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Ziprasidone

Pronunciation

Class: Atypical Antipsychotics
VA Class: CN709
Chemical Name: 5-[2-[4-(1,2-benzisothiazol-3-yl)-1-piperazinyl]ethyl]-6-chloro-1,3-dihydro-2H-indol-2-one monohydrochloride monohydrate
Molecular Formula: C21H21ClN4OS•HCl•H2OC21H21ClN4OS•CH4O3S•3H2O
CAS Number: 138982-67-9
Brands: Geodon

Warning(s)

  • Increased Mortality in Geriatric Patients with Dementia-related Psychosis
  • Geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death.1 68 77 78

  • Analyses of 17 placebo-controlled trials in geriatric patients mainly receiving atypical antipsychotic agents revealed an approximate 1.6- to 1.7-fold increase in mortality compared with that in patients receiving placebo.1 68 78

  • Most fatalities appeared to result from cardiovascular-related events (e.g., heart failure, sudden death) or infections (mostly pneumonia).1 68

  • Observational studies suggest that conventional or first-generation antipsychotic agents also may increase mortality in such patients.1 78

  • Atypical antipsychotic agents, including ziprasidone, are not approved for the treatment of dementia-related psychosis.1 68 78

Introduction

Benzisothiazolyl piperazine-derivative; atypical or second-generation antipsychotic agent.1 4 10 11 29

Uses for Ziprasidone

Schizophrenia

Orally for acute and maintenance treatment of schizophrenia in adults.1 2 3 6 7 12 115

IM injection used for management of acute agitation in adults with schizophrenia for whom treatment with ziprasidone is appropriate and who require an IM antipsychotic agent for rapid control of behaviors that interfere with diagnosis and care (e.g., threatening behaviors, escalating or urgently distressing behavior, self-exhausting behavior).1

American Psychiatric Association (APA) considers most atypical antipsychotic agents first-line drugs for management of the acute phase of schizophrenia (including first psychotic episodes).29

Patients who do not respond to or tolerate one drug may be successfully treated with an agent from a different class or with a different adverse effect profile.29 70 71 72

When deciding among treatment alternatives, consider that ziprasidone may prolong the QT interval.1 Some other drugs that prolong the QT interval cause torsades de pointes-type arrhythmia; it is not yet known whether ziprasidone causes torsades de pointes or increases the rate of sudden death.1 In many cases, other drugs should be tried first.1 (See Prolongation of QT Interval and Risk of Sudden Death under Cautions.)

Bipolar Disorder

Orally for acute treatment (as monotherapy) of manic or mixed episodes (with or without psychotic features) associated with bipolar I disorder in adults.1 73 74

Orally for maintenance treatment (as adjunct to lithium or valproate) of bipolar I disorder in adults.1 7 92 103

When deciding among treatment alternatives, consider that ziprasidone may prolong the QT interval.1 Some other drugs that prolong the QT interval cause torsades de pointes-type arrhythmia; it is not yet known whether ziprasidone causes torsades de pointes or increases the rate of sudden death.1 In many cases, other drugs should be tried first.1 (See Prolongation of QT Interval and Risk of Sudden Death under Cautions.)

Ziprasidone Dosage and Administration

Administration

Administer ziprasidone hydrochloride capsules orally.1

Administer ziprasidone mesylate injection IM; do not administer IV.1

Concomitant use of oral and IM ziprasidone not recommended by manufacturer.1

Oral Administration

Administer capsules orally twice daily with food for optimal absorption.1 (See Food under Pharmacokinetics.)

IM Administration

Vials are for single use only.1

Reconstitution

Reconstitute vial containing 20 mg with 1.2 mL of sterile water for injection to provide a solution containing 20 mg/mL.1 Do not use other solutions to reconstitute the injection, and do not admix with other drugs.1 Shake vigorously to ensure complete dissolution.1

Observe strict aseptic technique since the drug contains no preservative.1 Discard unused portions.1

Dosage

Available as ziprasidone hydrochloride or ziprasidone mesylate; dosage of ziprasidone hydrochloride expressed in terms of the hydrochloride monohydrate and dosage of ziprasidone mesylate expressed in terms of ziprasidone.1 12

Adults

Schizophrenia
Acute and Maintenance Therapy
Oral

Initially, 20 mg twice daily.1 In some patients, may adjust dosage based on clinical status up to 80 mg twice daily.1

