FGA Depot·Psychiatry - Depot Antipsychotics

Haloperidol decanoate

Maintenance treatment of Schizophrenia

PBSDEPOT Q4WSerenace (oral/IM), Haldol, Haldol Decanoate (depot)5 mg tabletS4+1

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At a glance

Max Dose

300 mg Q4W

Half-life

3 Weeks

High risk: EPS Risk

CRITICAL

Caution: Z-Track IM

REQUIRED

Cautions

Avoid / Cautions

Parkinson's disease, severe CNS depression, sesame oil allergy. Pregnancy Category C.

Where it stands

Rapid Summary

Overview

First-Generation Antipsychotic (FGA) butyrophenone. Formulations include immediate-release oral (tablets/liquid), immediate-release IM for acute agitation, and long-acting decanoate depot in sesame oil for maintenance. Extremely potent D2 antagonist.

Clinical Focus

Because it is oil-based, it MUST be injected using the Z-Track method to prevent the oil leaking back into the subcutaneous fat and causing tissue necrosis.

Bottom Line

Haloperidol decanoate is a first-generation long-acting injectable antipsychotic for chronic schizophrenia, but causes significant extrapyramidal side effects and tardive dyskinesia with long-term use.

Formulation & Access

Brand Names

Serenace (oral/IM), Haldol, Haldol Decanoate (depot)

Oral Routes

Tablets (0.5 mg, 1.5 mg, 5 mg), oral liquid (2 mg/mL). Rapid gastrointestinal absorption; bioavailability ~60%.

Parenteral

Immediate-release ampoules (5 mg/1 mL for IM/IV); Long-acting depot injection (haloperidol decanoate 50 mg/1 mL, 100 mg/1 mL in sesame oil for deep IM gluteal injection only — never IV).

Prescribing & PBS

Unrestricted General Benefit (S4).

Indications & Use

Primary

PBSTGA

Maintenance treatment of Schizophrenia.

Clinical Place

Reserved for older patients stabilized on it for decades, or highly severe psychotic patients who fail SGAs. Almost never used as a first-line depot today.

Quick reference

Class & Role

FGA / Butyrophenone — High-potency First-Generation Antipsychotic available in immediate-release oral, immediate-release IM, and long-acting depot decanoate formulations.

Route / Formulation

Oral tablets (0.5, 1.5, 5 mg), oral liquid (2 mg/mL); immediate-release IM/IV injection (5 mg/1 mL); depot decanoate injection (50 mg/1 mL, 100 mg/1 mL oily solution for deep IM). (Serenace, Haldol, Haldol Decanoate)

Usual Dose & Max

Oral IR: 1-5 mg 2-3 times daily (max 15-20 mg/day); IM IR: 2.5-5 mg STAT (max 10-20 mg/day); Depot decanoate: IM 50-100 mg every 4 weeks (max 300 mg Q4W). Elderly: start 0.25-0.5 mg oral or 0.5-1 mg IM.

Key Indication Doses

Acute Psychosis / Agitation (Oral IR): PO 1-5 mg bd-tds, titrate as needed. Max 15-20 mg/day. Acute Behavioural Disturbance (IM IR): IM 2.5-5 mg STAT (0.5-1 mg in elderly/frail), repeat after 30-60 min if needed. Max 10-20 mg/day. Schizophrenia Maintenance (IM Depot): IM 50-100 mg every 4 weeks (deep gluteal Z-track). Max 300 mg Q4W. Elderly / Delirium: PO 0.25-0.5 mg once or twice daily; max 2-5 mg/day.

Best Uses

Key Risks

Neurological: Severe Extrapyramidal Side Effects (Parkinsonism, acute dystonia, severe akathisia). Tardive Dyskinesia risk is very high. Neuroleptic Malignant Syndrome (NMS). Cardiovascular: QTc prolongation. Endocrine: Hyperprolactinemia.

Key Interactions

Avoid concurrent QTc prolonging drugs (e.g., Amiodarone, Macrolides). Strong CYP2D6 or CYP3A4 inhibitors significantly raise haloperidol levels.

Monitoring

Monitor for EPS (stiffness, tremor). A PRN anticholinergic (Benzatropine) should be charted when initiating. Baseline ECG (QTc check) before first injection.

Clinical Pearl

Because the carrier is sesame oil, if you inject straight in and pull the needle out, the oil will track back up the needle hole into the subcutaneous fat, causing a painful sterile abscess. You MUST pull the skin to the side (Z-Track), inject, wait 10 seconds, pull the needle out, and let the skin slide back to 'trap' the oil in the muscle.

Access

Serenace (oral/IM), Haldol, Haldol Decanoate (depot)0.5 mg tablet

Brand: Serenace (oral/IM), Haldol, Haldol Decanoate (depot)
Formulation: Tablets (0.5 mg, 1.5 mg, 5 mg), oral liquid (2 mg/mL). Rapid gastrointestinal absorption; bioavailability ~60%.

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