day 1. It will take approximately 3 days to reach steady-state plasma concentrations. The product information recommends starting at the target dose, but in clinical practice start at 200 mg to avoid acute dystonia and increase to target dose. For positive symptoms of psychosis, the target dose is 200–800 mg daily.

Amisulpride is more likely to increase prolactin and cause sexual dysfunction. There is some risk of cholinergic rebound when olanzapine is withdrawn.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Olanzapine to lurasidone

Formulation: oral to oral
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Direct switch and cross titration

Low doses of olanzapine can be stopped on day 1. Higher doses (>10 mg) should be reduced by 50% on day 1 and stopped after 7 days.

Start lurasidone at 40 mg once daily on day 1. Initial dose titration is not required and optimal clinical response and tolerability for most patients is expected to be 40 mg or 80 mg once daily. Doses up to 160 mg a day may be needed. Lurasidone should be taken with food.

There is some risk of cholinergic rebound when olanzapine is withdrawn.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Olanzapine to paliperidone

Formulation: oral to oral
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Direct switch and cross titration

Low doses of olanzapine can be stopped on day 1. Higher doses (>10 mg) should be reduced by 50% on day 1 and stopped after 7 days.

The patient should be advised to take paliperidone at the same time in relation to food and should not be concerned if they occasionally notice something in their stools that looks like a tablet.

Paliperidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5.

Paliperidone is more likely to increase prolactin. There is some risk of cholinergic rebound when olanzapine is withdrawn.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Olanzapine to risperidone

Formulation: oral to oral
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Direct switch and cross titration

Low doses of olanzapine can be stopped on day 1. Higher doses (>10 mg) should be reduced by 50% on day 1 and stopped after 7 days.

Risperidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is unknown, an initial dose of 1 mg daily is recommended. In some patients a slower titration phase and lower starting and maintenance dose may be appropriate. Titrate gradually in view of the risk of first-dose postural hypotension. Risperidone can be given once or twice daily.

Risperidone is more likely to increase prolactin. There is some risk of cholinergic rebound when olanzapine is withdrawn.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Olanzapine to ziprasidone

Formulation: oral to oral
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Direct switch and cross titration

Low doses of olanzapine can be stopped on day 1. Higher doses (>10 mg) should be reduced by 50% on day 1 and stopped after 7 days.

Ziprasidone is poorly absorbed if not taken with food.

Ziprasidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is not known, start ziprasidone at 40 mg twice daily and adjust the dose based on clinical effects. The dose may be increased as early as day 3.

Ziprasidone has a higher risk of causing QTc prolongation, therefore baseline serum magnesium, potassium and an ECG should be taken. There is some risk of cholinergic rebound when olanzapine is withdrawn.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Clozapine to olanzapine

Formulation: oral to oral
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Direct switch

Not recommended.

Cross titration

Always consult a psychiatrist when discontinuing clozapine. Abrupt cessation of clozapine carries a high risk of rebound psychosis and rebound anticholinergic symptoms. If rebound psychosis occurs, it can be severe and accompanied by physical and autonomic symptoms that resemble neuroleptic malignant syndrome. In severe cases, sometimes the only option is to restart clozapine. If this is not feasible because of adverse effects such as severe neutropenia, myocarditis or cardiomyopathy, specialist consultation is advised.

If possible, clozapine should be stopped very slowly over 6 weeks. Very high-risk patients should stop clozapine over 3–6 months.

Olanzapine should be started at night on day 1. For schizophrenia and related disorders, start at 5–10 mg/day as a single daily dose. The dose may be adjusted based on clinical response and adverse effects.

For acute mania associated with bipolar disorder, the recommended starting dose is 10 or 15 mg once a day as monotherapy, or 10 mg once daily in combination with lithium or valproate. If indicated, dose adjustments should generally occur at intervals of not less than 24 hours and in increments or decrements of 5 mg daily.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Periciazine to risperidone

Formulation: oral to oral
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Direct switch and cross titration

Higher doses of periciazine (>30 mg daily) should be reduced by 50% on day 1 and then stopped after approximately 10 days. Periciazine is a low-to-medium-potency, typical antipsychotic with a short half-life, so an extended period of reduction is recommended because of the risk of relapse or cholinergic rebound.

Risperidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is unknown, an initial dose of 1 mg daily is recommended. In some patients a slower titration phase and lower starting and maintenance dose may be appropriate. Titrate gradually in view of the risk of first-dose postural hypotension. Risperidone can be given once or twice daily.

Risperidone is more likely to increase prolactin and cause extrapyramidal effects.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to risperidone

Formulation: depot to depot
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Stop zuclopenthixol.

Patients should be initially converted to oral risperidone to exclude hypersensitivity or allergy which may manifest with a variety of symptoms including angioedema, urticaria and rash. Tablets may be started while the patient still has significant zuclopenthixol plasma concentrations from the depot. If starting oral risperidone within a week of the last zuclopenthixol depot, give 25% of the target dose and titrate up according to clinical effects.

Risperidone depot has a 3-week lag before significant release of risperidone from the injection. When converting from oral to depot risperidone, continue the oral risperidone for at least 3 weeks to ensure antipsychotic coverage in that period.

If converting to risperidone depot without using oral risperidone, the risperidone depot should be started 3 weeks before the next dose of zuclopenthixol was to be given. This avoids a significant trough in antipsychotic concentrations. Zuclopenthixol is most commonly given every 2 weeks which creates a complicated situation. Another zuclopenthixol dose must be given after the first risperidone dose is given because there is a risk of breakthrough symptoms before the risperidone depot starts to release.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Zuclopenthixol to olanzapine

Formulation: depot to depot
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Stop zuclopenthixol.

Patients should be initially converted to oral olanzapine tablets to establish tolerance and exclude allergy. Oral olanzapine may be started while the patient still has significant zuclopenthixol plasma concentrations. If starting oral olanzapine within a week of the last zuclopenthixol depot, give 25% of the target dose.

Supplementation with oral olanzapine is not necessary at the start of treatment with olanzapine depot.

If the patient has used olanzapine in the past, switch directly from zuclopenthixol depot to olanzapine depot. In this case, the first olanzapine depot should be given on the day that the zuclopenthixol depot was next due.

Olanzapine is more sedating than other antipsychotic depot drugs. Because of the risk of post-injection syndrome, the patient must be observed for 2 hours after each injection of olanzapine depot.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to paliperidone (once-monthly)

Formulation: depot to depot
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Stop zuclopenthixol.

If the patient has never been exposed to paliperidone (or risperidone), an oral dose should be given to test for hypersensitivity or allergy.

Paliperidone depot can be given on the day that the next zuclopenthixol depot dose was to be given. If converting the patient in this way, the loading dose regimen for paliperidone should not be used. Patients can only be converted to paliperidone 4-weekly (Invega Sustenna). The paliperidone 12-weekly injection (Invega Trinza) is not suitable for use in patients who have not been stabilised on the 4-weekly paliperidone depot for at least 4 months.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Zuclopenthixol to haloperidol

Formulation: depot to depot
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Stop zuclopenthixol.

Patients should be initially converted to oral haloperidol to exclude allergy. Tablets may be started while the patient still has significant zuclopenthixol plasma concentrations from the depot. If starting oral haloperidol within a week of the last zuclopenthixol depot, give 25% of the target dose.

If switching the patient directly to haloperidol depot, give a test dose of 25 mg 5–10 days before the haloperidol depot is to be started. If there are no reactions, the full dose of haloperidol depot can be given.

If the patient is converting from oral to depot haloperidol, give an initial depot dose of 10–15 times the previous daily dose in oral haloperidol equivalents, but no more than a maximum initial dose of 100 mg (2 mL). To determine the minimum effective dose, start with lower doses and titrate upward as needed.

The dose of zuclopenthixol depot can be used to guide the target dose of the haloperidol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Zuclopenthixol to flupentixol

Formulation: depot to depot
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Stop zuclopenthixol.

Start flupentixol on the day zuclopenthixol depot was due.

If the patient has not had flupentixol before, give a test dose of 5–20 mg 5–10 days before the flupentixol is to be started. If there are no reactions, on the day the zuclopenthixol depot was due, the full dose of flupentixol can be given.