Dosage adjustments, if indicated, generally should be made after a minimum of 2 days.1 12 However, manufacturer recommends observing patients for several weeks prior to upward titrations of dosage to ensure use of the lowest effective dosage.1 Dosages ranging from 20–100 mg twice daily were effective in short-term controlled studies.1 Although there were trends toward a dose response within a dosage range of 20–80 mg twice daily, results were not consistent.1

Optimum duration of therapy not known, but efficacy maintained for up to 52 weeks in a clinical trial.1 115 In patients responding to ziprasidone therapy, continue the drug as long as clinically necessary and tolerated, but at lowest possible effective dosage;12 periodically reassess need for continued therapy.1

In patients with remitted first or multiple episodes, APA recommends either indefinite maintenance therapy or gradual discontinuance of the antipsychotic with close follow-up and a plan to reinstitute treatment upon symptom recurrence.29 Consider antipsychotic therapy discontinuance only after ≥1 year of symptom remission or optimal response while receiving the drug.29 Indefinite maintenance treatment recommended if patient has experienced multiple previous psychotic episodes or 2 episodes within 5 years.29

Acute Agitation in Schizophrenia
IM

Initially, 10–20 mg given as a single dose.1

Repeat doses of 10 mg every 2 hours or 20 mg every 4 hours, up to a maximum cumulative dosage of 40 mg daily.1

Oral therapy should replace IM therapy as soon as possible; safety and efficacy of administering ziprasidone IM injection for longer than 3 consecutive days not evaluated.1

Bipolar Disorder
Acute Manic and Mixed Episodes: Monotherapy
Oral

Initially, 40 mg twice daily on day 1.1 May increase dosage to 60 or 80 mg twice daily on the second day.1

Subsequent dosage adjustments based on efficacy and tolerability may be made within a dosage range of 40–80 mg twice daily.1

Efficacy of monotherapy for long-term use (i.e., >3 weeks) in patients with bipolar disorder not systematically evaluated.1

Maintenance Treatment: Combination Therapy
Oral

As adjunctive therapy with lithium or valproate, continue ziprasidone at same dosage on which patient was initially stabilized, within the dosage range of 40–80 mg twice daily.1

Periodically reevaluate need for continued maintenance therapy.1

Prescribing Limits

Adults

Schizophrenia
Acute and Maintenance Therapy
Oral

Manufacturer recommends maximum of 80 mg twice daily and states safety of dosages >100 mg twice daily not established.1

Acute Agitation
IM

Maximum cumulative dosage of 40 mg daily.1

Bipolar Disorder
Oral

Maximum 80 mg twice daily.1

Special Populations

Hepatic Impairment

No dosage adjustment of oral ziprasidone required.1 (See Absorption: Special Populations, under Pharmacokinetics and see Elimination: Special Populations, under Pharmacokinetics.)

IM injection not systematically evaluated in patients with hepatic impairment.1

Renal Impairment

No dosage adjustment of oral ziprasidone required.1

IM injection not systematically evaluated in patients with renal impairment.1 Cyclodextrin excipient present in IM injection cleared by renal filtration; use with caution.1 (See Renal Impairment under Cautions.)

Geriatric Patients

No dosage adjustment of oral ziprasidone required; lower initial dosages and slower titration may be considered.1

IM injection not systematically evaluated in geriatric patients.1

Gender or Race

No dosage adjustment of oral or IM ziprasidone required based on gender or race.1

Cautions for Ziprasidone

Contraindications

  • Known history of QT-interval prolongation (including congenital long QT syndrome).1 (See Prolongation of QT Interval and Risk of Sudden Death under Cautions.)

  • Recent AMI.1

  • Uncompensated heart failure.1

  • Concomitant therapy with drugs that prolong the QT interval.1 (See Prolongation of QT Interval and Risk of Sudden Death under Cautions and also see Drugs that Prolong QT Interval and Specific Drugs under Interactions.)

  • Known hypersensitivity to ziprasidone.1

Warnings/Precautions

Warnings

Increased Mortality in Geriatric Patients with Dementia-related Psychosis

Increased risk of death with use of either conventional (first-generation) or atypical (second-generation) antipsychotics in geriatric patients with dementia-related psychosis.1 68 78

Antipsychotic agents, including ziprasidone, are not approved for the treatment of dementia-related psychosis.1 68 78 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning and also see Dysphagia under Cautions.)