The dose of zuclopenthixol can be used to guide the target dose of flupentixol depot. Previous antipsychotic use from the patient’s history may also be a helpful guide.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to aripiprazole

Formulation: depot to depot
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Stop zuclopenthixol.

Patients should be initially converted to oral aripiprazole to exclude allergy. Start oral aripiprazole at the target dose on the day that zuclopenthixol depot was due. The recommended starting dose for aripiprazole is 10–20 mg daily, although some guidance can be taken from the dose of zuclopenthixol depot that was used. Two weeks of oral therapy is recommended to establish tolerability before the first aripiprazole depot is administered. The recommended dose of aripiprazole depot is 400 mg every 4 weeks for all patients except those who are known to be poor cytochrome P450 2D6 metabolisers or have demonstrated sensitivity to adverse effects from aripiprazole in the past.

For patients who have used typical antipsychotics for a considerable time, changing to a partial dopamine agonist like aripiprazole carries some risk of increased agitation and irritability, as well as psychotic relapse.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to zuclopenthixol

Formulation: depot to depot
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Stop risperidone

There is a delay of approximately 3 weeks following the last risperidone injection before the drug starts to release. The switch to zuclopenthixol should therefore be designed to avoid increasing peak antipsychotic concentrations. The most commonly suggested method is to delay the first dose of zuclopenthixol by 4 to 6 weeks. Another method, recommended in this tool, is to continue the regular injection cycle, to aid adherence, but start zuclopenthixol at a lower dose. This is based on the authors’ clinical experience of problems encountered when the injection cycle is broken.

Patients should be initially converted to oral zuclopenthixol tablets to exclude allergy. Oral zuclopenthixol may be started while the patient still has significant risperidone plasma concentrations from the depot. If starting oral zuclopenthixol within 3 weeks of the last injection of risperidone, the dose should be approximately 25% of the target dose.

If the patient has not had zuclopenthixol before and oral zuclopenthixol cannot be used, aim to start zuclopenthixol depot on the day the risperidone depot was due. Give a test dose of 50 mg of zuclopenthixol depot 5–10 days before the zuclopenthixol depot is to be started. If there are no reactions and it is within 3 weeks of the last injection of risperidone, the dose should be approximately 25% of the target dose, otherwise give the full dose on the day the risperidone depot was due.

If the patient is converting from oral to depot zuclopenthixol, oral zuclopenthixol should be continued for at least 1 week after the start of the zuclopenthixol depot.

The dose of risperidone depot can be used to guide the target dose of zuclopenthixol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Risperidone to paliperidone (once-monthly)

Formulation: depot to depot
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Stop risperidone.

Paliperidone depot can be given on the day that the next risperidone depot was due. If converting the patient in this way, the loading dose regimen for paliperidone should not be used. Patients can only be converted to paliperidone 4-weekly (Invega Sustenna). The paliperidone 12-weekly injection (Invega Trinza) is not suitable for use in patients who have not been stabilised on the 4-weekly paliperidone depot for at least 4 months.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to olanzapine

Formulation: depot to depot
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Stop risperidone.

There is a delay of approximately 3 weeks following the last risperidone injection before the drug starts to release. The switch to olanzapine should therefore be designed to avoid increasing peak antipsychotic concentrations. The most commonly suggested method is to delay the first dose of olanzapine by 4 to 6 weeks. Another method, recommended in this tool, is to continue the regular injection cycle, to aid adherence, but start olanzapine at a lower dose. This is based on the authors’ clinical experience of problems encountered when the injection cycle is broken.

Patients should be initially converted to oral olanzapine tablets to establish tolerance and exclude allergy. Oral olanzapine may be started while the patient still has significant risperidone plasma concentrations. If starting oral olanzapine within 3 weeks of the last injection of risperidone, the dose should be approximately 25% of the target dose.

Supplementation with oral olanzapine is not necessary at the start of treatment with olanzapine depot.

If the patient has used olanzapine in the past, it is possible to switch directly from risperidone depot to olanzapine depot. In this case, aim to start olanzapine depot on the day risperidone depot was due. If it is within five weeks of the last time risperidone depot was administered, the dose should be approximately 25% of the target dose, otherwise give the full dose on the day the risperidone depot was due.

Olanzapine is more sedating than other antipsychotic depots. Because of the risk of post-injection syndrome, the patient must be observed for 2 hours after each olanzapine injection.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to haloperidol

Formulation: depot to depot
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Stop risperidone.

There is a delay of approximately 3 weeks following the last risperidone injection before the drug starts to release. The switch to haloperidol should therefore be designed to avoid increasing peak antipsychotic concentrations. The most commonly suggested method is to delay the first dose of haloperidol by 4 to 6 weeks. Another method, recommended in this tool, is to continue the regular injection cycle, to aid adherence, but start haloperidol at a lower dose. This is based on the authors’ clinical experience of problems encountered when the injection cycle is broken.

Patients should be initially converted to oral haloperidol to exclude allergy. Tablets may be started within 3 weeks of the last injection of risperidone even though the patient still has significant risperidone plasma concentrations from the depot. The oral haloperidol dose should be approximately 25% of the target dose.

Aim to start haloperidol depot on the day risperidone depot was due.

If switching the patient directly to haloperidol depot, give a test dose of 25 mg 5–10 days before the haloperidol depot is to be started. If there are no reactions and it is within 3 weeks of the last injection of risperidone, the dose should be approximately 25% of the target dose, otherwise give the full dose on the day the risperidone depot was due.

If the patient is converting from oral to depot haloperidol, give an initial depot dose of 10–15 times the previous daily dose in oral haloperidol equivalents, but no more than a maximum initial dose of 100 mg (2 mL). To determine the minimum effective dose, start with lower doses and titrate upward as needed.

The dose of risperidone depot can be used as a rough guide to the target dose of haloperidol depot. Previous antipsychotic use from the patient’s history may also give a guide as to the target dose of haloperidol depot.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to flupentixol

Formulation: depot to depot
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Stop risperidone.

There is a delay of approximately 3 weeks following the last risperidone injection before the drug starts to release. The switch to flupentixol should therefore be designed to avoid increasing peak antipsychotic concentrations. The most commonly suggested method is to delay the first dose of flupentixol by 4 to 6 weeks. Another method, recommended in this tool, is to continue the regular injection cycle, to aid adherence, but start flupentixol at a lower dose. This is based on the authors’ clinical experience of problems encountered when the injection cycle is broken.

Aim to start flupentixol on the day risperidone depot was due.

If the patient has not had flupentixol before, give a test dose of 5–20 mg 5–10 days before the flupentixol is to be started. If there are no reactions and it is within 3 weeks of the last injection of risperidone, the dose should be approximately 25% of the target dose, otherwise give the full dose on the day the risperidone depot was due.

The dose of risperidone can be used to guide the target dose of flupentixol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to aripiprazole

Formulation: depot to depot
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Stop risperidone.

There is a delay of approximately 3 weeks following the last risperidone injection before the drug starts to release. The switch to aripiprazole should therefore be designed to avoid increasing peak antipsychotic concentrations. The most commonly suggested method is to delay the first dose of aripiprazole by 4 to 6 weeks. Another method, recommended in this tool, is to continue the regular injection cycle, to aid adherence, but start aripiprazole at a lower dose. This is based on the authors’ clinical experience of problems encountered when the injection cycle is broken.

Patients should be initially switched from risperidone depot to oral aripiprazole. If starting oral aripiprazole within 3 weeks of the last injection of risperidone, the dose of aripiprazole should be approximately 25% of the target dose. If the target dose is unknown, the recommended starting dose for aripiprazole is 10–20 mg daily, although some guidance can be taken from the dose of risperidone depot that was used.

Two weeks of oral aripiprazole is recommended to establish tolerability. The recommended dose of aripiprazole depot is 400 mg every 4 weeks for all patients except those who are known to be poor cytochrome P450 2D6 metabolisers or have had adverse effects from aripiprazole in the past.