Other Warnings and Precautions

Prolongation of QT Interval and Risk of Sudden Death

Greater capacity to prolong the QT/QTc (corrected QT) interval compared with that of several other antipsychotic agents (e.g., haloperidol, olanzapine, quetiapine, risperidone).1 29 No cases of torsades de pointes reported with ziprasidone during premarketing clinical trials; however, rare postmarketing cases of torsades de pointes (in the presence of multiple confounding factors) reported with the drug.1

Sudden unexplained deaths have been reported in patients receiving ziprasidone or other antipsychotic agents at recommended dosages.1 Although premarketing experience with ziprasidone did not demonstrate an excess risk of mortality compared with that of other antipsychotic agents, the extent of exposure was limited.1 The greater risk of QT-interval prolongation compared with several other antipsychotic agents raises the possibility that the risk of sudden death may be greater with ziprasidone than for other antipsychotic agents.1 This possibility should be considered in deciding among alternative antipsychotic agents.1 (See Uses.)

Factors that may increase the risk of torsades de pointes and/or sudden death include bradycardia, hypokalemia or hypomagnesemia; concomitant use of other drugs that prolong the QT interval; and congenital prolongation of the QT interval.1 Avoid use in patients with a history of clinically important cardiovascular disease (e.g., congenital prolongation of the QT interval, QT-interval prolongation, recent AMI, uncompensated heart failure, history of cardiac arrhythmias) and in those concurrently receiving other drugs that prolong the QTc interval.1 (See Contraindications under Cautions and also see Drugs that Prolong QT Interval and Specific Drugs under Interactions.)

Obtain serum potassium and magnesium concentrations in patients at risk for substantial electrolyte disturbances, particularly hypokalemia; correct hypokalemia or hypomagnesemia prior to initiating ziprasidone.1 Periodically monitor serum electrolytes if diuretic therapy is initiated during ziprasidone therapy.1

Clinical and ECG monitoring of cardiac function, including appropriate ambulatory ECG monitoring (e.g., Holter monitoring), is recommended during ziprasidone therapy in patients with symptoms that could indicate torsades de pointes (e.g., dizziness, palpitations, syncope).1

Discontinue ziprasidone in patients with persistent QTc interval measurements >500 msec.1

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS), a potentially fatal syndrome characterized by hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability, reported with antipsychotic agents, including rare cases associated with ziprasidone.1 79 80 81 82

Immediately discontinue therapy and initiate supportive and symptomatic treatment if NMS occurs.1 Careful monitoring recommended if therapy is reinstituted following recovery; the risk that NMS can recur must be considered.1

Severe Cutaneous Adverse Reactions

Drug reaction with eosinophilia and systemic symptoms (DRESS; also known as multiorgan hypersensitivity reaction) reported.1 108 116 DRESS, which is fatal in some cases, consists of a combination of 3 or more of the following: cutaneous reaction (e.g., rash, exfoliative dermatitis), eosinophilia, fever, lymphadenopathy, and one or more systemic complications (e.g., hepatitis, nephritis, pneumonitis, myocarditis, pericarditis, pancreatitis).1 108

In an FDA review of 6 cases of DRESS associated with ziprasidone use worldwide, onset of DRESS symptoms occurred 11–30 days after initiation of therapy.108 In 3 of the cases, discontinuance and reinitiation of the drug resulted in recurrence of symptoms with a faster time to onset.108 In half of the cases, other drugs associated with DRESS were used concomitantly.108 Serious outcomes, including hospitalization, occurred, but no deaths were reported.108

Other severe cutaneous adverse reactions (e.g., Stevens-Johnson syndrome), reported; sometimes fatal.1

Discontinue ziprasidone immediately if DRESS or severe cutaneous adverse reactions are suspected and initiate supportive care.1 108 Consider corticosteroid treatment in cases with extensive organ involvement.108 (See Rash under Cautions.)

Tardive Dyskinesia

Tardive dyskinesia, a syndrome of potentially irreversible, involuntary dyskinetic movements, reported with use of antipsychotic agents, including ziprasidone.1 83 84 85 86 87 88 89

Reserve long-term antipsychotic treatment for patients with chronic illness known to respond to antipsychotic agents, and for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate.1 In patients requiring chronic treatment, use smallest dosage and shortest duration of treatment producing a satisfactory clinical response; periodically reassess need for continued therapy.1

APA recommends assessing patients receiving atypical antipsychotic agents for abnormal involuntary movements every 12 months; for patients at increased risk for tardive dyskinesia, assess every 6 months.29 Consider discontinuance of ziprasidone if signs and symptoms of tardive dyskinesia appear.1 However, some patients may require treatment despite presence of the syndrome.1

Metabolic Changes

Atypical antipsychotic agents are associated with metabolic changes that may increase cardiovascular and cerebrovascular risk (e.g., hyperglycemia, dyslipidemia, weight gain).1 While all atypical antipsychotics produce some metabolic changes, each drug has its own specific risk profile.1 (See Hyperglycemia and Diabetes Mellitus, see Dyslipidemia, and also see Weight Gain under Cautions.)

Hyperglycemia and Diabetes Mellitus

Hyperglycemia, sometimes severe and associated with ketoacidosis, hyperosmolar coma, or death, reported in patients receiving atypical antipsychotic agents.1 13 14 16 17 18 19 20 21 22 23 24 25 26 40 41 42 43 47 67 There have been few reports of hyperglycemia or diabetes in ziprasidone-treated patients; not known whether paucity of such reports is due to relatively limited experience with the drug.1 16 20 25 60 61 62 63 64 65

Closely monitor patients with diabetes mellitus for worsening of glycemic control, and perform fasting glucose testing at baseline and periodically in patients with risk factors for diabetes (e.g., obesity, family history of diabetes).1 13 14 16 17 18 19 20 21 22 23 24 25 If manifestations of hyperglycemia occur in any ziprasidone-treated patient, perform fasting blood glucose testing.1 13 14 16 17 18 19 20 21 22 23 24 25

Some patients who developed hyperglycemia while receiving an atypical antipsychotic have required continuance of antidiabetic treatment despite discontinuance of the suspect drug; in other patients, hyperglycemia resolved with discontinuance of the antipsychotic.1 13 14 16 17 18 19 20 21 22 23 24 25 47

Dyslipidemia

Undesirable changes in lipid parameters observed in patients treated with atypical antipsychotics; however, ziprasidone generally does not adversely affect the lipid profile in most patients.1 29

Weight Gain

Weight gain observed with atypical antipsychotic therapy.1 Although ziprasidone generally appears to be associated with no or minimal weight gain and has a lower risk of weight gain than some other atypical antipsychotic agents (e.g., clozapine, olanzapine, quetiapine, risperidone),1 29 manufacturer recommends clinical monitoring of weight in patients receiving the drug.1

Rash

Rash and/or urticaria, possibly related to dosage and/or duration of therapy, occurred in about 5% of patients in premarketing clinical studies and necessitated discontinuance of the drug in about 17% of these patients.1 Several patients with rash had signs and symptoms of associated systemic illness (e.g., elevated WBC count).1

Adjunctive treatment with antihistamines or corticosteroids and/or drug discontinuance may be required.1 Discontinue ziprasidone if alternative etiology of rash cannot be identified.1 (See Severe Cutaneous Adverse Reactions under Cautions.)

Orthostatic Hypotension

Risk of orthostatic hypotension associated with dizziness, tachycardia, and syncope, particularly during the initial dosage titration period, because of ziprasidone's α1-adrenergic blocking activity.1 Syncope reported in 0.6% of ziprasidone-treated patients in clinical studies.1

Use with particular caution in patients with known cardiovascular disease (e.g., history of MI or ischemic heart disease, heart failure, conduction abnormalities), cerebrovascular disease, or conditions that would predispose patients to develop hypotension (e.g., dehydration, hypovolemia, concomitant antihypertensive therapy).1

Leukopenia, Neutropenia, and Agranulocytosis

Leukopenia and neutropenia temporally related to antipsychotic agents reported during clinical trial and/or postmarketing experience.1 98 Agranulocytosis (including fatal cases) also reported with antipsychotic agents.1

Possible risk factors for leukopenia and neutropenia include preexisting low WBC count and history of drug-induced leukopenia or neutropenia.1 98 Monitor CBC frequently during the first few months of therapy in patients with such risk factors.1 Discontinue ziprasidone at the first sign of a decline in WBC count in the absence of other causative factors.1

Carefully monitor patients with neutropenia for fever or other signs and symptoms of infection and treat promptly if they occur.1 In patients with severe neutropenia (ANC <1000/mm3), discontinue ziprasidone and monitor WBC until recovery occurs.1

Seizures

Seizures reported in 0.4% of ziprasidone-treated patients in clinical trials.1

Use with caution in patients with a history of seizures or with conditions that may lower the seizure threshold (e.g., dementia of the Alzheimer’s type); conditions that lower seizure threshold may be more prevalent in patients ≥65 years of age.1

Dysphagia

Esophageal dysmotility and aspiration associated with the use of antipsychotic agents.1

Aspiration pneumonia is a common cause of morbidity and mortality in geriatric patients, particularly in those with advanced Alzheimer's dementia.1 Use with caution in patients at risk for aspiration pneumonia.1 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning.)