For patients who have used typical antipsychotics for a considerable time, changing to a partial dopamine agonist like aripiprazole carries some risk of increased agitation and irritability.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Paliperidone (once-monthly) to zuclopenthixol

Formulation: depot to depot
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Patients should be initially converted to oral zuclopenthixol tablets to exclude allergy and establish tolerability. Oral zuclopenthixol may be started while the patient still has significant paliperidone plasma concentrations from the depot. If starting oral zuclopenthixol within a week of the last paliperidone depot, give 25% of the target dose.

If the patient has not had zuclopenthixol before and oral zuclopenthixol cannot be used, give a test dose of 50 mg of zuclopenthixol depot 5–10 days before the zuclopenthixol depot is to be started. If there are no reactions, give the full dose of zuclopenthixol depot.

The dose of paliperidone depot can be used to guide the target dose of zuclopenthixol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Paliperidone (once-monthly) to risperidone

Formulation: depot to depot
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Stop paliperidone.

Risperidone depot has a 3-week lag before significant release of risperidone from the injection site so it can be started 3 weeks before the next dose of paliperidone depot was due. Because of the long half-life of paliperidone depot, oral risperidone supplementation is regarded as unnecessary.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Paliperidone (once-monthly) to olanzapine

Formulation: depot to depot
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Stop paliperidone.

Patients should be initially converted to oral olanzapine tablets to establish tolerance and exclude allergy. Tablets may be started while the patient still has significant paliperidone plasma concentrations. If starting oral olanzapine within a week of the last paliperidone depot, give 25% of the target dose.

Supplementation with oral olanzapine is not necessary at the start of treatment with olanzapine depot.

If the patient has used olanzapine in the past, switch paliperidone depot directly to olanzapine depot. In this case, the first olanzapine depot should be given on the day that the paliperidone depot was next due.

Olanzapine is more sedating than other antipsychotic depots. Because of the risk of post-injection syndrome, the patient must be observed for 2 hours after each olanzapine injection.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Paliperidone (once-monthly) to haloperidol

Formulation: depot to depot
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Stop paliperidone.

Patients should be initially converted to oral haloperidol to exclude allergy. Tablets may be started while the patient still has significant paliperidone plasma concentrations from the depot. If starting oral haloperidol within a week of the last paliperidone depot, give 25% of the target dose.

If switching the patient directly to haloperidol depot, give a test dose of 25 mg 5–10 days before the haloperidol depot is to be started. If there are no reactions, the full dose can be given.

If the patient is converting from oral to depot haloperidol, give an initial depot dose of 10–15 times the previous daily dose in oral haloperidol equivalents, but no more than a maximum initial dose of 100 mg (2 mL). To determine the minimum effective dose, start with lower doses and titrate upward as needed.

The dose of paliperidone depot can be used as a rough guide to the target dose of haloperidol depot. Previous antipsychotic use from the patient’s history may also give a guide as to the target dose of haloperidol depot.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Paliperidone (once-monthly) to flupentixol

Formulation: depot to depot
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Stop paliperidone.

Start flupentixol on the day paliperidone depot was due.

If the patient has not had flupentixol before give a test dose of 5–20 mg 5–10 days before the flupentixol is to be started. If there are no reactions, give the full dose.

The dose of paliperidone can be used to guide the target dose of flupentixol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Paliperidone (once-monthly) to aripiprazole

Formulation: depot to depot
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Stop paliperidone.

Convert paliperidone depot to oral aripiprazole by starting the oral aripiprazole at the target dose on the day that paliperidone depot was due. The recommended starting dose for aripiprazole is 10–20 mg daily, although some guidance can be taken from the dose of paliperidone depot that was used. Two weeks of oral therapy is recommended to establish tolerability to aripiprazole before the first depot is administered. The recommended dose of aripiprazole depot is 400 mg every 4 weeks for all patients except those who are known to be poor cytochrome P450 2D6 metabolisers or were sensitive to adverse effects from aripiprazole in the past.

For patients who have used typical antipsychotics for a considerable time, changing to a partial dopamine agonist like aripiprazole carries some risk of increased agitation and irritability.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Olanzapine to zuclopenthixol

Formulation: depot to depot
Print

Stop olanzapine.

Patients should be initially converted to oral zuclopenthixol to exclude allergy. Tablets may be started while the patient still has significant olanzapine plasma concentrations from the depot. If starting oral zuclopenthixol within a week of the last olanzapine depot, give 25% of the target dose.

If the patient has not had zuclopenthixol before and oral zuclopenthixol cannot be used, give a test dose of 50 mg of zuclopenthixol depot 5–10 days before the zuclopenthixol depot is to be started. If there are no reactions, the full dose of zuclopenthixol depot can be given.

If the patient is converting from oral to depot zuclopenthixol, oral zuclopenthixol should be continued for at least 1 week after the start of depot treatment.

The dose of olanzapine depot can be used to guide the target dose of zuclopenthixol depot. Previous antipsychotic use from the patient’s history may also be a helpful guide.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Olanzapine to risperidone

Formulation: depot to depot
Print

Stop olanzapine.

Patients should be initially converted to oral risperidone to exclude hypersensitivity or allergy which may manifest with symptoms including angioedema, urticaria and rash. Tablets may be started while the patient still has significant olanzapine plasma concentrations from the depot. If starting oral risperidone within a week of the last olanzapine depot, give 25% of the target dose and titrate up according to clinical effects.

Risperidone depot has a 3-week lag before significant release of risperidone from the injection site so risperidone depot can be started 3 weeks before the next dose of olanzapine depot was to be given.

When converting from oral to depot risperidone, continue the oral risperidone for at least 3 weeks to ensure antipsychotic coverage in that period.

If olanzapine depot was given as a 2-weekly injection and it is intended to convert to risperidone depot without using oral risperidone, a complicated situation arises. Another olanzapine dose must be given after the first risperidone dose is given because there is a risk of breakthrough symptoms before the risperidone depot starts to release. Clinicians must weigh the risks and benefits of converting to risperidone without using oral risperidone as a bridge.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Olanzapine to paliperidone (once-monthly)

Formulation: depot to depot
Print

Stop olanzapine.

If the patient has never been exposed to paliperidone (or risperidone), an oral dose should be given to test for hypersensitivity or allergy.

Paliperidone depot can be given on the day that the next olanzapine depot was due. If converting the patient in this way, the loading dose regimen for paliperidone should not be used. Patients can only be converted to paliperidone 4-weekly (Invega Sustenna). The paliperidone 12-weekly injection (Invega Trinza) is not suitable for use in patients who have not been stabilised on the 4-weekly paliperidone depot for at least 4 months.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Olanzapine to haloperidol

Formulation: depot to depot
Print

Stop olanzapine.

Patients should be initially converted to oral haloperidol to exclude allergy. Tablets may be started while the patient still has significant olanzapine plasma concentrations from the depot. If starting oral haloperidol within a week of the last olanzapine depot, give 25% of the target dose.

If switching the patient directly to haloperidol depot, give a test dose of 25 mg 5–10 days before the haloperidol depot is to be started. If there are no reactions, the full dose of haloperidol depot can be given.

If the patient is converting from oral to depot haloperidol, give an initial depot dose of 10–15 times the previous daily dose in oral haloperidol equivalents, but no more than a maximum initial dose of 100 mg (2 mL). To determine the minimum effective dose, start with lower doses and titrate upward as needed.

The dose of olanzapine depot can be used to guide the target dose of haloperidol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Olanzapine to flupentixol

Formulation: depot to depot
Print

Stop olanzapine.

Start flupentixol depot on the day olanzapine depot was due.

If the patient has not had flupentixol before, give a test dose of 5–20 mg 5–10 days before the flupentixol is to be started. If there are no reactions, the full dose of flupentixol can be given.

The dose of olanzapine can be used to guide the target dose of flupentixol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Olanzapine to aripiprazole

Formulation: depot to depot
Print

Stop olanzapine.

Start oral aripiprazole at the target dose on the day that olanzapine depot was due. The recommended starting dose for aripiprazole is 10–20 mg daily, although some guidance can be taken from the dose of olanzapine depot that was used. Two weeks of oral therapy is recommended to establish tolerability to aripiprazole before the first depot is administered. The recommended dose of aripiprazole depot is 400 mg every 4 weeks for all patients except those who are known to be poor cytochrome P450 2D6 metabolisers or have demonstrated sensitivity to adverse effects from aripiprazole in the past.

For patients who have used typical antipsychotics for a considerable time, changing to a partial dopamine agonist like aripiprazole carries some risk of increased agitation and irritability.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Haloperidol to zuclopenthixol

Formulation: depot to depot
Print

Stop haloperidol.

Patients should be initially converted to oral zuclopenthixol tablets to exclude allergy. Oral zuclopenthixol may be started while the patient still has significant haloperidol plasma concentrations from the depot. If starting oral zuclopenthixol within a week of the last haloperidol depot, the dose should be approximately 25% of the target dose.

If the patient has not had any zuclopenthixol before and oral zuclopenthixol cannot be used, a test dose of 50 mg of zuclopenthixol depot should be given 5–10 days before the zuclopenthixol depot is to be started. If there are no reactions, give the full dose of zuclopenthixol depot on the day the haloperidol depot was due.

If the patient is converting from oral zuclopenthixol to zuclopenthixol depot, the chance of allergy to the vehicle is considered low. Oral zuclopenthixol should be continued for at least 1 week after the start of treatment with zuclopenthixol depot.

The dose of haloperidol depot can be used to guide the target dose of zuclopenthixol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Haloperidol to risperidone

Formulation: depot to depot
Print

Stop haloperidol.

Patients should be initially converted to oral risperidone tablets to exclude hypersensitivity or allergy which may manifest with symptoms including angioedema, urticaria and rash. Oral risperidone may be started while the patient still has significant haloperidol plasma concentrations from the depot. If starting oral risperidone within a week of the last haloperidol depot, the dose should be approximately 25% of the target dose and titrated up according to clinical effects. Risperidone depot has a 3-week lag before significant release of risperidone from the injection site so it can be started 3 weeks before the next dose of haloperidol depot was due.

When converting from oral risperidone to risperidone depot, continue the oral risperidone for at least 3 weeks to ensure antipsychotic coverage.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Haloperidol to paliperidone (once-monthly)

Formulation: depot to depot
Print

Stop haloperidol.

If the patient has never been exposed to paliperidone (or risperidone), an oral dose should be given to test for hypersensitivity or allergy.

Paliperidone depot can be given on the day that the next haloperidol depot dose was to be given. If converting the patient in this way, the loading dose regimen for paliperidone should not be used. Patients can only be converted to paliperidone 4-weekly (Invega Sustenna). The paliperidone 12-weekly injection (Invega Trinza) is not suitable for use in patients who have not been stabilised on the 4-weekly paliperidone depot for at least 4 months.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Haloperidol to olanzapine

Formulation: depot to depot
Print

Stop haloperidol.

Patients should be initially converted to oral olanzapine tablets to establish tolerance and exclude allergy. Oral olanzapine may be started while the patient still has significant haloperidol plasma concentrations. If starting oral olanzapine within a week of the last haloperidol depot, the dose should be approximately 25% of the target dose.

Supplementation with oral olanzapine is not necessary at the start of treatment with olanzapine depot.

If the patient has used olanzapine in the past, it is possible to switch directly from haloperidol depot to olanzapine depot. In this case, the first olanzapine depot should be given on the day that the haloperidol depot was due.

Olanzapine is more sedating than other antipsychotic depot drugs. Because of the risk of post-injection syndrome, the patient must be observed for 2 hours after each olanzapine injection.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Haloperidol to flupentixol

Formulation: depot to depot
Print

Stop haloperidol.

Start flupentixol on the day haloperidol depot was due.

If the patient has not had flupentixol before, there is a small chance of allergy to the drug and possibly the vehicle (coconut oil). A test dose of 5–20 mg should be given 5–10 days before the flupentixol is to be started. If there are no reactions, on the day the haloperidol depot was due, the full dose of flupentixol can be given.

The dose of haloperidol can be used to guide the target dose of flupentixol depot. Previous antipsychotic use from the patient’s history may also be helpful.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Haloperidol to aripiprazole

Formulation: depot to depot
Print

Stop haloperidol.

Convert haloperidol depot to oral aripiprazole by starting the oral aripiprazole at the target dose on the day that haloperidol depot was due. The recommended starting dose for aripiprazole is 10–20 mg daily, although some guidance can be taken from the dose of haloperidol depot that was used. Two weeks of oral therapy is recommended to establish tolerability to aripiprazole before the first depot is administered. The recommended dose of aripiprazole depot is 400 mg every 4 weeks for all patients except those who are known to be poor cytochrome P450 2D6 metabolisers or have demonstrated sensitivity to adverse effects from aripiprazole in the past.

For patients who have used typical antipsychotics for a considerable length of time, a change to a partial dopamine agonist like aripiprazole carries some risk of increased agitation and irritability.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Fluphenazine* to zuclopenthixol

Formulation: depot to depot
Print

Patients should be initially converted to oral zuclopenthixol tablets to exclude allergy. Oral zuclopenthixol may be started while the patient still has significant fluphenazine plasma concentrations from the depot. If starting oral zuclopenthixol within a week of the last fluphenazine depot, the dose should be approximately 25% of the target dose.

If the patient has not had any zuclopenthixol before and oral zuclopenthixol cannot be used, a test dose of 50 mg of zuclopenthixol depot should be given 5–10 days before the full dose is to be started. If there are no reactions, give the full dose of zuclopenthixol depot on the day the fluphenazine depot was due.

If the patient is converting from oral zuclopenthixol to zuclopenthixol depot, the chance of allergy to the vehicle is considered low. Oral zuclopenthixol should be continued for at least 1 week after the start of treatment with zuclopenthixol depot.

The dose of fluphenazine depot can be used to guide the target dose of zuclopenthixol depot. Previous antipsychotic use from the patient’s history may also help.

* No longer available in Australia

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Fluphenazine* to risperidone

Formulation: depot to depot
Print

Stop fluphenazine.

Patients should be initially converted to oral risperidone tablets to exclude hypersensitivity or allergy which may manifest with symptoms including angioedema, urticaria and rash. Oral risperidone may be started while the patient still has significant fluphenazine plasma concentrations from the depot. If starting oral risperidone within a week of the last fluphenazine depot, the dose should be approximately 25% of the target dose and titrated up according to clinical effects. However, risperidone depot can theoretically be started 3 weeks before the next dose of fluphenazine depot was to be given. This will ensure that risperidone depot will release significant amounts of risperidone by the time the next fluphenazine depot was to be given.

When converting from oral risperidone to risperidone depot, it is important to continue the oral risperidone for at least 3 weeks to ensure antipsychotic coverage in that period. Risperidone depot has a 3-week lag before significant release of risperidone from the injection site.

* No longer available in Australia

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Fluphenazine* to paliperidone (once-monthly)

Formulation: depot to depot
Print

Stop fluphenazine.

If the patient has never been exposed to paliperidone (or risperidone), an oral dose should be given to test for hypersensitivity or allergy.

Paliperidone depot can be given on the day that the next fluphenazine depot was due. If converting the patient in this way, the loading dose regimen for paliperidone should not be used. Patients can only be converted to paliperidone 4-weekly (Invega Sustenna). The paliperidone 12-weekly injection (Invega Trinza) is not suitable for use in patients who have not been stabilised on the 4-weekly paliperidone depot for at least 4 months.

* No longer available in Australia

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Fluphenazine* to olanzapine

Formulation: depot to depot
Print

Stop fluphenazine.

Patients should be initially converted to oral olanzapine tablets to establish tolerance and exclude allergy. Oral olanzapine may be started while the patient still has significant fluphenazine plasma concentrations. If starting oral olanzapine within a week of the last fluphenazine depot, the dose should be approximately 25% of the target dose.

Supplementation with oral olanzapine is not necessary at the start of treatment with olanzapine depot.

If the patient has used olanzapine in the past, it is possible to switch directly from fluphenazine depot to olanzapine depot. In this case, the first olanzapine depot should be given on the day that the fluphenazine depot was due.

Olanzapine is more sedating than other antipsychotic depots. Because of the risk of post-injection syndrome, the patient must be observed for 2 hours after each olanzapine injection.

* No longer available in Australia

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Fluphenazine* to haloperidol

Formulation: depot to depot
Print

Patients should be initially converted to oral haloperidol tablets to exclude allergy. Oral haloperidol may be started while the patient still has significant fluphenazine plasma concentrations from the depot. If starting oral haloperidol within a week of the last fluphenazine dose, give 25% of the target haloperidol dose.

If switching the patient directly to haloperidol depot, give a test dose of 25 mg 5–10 days before the haloperidol depot is to be started. If there are no reactions, the full dose of haloperidol depot can be given.

If the patient is converting from oral to depot haloperidol, give an initial depot dose of 10–15 times the previous daily dose in oral haloperidol equivalents, but no more than a maximum initial dose of 100 mg (2 mL). To determine the minimum effective dose, start with lower doses and titrate upward as needed.

The dose of fluphenazine can be used to guide to the target dose of haloperidol depot. Previous antipsychotic use from the patient’s history may also be helpful.

* No longer available in Australia

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Fluphenazine* to flupentixol

Formulation: depot to depot
Print

Stop fluphenazine.

Start flupentixol on the day fluphenazine was due.

If the patient has not had flupentixol before, there is a small chance of allergy so a flupentixol test dose of 5–20 mg should be given 5–10 days before the flupentixol is to be started. If there are no reactions, give the full dose of flupentixol depot.

The dose of fluphenazine can be used to guide the target dose of flupentixol. Previous antipsychotic use from the patient’s history may also be helpful.

* No longer available in Australia

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Fluphenazine* to aripiprazole

Formulation: depot to depot
Print

Stop fluphenazine.

Convert fluphenazine depot to oral aripiprazole by starting the oral aripiprazole at the target dose on the day that fluphenazine was due. The recommended starting dose for aripiprazole is 10–20 mg daily, although guidance can be taken from the fluphenazine that was used. Two weeks of oral therapy is recommended to establish tolerability to aripiprazole before the first depot is administered. The recommended dose of aripiprazole depot is 400 mg every 4 weeks. Lower doses may be needed for patients who are poor cytochrome P450 2D6 metabolisers or who have been sensitive to adverse effects from aripiprazole in the past.

For patients who have used typical antipsychotics for a considerable time, a change to a partial dopamine agonist like aripiprazole carries some risk of increased agitation and irritability.

* No longer available in Australia

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Flupentixol to zuclopenthixol

Formulation: depot to depot
Print

Stop flupentixol.

Patients should be initially converted to oral zuclopenthixol tablets to exclude allergy. Oral zuclopenthixol may be started while the patient still has significant flupentixol plasma concentrations from the depot. If starting oral zuclopenthixol within a week of the last flupentixol dose, give 25% of the zuclopenthixol target dose.

If the patient has not had any zuclopenthixol before and oral zuclopenthixol cannot be used, a test dose of 50 mg of zuclopenthixol depot should be given 5–10 days before the full dose is to be started. If there are no reactions, give the full dose of zuclopenthixol depot on the day the flupentixol depot was due.

If the patient is converting from oral zuclopenthixol to zuclopenthixol depot, oral zuclopenthixol should be continued for at least 1 week after zuclopenthixol depot is started.

The dose of flupentixol depot can be used as a guide to the target dose of zuclopenthixol depot. Previous antipsychotic use from the patient’s history may also give a guide as to the target dose of zuclopenthixol depot.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Flupentixol to risperidone

Formulation: depot to depot
Print

Stop flupentixol.

Patients should be initially converted to oral risperidone tablets to exclude hypersensitivity or allergy which may manifest with symptoms including angioedema, urticaria and rash. Oral risperidone may be started while the patient still has significant flupentixol plasma concentrations from the depot. If starting oral risperidone within a week of the last flupentixol dose, give 25% of the risperidone target dose.

When converting from oral risperidone to risperidone depot, continue the oral risperidone for at least 3 weeks to ensure antipsychotic coverage. Risperidone depot has a 3-week lag before significant release of risperidone from the injection site.

If converting to risperidone depot without using oral risperidone, the risperidone depot should be started 3 weeks before the next dose of flupentixol was to be given. This avoids a significant trough in antipsychotic concentrations. However, flupentixol is most commonly given every 2 weeks which creates a complicated situation. Another flupentixol dose must be given after the first risperidone dose is given because there is a risk of breakthrough symptoms before the risperidone depot starts to release.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Flupentixol to paliperidone (once-monthly)

Formulation: depot to depot
Print

Stop flupentixol.

If the patient has never been exposed to paliperidone (or risperidone), an oral dose should be given to test for hypersensitivity or allergy.

Paliperidone depot can be given on the day that the next flupentixol depot was due. If converting the patient in this way, the loading dose regimen for paliperidone should not be used, unless it is necessary in a case of high clinical urgency. Patients should only be converted to paliperidone 4-weekly (Invega Sustenna). The paliperidone 12-weekly injection (Invega Trinza) is not suitable for patients who have not been stabilised on 4-weekly paliperidone depot for at least 4 months.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Flupentixol to olanzapine

Formulation: depot to depot
Print

Stop flupentixol.

Patients should be initially converted to oral olanzapine tablets to establish tolerance and exclude allergy. Oral olanzapine may be started while the patient still has significant flupentixol plasma concentrations. If starting oral olanzapine within a week of the last flupentixol dose, use 25% of the target olanzapine dose.

Supplementation with oral olanzapine is not necessary at the start of treatment with olanzapine depot.

If the patient has used olanzapine in the past, it is possible to switch directly from flupentixol to olanzapine depot. In this case, the first olanzapine depot should be given on the day that the flupentixol dose was next due.

Olanzapine is more sedating than other antipsychotic depots. As there is a risk of post-injection syndrome, the patient must be observed for 2 hours after each injection of olanzapine depot.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Flupentixol to haloperidol

Formulation: depot to depot
Print

Stop flupentixol.

Patients should be initially converted to oral haloperidol tablets to exclude allergy. Oral haloperidol may be started while the patient still has significant plasma concentrations of flupentixol from the depot. If starting oral haloperidol within a week of the last flupentixol dose, use 25% of the target dose.

If switching the patient directly to haloperidol depot, give a test dose of 25 mg 5–10 days before the haloperidol depot is to be started. If there are no reactions, the full dose of haloperidol depot can be given.

If the patient is converting from oral to depot haloperidol, give an initial depot dose of 10–15 times the previous daily dose in oral haloperidol equivalents, but no more than a maximum initial dose of 100 mg (2 mL). To determine the minimum effective dose, start with lower doses and titrate upward as needed.

The dose of flupentixol can be used to guide the target dose of haloperidol depot. Previous antipsychotic use from the patient’s history may be helpful.

Haloperidol is regarded as having a moderate effect on QTc, while flupentixol has a low effect. QTc monitoring may be necessary when switching from flupentixol to haloperidol.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Flupentixol to aripiprazole

Formulation: depot to depot
Print

Stop flupentixol.

To switch from flupentixol to oral aripiprazole, start oral aripiprazole (10–20 mg daily) on the day that flupentixol was due. Two weeks of oral therapy is recommended to establish tolerability of aripiprazole before the first depot is administered. The recommended dose of aripiprazole depot is 400 mg every 4 weeks. Lower doses may be needed for patients who are poor cytochrome P450 2D6 metabolisers or who have been sensitive to adverse effects from aripiprazole in the past.

For patients who have used typical antipsychotics for a considerable time, a change to a partial dopamine agonist like aripiprazole carries some risk of increased agitation and irritability.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Aripiprazole to zuclopenthixol

Formulation: depot to depot
Print

Stop aripiprazole.

Patients should be initially converted to oral zuclopenthixol tablets to establish tolerance and exclude allergy. Oral zuclopenthixol may be started while the patient still has significant aripiprazole plasma concentrations. If starting oral zuclopenthixol within a week of the last aripiprazole depot, the zuclopenthixol dose should be approximately 25% of the target dose.

Oral zuclopenthixol should be continued for at least 1 week after the start of treatment with zuclopenthixol depot.

If the patient has used zuclopenthixol before, it is possible to switch directly from aripiprazole depot to zuclopenthixol depot on the day the next aripiprazole depot was due.

Because aripiprazole is recommended as a fixed-dose depot, an equivalent dose of zuclopenthixol cannot be estimated reliably. Previous antipsychotic use from the patient’s history may help to guide the target dose of zuclopenthixol.

Zuclopenthixol is significantly more sedating than aripiprazole.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Aripiprazole to risperidone

Formulation: depot to depot
Print

Stop aripiprazole.

Patients should be initially converted to oral risperidone tablets to exclude hypersensitivity or allergy which may manifest with symptoms including angioedema, urticaria and rash. Tablets may be started while the patient still has significant aripiprazole plasma concentrations. If starting oral risperidone within a week of the last aripiprazole depot, the oral dose should be approximately 25% of the target dose. However, risperidone depot can be started 3 weeks before the next dose of aripiprazole depot was to be given. This will ensure that risperidone depot will release significant amounts of risperidone by the time the next aripiprazole depot was due.

When converting from oral to depot risperidone, continue the oral risperidone for at least 3 weeks to ensure antipsychotic coverage. Risperidone depot has a 3-week lag before significant release of risperidone from the injection site.

Because aripiprazole is recommended as a fixed-dose depot, an equivalent dose of risperidone cannot be estimated reliably. Previous antipsychotic use from the patient’s history may help to guide the target dose of risperidone.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Aripiprazole to paliperidone (once-monthly)

Formulation: depot to depot
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Stop aripiprazole.

If the patient has never been exposed to paliperidone (or risperidone), an oral dose should be given to test for hypersensitivity or allergy.

Paliperidone depot can be given on the day that the next aripiprazole dose was due. If converting the patient in this way, the loading dose regimen for paliperidone should not be used unless immediate efficacy is required (e.g. if the patient has had no clinical response to aripiprazole and oral treatment is not feasible). Patients should only be converted to paliperidone 4-weekly (Invega Sustenna). The paliperidone 12-weekly injection (Invega Trinza) is not suitable for patients who have not been stabilised on 4-weekly paliperidone depot for at least 4 months.

Because aripiprazole is recommended as a fixed-dose depot, an equivalent dose of paliperidone cannot be estimated reliably. Previous antipsychotic use from the patient’s history may help to guide the target dose of paliperidone.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Aripiprazole to olanzapine

Formulation: depot to depot
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Stop aripiprazole.

Patients should be initially converted to oral olanzapine tablets to establish tolerance and exclude allergy. Oral olanzapine may be started while the patient still has significant aripiprazole plasma concentrations from the depot. If starting oral olanzapine within a week of the last aripiprazole depot, the olanzapine dose should be approximately 25% of the target dose.

Supplementation with oral olanzapine is not necessary at the start of treatment with olanzapine depot.

If the patient has used olanzapine in the past, it is possible to switch directly to olanzapine depot on the day that the aripiprazole depot was due.

Because aripiprazole is recommended as a fixed-dose depot, an equivalent dose of olanzapine cannot be estimated reliably. Previous antipsychotic use from the patient’s history may help to guide the target dose of olanzapine.

Olanzapine is significantly more sedating than aripiprazole and patients may experience sedation.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Aripiprazole to haloperidol

Formulation: depot to depot
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Stop aripiprazole.

Patients should be initially converted to oral haloperidol tablets to exclude allergy. Tablets may be started while the patient still has significant aripiprazole plasma concentrations. If starting oral haloperidol within a week of the last aripiprazole dose, give 25% of the target haloperidol.

If switching the patient directly to haloperidol depot, give a test dose of 25 mg 5–10 days before the haloperidol is to be started. If there are no reactions, the full dose of haloperidol can be given.

If the patient is converting from oral to depot haloperidol, give an initial depot dose of 10–15 times the previous daily dose in oral haloperidol equivalents, but no more than a maximum initial dose of 100 mg (2 mL). To determine the minimum effective dose, start with lower doses and titrate upward as needed.

Because aripiprazole is recommended as a fixed-dose depot, an equivalent dose of haloperidol cannot be estimated reliably. Previous antipsychotic use from the patient’s history may help to guide the target dose of haloperidol.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Aripiprazole to flupentixol

Formulation: depot to depot
Print

Stop aripiprazole and start flupentixol on the day aripiprazole was due.

If the patient has not had flupentixol before, give a test dose of 5–20 mg 5–10 days before the flupentixol is started to check for allergy. If there are no reactions, the full dose of flupentixol can be given.

Because aripiprazole is recommended as a fixed-dose depot, an equivalent dose of flupentixol cannot be estimated reliably. Previous antipsychotic use from the patient’s history may help to guide the target dose of flupentixol.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to risperidone

Formulation: oral to oral
Print

Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Risperidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is unknown, an initial dose of 1 mg daily is recommended. In some patients a slower titration phase and lower starting and maintenance dose may be appropriate. Titrate gradually in view of the risk of first-dose postural hypotension. Risperidone can be given once or twice daily.

Risperidone is more likely to increase prolactin.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to ziprasidone

Formulation: oral to oral
Print

Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Ziprasidone is poorly absorbed if not taken with food.

Ziprasidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is not known, start ziprasidone at 40 mg twice daily and adjust the dose based on clinical effects. The dose may be increased as early as day 3.

Ziprasidone has a higher risk of causing QTc prolongation, therefore baseline serum magnesium, potassium and an ECG should be taken.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to quetiapine

Formulation: oral to oral
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Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

For bipolar depression, immediate- or modified-release quetiapine should be administered once daily at bedtime and titrated from a low dose. A suggested regimen is:

  • 50 mg on day 1
  • 100 mg on day 2
  • 200 mg on day 3
  • 300 mg on day 4.

The dose may be adjusted up to 600 mg/day in increments of 100 mg/day depending on clinical response and tolerability.

For acute mania, immediate-release quetiapine should be administered twice daily. A recommended regimen to introduce quetiapine is:

  • 100 mg on day 1
  • 200 mg on day 2
  • 300 mg on day 3
  • 400 mg on day 4.

It can be used alone or in combination with a mood stabiliser. Further dosage adjustments up to 800 mg/day by day 6, should be in increments of no greater than 200 mg/day. The dose may be adjusted depending on clinical response and tolerability to 200–800 mg/day. The usual effective dose is 400–800 mg/day.

For schizophrenia, immediate-release quetiapine should be administered twice daily and modified-release should be administered once daily. A suggested regimen is:

  • 50 mg on day 1
  • 100 mg on day 2
  • 200 mg on day 3
  • 300 mg on day 4.

From day 4, the dose should be titrated to the usual effective dose of 300–450 mg/day. Depending on clinical response and tolerability, the dose may be adjusted to 150–750 mg/day.

Quetiapine will be more sedating and is likely to have more anticholinergic effects.

Care should be taken with initial cross titration in relation to postural hypotension and risk of falls.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to periciazine

Formulation: oral to oral
Print

Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Periciazine may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5.

Periciazine is likely to have more anticholinergic effects.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to paliperidone

Formulation: oral to oral
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Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Paliperidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. The patient should be advised to take paliperidone at the same time in relation to food and should not be concerned if they occasionally notice something in their stools that looks like a tablet.

Paliperidone is more likely to increase prolactin.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to olanzapine

Formulation: oral to oral
Print

Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Olanzapine should be started at night on day 1. For schizophrenia and related disorders, start at 5–10 mg/day, administered as a single daily dose. The dose should be adjusted based on individual clinical response and adverse effects.

For acute mania associated with bipolar disorder, the recommended starting dose is 10 or 15 mg once a day as monotherapy, or 10 mg once daily in combination with lithium or valproate. If indicated, dose adjustments should generally occur at intervals of not less than 24 hours and in increments or decrements of 5 mg daily, unless in acute settings.

Olanzapine is likely to be more sedating and carries significantly higher risk of weight gain.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to lurasidone

Formulation: oral to oral
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Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Start lurasidone at 40 mg once daily on day 1. Initial dose titration is not required and optimal clinical response and tolerability for most patients is expected to be 40 mg or 80 mg once daily. Doses up to 160 mg a day may be needed. Lurasidone should be taken with food.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to haloperidol

Formulation: oral to oral
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Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Haloperidol should be started at 50% of the target dose on day 1 and increased to the target dose on day 5.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to clozapine

Formulation: oral to oral
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Direct switch

A direct switch is not recommended as clozapine is slowly titrated from 12.5 mg (or 25 mg) and cessation of zuclopenthixol is likely to leave an extended period when the patient has no effective antipsychotic cover.

Cross titration

Start clozapine according to standard titration schedules (from 12.5 mg or 25 mg).

Once the clozapine dose has reached 200 mg or plasma concentrations have reached 350 microgram/L, and the patient has shown significant clinical effect, zuclopenthixol can be reduced over 5 days or stopped.

Clozapine will cause significantly more sedation, postural hypotension and dizziness, tachycardia, hypersalivation and constipation than zuclopenthixol.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to chlorpromazine

Formulation: oral to oral
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Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

If the target dose of chlorpromazine is known, titrate it to reduce the anticholinergic and hypotensive adverse effects. A suggested regimen is giving 25% of the target dose on days 1–4, 50% on days 5–8, 75% on days 9–12, then the target dose on day 13. If the target dose is not known, be guided by the patient’s previous medication history to estimate the chlorpromazine dose.

Chlorpromazine is more likely to cause anticholinergic adverse effects and sedation. It also carries a higher risk of postural hypotension.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to brexpiprazole

Formulation: oral to oral
Print

Direct switch and cross titration

Brexpiprazole has a long half-life and will take 10 to 12 days to reach steady-state concentrations. The manufacturer recommends starting brexpiprazole at 1 mg and increasing to the lower range of the target dose after 5 days.

It is advised to start brexpiprazole on day 1 but stop or reduce the zuclopenthixol dose on day 4. At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), the dose of zuclopenthixol should be reduced to 50% of the initial dose on day 4 and stopped after day 14.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to asenapine

Formulation: oral to oral
Print

Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Asenapine has a terminal elimination half-life of about 24 hours and steady state is reached within 5 days (Australian product information states 3 days).

For schizophrenia, start asenapine at 5 mg twice a day on day 2 and titrate the dose as required. For bipolar disorder, asenapine should be started at 10 mg twice a day and, if necessary, the dose can be reduced.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to aripiprazole

Formulation: oral to oral
Print

Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Start aripiprazole at 10 mg on day 1. If target dose is known, aripiprazole can be started at the target dose on day 1, but be aware of the risk of akathisia, insomnia and agitation at higher doses. Consider dose increase after 14 days.

Aripiprazole is likely to be more activating or at least less sedating than zuclopenthixol. There is a risk of akathisia developing, and some chance of agitation and irritability, with the change to aripiprazole.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Zuclopenthixol to amisulpride

Formulation: oral to oral
Print

Direct switch and cross titration

At lower doses, zuclopenthixol can be stopped immediately. At higher doses (>20 mg daily), it should be reduced to 50% of the initial dose and stopped after day 7.

Start amisulpride on day 1. It will take approximately 3 days to reach steady-state plasma concentrations. The product information recommends starting at the target dose, but in clinical practice start at 200 mg to avoid acute dystonia and increase to target dose. For positive symptoms of psychosis, the target dose is 200–800 mg daily.

Amisulpride is more likely to increase prolactin and cause sexual dysfunction.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to zuclopenthixol

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5. Zuclopenthixol may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is not known, start zuclopenthixol at 20 mg daily and adjust the dose based on clinical effects. Do not increase the dose more frequently than every 5 days.

Zuclopenthixol is more likely to cause extrapyramidal effects, sedation and increase prolactin.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to risperidone

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5.

Risperidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is unknown, an initial dose of 1 mg daily is recommended. In some patients a slower titration phase and lower starting and maintenance dose may be appropriate. Titrate gradually in view of the risk of first-dose postural hypotension. Risperidone can be given once or twice daily.

Risperidone is more likely to increase prolactin.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to quetiapine

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Quetiapine needs to be introduced slowly starting on day 1. The titration schedule depends on the indication. Reduce the ziprasidone dose to 50% of the original dose on day 4 and stop it on day 9.

For bipolar depression, immediate- or modified-release quetiapine should be administered once daily at bedtime and titrated from a low dose. A suggested regimen is:

  • 50 mg on day 1
  • 100 mg on day 2
  • 200 mg on day 3
  • 300 mg on day 4.

The dose may be adjusted up to 600 mg/day in increments of 100 mg/day depending on clinical response and tolerability.

For acute mania, immediate-release quetiapine should be administered twice daily. A recommended regimen to introduce quetiapine is:

  • 100 mg on day 1
  • 200 mg on day 2
  • 300 mg on day 3
  • 400 mg on day 4.

It can be used alone or in combination with a mood stabiliser. Further dosage adjustments up to 800 mg/day by day 6, should be in increments of no greater than 200 mg/day. The dose may be adjusted depending on clinical response and tolerability to 200–800 mg/day. The usual effective dose is 400–800 mg/day.

For schizophrenia, immediate-release quetiapine should be administered twice daily and modified-release should be administered once daily. A suggested regimen is:

  • 50 mg on day 1
  • 100 mg on day 2
  • 200 mg on day 3
  • 300 mg on day 4.

From day 4, the dose should be titrated to the usual effective dose of 300–450 mg/day. Depending on clinical response and tolerability, the dose may be adjusted to 150–750 mg/day.

Quetiapine will be more sedating and is likely to have more anticholinergic effects. Care should be taken regarding the risk of hypotension and falls.


Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to periciazine

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5. Periciazine may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5.

Periciazine is likely to be more sedating and have more anticholinergic effects.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to paliperidone

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Reduce ziprasidone to 50% of the original dose on day 1 and stop after day 5.

Paliperidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. The patient should be advised to take paliperidone at the same time in relation to food and should not be concerned if they occasionally notice something in their stools that looks like a tablet.

Paliperidone is more likely to increase prolactin.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to olanzapine

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5.

Olanzapine should be started at night on day 1. For schizophrenia and related disorders, start at 5–10 mg/day, administered as a single daily dose. The dose should be adjusted based on individual clinical response and adverse effects.

For acute mania associated with bipolar disorder, the recommended starting dose is 10 or 15 mg once a day as monotherapy, or 10 mg once daily in combination with lithium or valproate. If indicated, dose adjustments should generally occur at intervals of not less than 24 hours and in increments or decrements of 5 mg daily.

Olanzapine is likely to be more sedating and carries a higher risk of weight gain.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to lurasidone

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5. Start lurasidone at 40 mg once daily on day 1. Initial dose titration is not required and optimal clinical response and tolerability for most patients is expected to be 40 mg or 80 mg once daily. Doses up to 160 mg a day may be needed. Lurasidone should be taken with food.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to haloperidol

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5.

Haloperidol should be started at 50% of the target dose on day 1 and increased to the target dose on day 5.

Haloperidol is more likely to cause extrapyramidal effects and carries a higher risk of increasing prolactin.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to clozapine

Formulation: oral to oral
Print

Direct switch

A direct switch is not recommended as clozapine is slowly titrated from 12.5 mg (or 25 mg) and cessation of ziprasidone is likely to leave an extended period when the patient has no effective antipsychotic cover.

Cross titration

Start clozapine according to standard titration schedules (from 12.5 mg or 25 mg).

Ziprasidone carries a significant risk of QTc prolongation. Reduce the ziprasidone dose to 50% of the initial dose on day 5 of a standard clozapine initiation regimen. Once the clozapine dose has reached 200 mg or plasma concentrations have reached 350 microgram/L, and the patient has shown significant clinical effect, ziprasidone should be stopped.

Clozapine will cause significantly more sedation, postural hypotension and dizziness, tachycardia, hypersalivation and constipation than ziprasidone.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to chlorpromazine

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended period of reduction is recommended. Chlorpromazine should be introduced slowly to reduce the risk of hypotensive and anticholinergic adverse effects.

A suggested regimen for ziprasidone is to reduce the original dose by 50% on day 4 and stop it on day 14.

If the target dose of chlorpromazine is known, give 25% of the target dose on days 1–4, 50% on days 5–8, 75% on days 9–12, then the target dose on day 13. If the target dose is not known, be guided by the patient’s previous medication history to estimate the chlorpromazine dose.

Chlorpromazine is more likely to cause anticholinergic adverse effects, sedation and increase prolactin. It also carries a higher risk of postural hypotension.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to brexpiprazole

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life and an extended period of reduction is recommended to reduce the risk of relapse.

Brexpiprazole has a long half-life and will take 10 to 12 days to reach steady-state concentrations. The manufacturer recommends starting brexpiprazole at 1 mg and increasing to the lower range of the target dose after 5 days.

It is advised to start brexpiprazole on day 1 but start the reduction in ziprasidone dose on day 4. A suggested regimen is to reduce the original ziprasidone dose by 50% on day 4 and stop it on day 14.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to asenapine

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5.

For schizophrenia, start asenapine at 5 mg twice a day on day 1 and titrate the dose as required. For bipolar disorder, asenapine should be started at 10 mg twice a day and, if necessary, the dose can be reduced.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to aripiprazole

Formulation: oral to oral
Print

Direct switch

Not recommended.

Cross titration

Ziprasidone has a short half-life so an extended dose titration is recommended to reduce the risk of relapse. A suggested regimen is to reduce the original dose by 50% on day 1 and stop ziprasidone on day 10.

Start aripiprazole at 10 mg on day 1. If the target dose is known, aripiprazole can be started at the target dose on day 1, but be aware of the risk of akathisia, agitation and insomnia at higher doses. Consider dose increase after 14 days.

Aripiprazole is likely to be more activating than ziprasidone. There is a risk of akathisia developing, and some chance of agitation and irritability, with the change to aripiprazole.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Ziprasidone to amisulpride

Formulation: oral to oral
Print

Direct switch

A direct switch to amisulpride is not recommended because of the differences in effects.

Cross titration

Reduce the ziprasidone dose to 50% of the original dose on day 1 and stop after day 5.

Start amisulpride on day 1. It will take approximately 3 days to reach steady-state plasma concentrations. The product information recommends starting at the target dose, but in clinical practice start at 200 mg to avoid acute dystonia and increase to target dose. For positive symptoms of psychosis, the target dose is 200–800 mg daily.

Amisulpride is more likely to increase prolactin and cause sexual dysfunction.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to zuclopenthixol

Formulation: oral to oral
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Direct switch and cross titration

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 1 and then stopped at day 5.

Zuclopenthixol may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is not known, start zuclopenthixol at 20 mg daily and adjust the dose based on clinical effects. Increases in dose should not be made more frequently than every 5 days.

Zuclopenthixol is more likely to cause sedation.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

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Risperidone to ziprasidone

Formulation: oral to oral
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Direct switch and cross titration

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 1 and then stopped at day 5.

Ziprasidone is poorly absorbed if not taken with food.

Ziprasidone may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5. If the target dose is not known, start ziprasidone at 40 mg twice daily and adjust the dose based on the clinical effects. The dose may be increased as early as day 3.

Ziprasidone has a higher risk of QTc prolongation, therefore baseline serum magnesium, potassium and an ECG should be taken.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to quetiapine

Formulation: oral to oral
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Direct switch and cross titration

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 1 and then stopped at day 5.

For bipolar depression, immediate- or modified-release quetiapine should be administered once daily at bedtime and titrated from a low dose. A suggested regimen is:

  • 50 mg on day 1
  • 100 mg on day 2
  • 200 mg on day 3
  • 300 mg on day 4.

The dose may be adjusted up to 600 mg/day in increments of 100 mg/day depending on clinical response and tolerability.

For acute mania, immediate-release quetiapine should be administered twice daily. A recommended regimen to introduce quetiapine is:

  • 100 mg on day 1
  • 200 mg on day 2
  • 300 mg on day 3
  • 400 mg on day 4.

It can be used alone or in combination with a mood stabiliser. Further dosage adjustments up to 800 mg/day by day 6, should be in increments of no greater than 200 mg/day. The dose may be adjusted depending on clinical response and tolerability to 200–800 mg/day. The usual effective dose is 400–800 mg/day.

For schizophrenia, immediate-release quetiapine should be administered twice daily and modified-release should be administered once daily. A suggested regimen is:

  • 50 mg on day 1
  • 100 mg on day 2
  • 200 mg on day 3
  • 300 mg on day 4.

From day 4, the dose should be titrated to the usual effective dose of 300–450 mg/day. Depending on clinical response and tolerability, the dose may be adjusted to 150–750 mg/day.

Quetiapine will be more sedating and is likely to have more anticholinergic effects.

Care should be taken with initial cross titration in relation to postural hypotension and risk of falls.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to periciazine

Formulation: oral to oral
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Direct switch and cross titration

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 1 and then stopped at day 5.

Periciazine may be started at 50% of the target dose on day 1 and increased, if necessary, on day 5.

Periciazine is likely to be more sedating and have more anticholinergic effects.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to paliperidone

Formulation: oral to oral
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Direct switch

Paliperidone is the main metabolite of risperidone and has a similar adverse-effect profile. A direct switch is recommended. Risperidone should be stopped on day 1 and paliperidone should be started on day 1 at the target dose.

The patient should be advised to take paliperidone at the same time in relation to food and should not be concerned if they occasionally notice something in their stools that looks like a tablet.

Cross titration

This is not recommended as paliperidone is the active metabolite of risperidone and will be present at some level already.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to lurasidone

Formulation: oral to oral
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Direct switch and cross titration

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 1 and then stopped at day 5.

Start lurasidone at 40 mg once daily on day 1. Initial dose titration is not required and optimal clinical response and tolerability for most patients is expected to be 40 mg or 80 mg once daily. Doses up to 160 mg a day may be needed. Lurasidone should be taken with food.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to olanzapine

Formulation: oral to oral
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Direct switch and cross titration

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 1 and then stopped at day 5.

Olanzapine should be started at night on day 1. For schizophrenia and related disorders, start at 5–10 mg/day, administered as a single daily dose. The dose may be adjusted based on individual clinical response and adverse effects.

For acute mania associated with bipolar disorder, the recommended starting dose is 10 or 15 mg once a day as monotherapy, or 10 mg once daily in combination with lithium or valproate. If indicated, dose adjustments should generally occur at intervals of not less than 24 hours and in increments or decrements of 5 mg daily.

Olanzapine is likely to be more sedating and cause more weight gain.

A slower cross titration and higher treatment doses may be necessary in some high-risk patients, especially in community settings.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to haloperidol

Formulation: oral to oral
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Direct switch and cross titration

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 1 and then stopped at day 5.

Haloperidol should be started at 50% of the target dose on day 1 and increased to the target dose on day 5.

Haloperidol is more likely to cause extrapyramidal effects.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to clozapine

Formulation: oral to oral
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Direct switch

A direct switch is not recommended as clozapine is slowly titrated from 12.5 mg (or 25 mg) and cessation of risperidone is likely to leave an extended period when the patient has no effective antipsychotic cover.

Cross titration

Start clozapine according to standard titration schedules (from 12.5 mg or 25 mg)

If risperidone was prescribed in doses above 3 mg daily, the dose should be reduced to 50% on day 7 of a standard clozapine initiation regimen.

Once the clozapine dose has reached 200 mg or clozapine plasma concentrations have reached 350 microgram/L, and the patient has shown significant clinical effect, risperidone should be stopped.

Clozapine will cause significantly more sedation, postural hypotension and dizziness, tachycardia, hypersalivation and constipation than risperidone.

Source: Keks N, Schwartz D, Hope J. Antipsychotic switching tool. Aust Prescr 2019;42:156. https://doi.org/10.18773/austprescr.2019.056

Australian Prescriber An independent Review Logo

Risperidone to chlorpromazine

Formulation: oral to oral