Hyperprolactinemia

May cause elevated serum prolactin concentrations, which may lead to clinical disturbances (e.g., galactorrhea, amenorrhea, gynecomastia, impotence); chronic hyperprolactinemia associated with hypogonadism may lead to decreased bone density.1

If contemplating ziprasidone therapy in a patient with previously detected breast cancer, consider that approximately one-third of human breast cancers are prolactin dependent in vitro.1

Cognitive and Motor Impairment

Somnolence reported in 14% of ziprasidone-treated patients during short-term clinical trials; somnolence may be dose related.1 Judgment, thinking, or motor skills may be impaired.1 (See Specific Drugs under Interactions and also see Advice to Patients.)

Priapism

Priapism reported in several ziprasidone-treated patients.1 110 111 112 113 114 May require surgical intervention in severe cases.1 112

Body Temperature Regulation

Antipsychotic agents may disrupt ability to regulate core body temperature.1

Use appropriate caution in patients who will be experiencing conditions that may contribute to an elevation in core body temperature (e.g., strenuous exercise, extreme heat, concomitant use of agents with anticholinergic activity, dehydration).1

Suicide

Attendant risk with psychotic illness and bipolar disorder; closely supervise high-risk patients.1 Prescribe in the smallest quantity consistent with good patient management to reduce the risk of overdosage.1

Concomitant Illness

Limited experience with ziprasidone in patients with certain concomitant diseases.1

Not adequately evaluated in patients with a recent history of MI or unstable cardiovascular disease; use with caution in cardiac patients.1 (See Contraindications under Cautions, see Prolongation of QT Interval and Risk of Sudden Death under Cautions, and also see Orthostatic Hypotension under Cautions.)

Specific Populations

Pregnancy

Category C.1

Risk for extrapyramidal and/or withdrawal symptoms (e.g., agitation, hypertonia, hypotonia, tardive dyskinetic-like symptoms, tremor, somnolence, respiratory distress, feeding disorder) in neonates exposed to antipsychotic agents during the third trimester; monitor neonates exhibiting such symptoms.1 104 105 106 Symptoms were self-limiting in some neonates but varied in severity; some infants required intensive support and prolonged hospitalization.1 104 105 106

National Pregnancy Registry for Atypical Antipsychotics (for women 18–45 years of age exposed to ziprasidone during pregnancy) at 866-961-2388.95

Effects on labor and delivery are unknown.1

Lactation

Manufacturer states not known whether ziprasidone or its metabolites are distributed into milk.1 However, a low concentration of ziprasidone was reported in milk and also in the plasma of one breast-fed infant.109 (See Distribution under Pharmacokinetics.) Women receiving ziprasidone should not breast-feed.1

Pediatric Use

Safety and efficacy not established in pediatric patients <18 years of age.1

Geriatric Use

No substantial differences in safety or efficacy of oral ziprasidone relative to younger adults; however, possibility of greater sensitivity in some geriatric patients cannot be ruled out.1

Risk of increased pharmacodynamic response, poorer tolerance, or orthostasis; lower initial dosages, slower titration, and careful monitoring during the initial dosing period may be advisable in some geriatric patients.1

IM ziprasidone mesylate not systematically evaluated in geriatric patients.1

Geriatric patients with dementia-related psychosis treated with either conventional or atypical antipsychotic agents are at an increased risk of death.1 68 78 Substantial (1.6- to 1.7-fold) increase in mortality rate reported in geriatric patients with dementia who received atypical antipsychotic agents (e.g., aripiprazole, olanzapine, quetiapine, risperidone) for treatment of behavioral disorders; most fatalities resulted from cardiac-related events (e.g., heart failure, sudden death) or infections (mostly pneumonia).1 68 Ziprasidone is not approved for the treatment of patients with dementia-related psychosis.1 (See Boxed Warning and Increased Mortality in Geriatric Patients with Dementia-related Psychosis under Cautions.)

Renal Impairment

Renal impairment alone unlikely to substantially affect pharmacokinetics of oral ziprasidone.1 Dosage adjustment based on degree of renal impairment not necessary.1 (See Special Populations under Pharmacokinetics.)

IM ziprasidone not studied in patients with renal impairment.1 Commercially available ziprasidone mesylate injections contain sulfobutylether β-cyclodextrin sodium, an excipient that is cleared by renal filtration; use with caution.1

Common Adverse Effects

Oral therapy for schizophrenia: Somnolence, respiratory tract infection.1

Oral therapy for bipolar mania: Somnolence, extrapyramidal symptoms, dizziness, akathisia, abnormal vision, asthenia, vomiting.1 73 74

IM therapy for acute agitation in schizophrenia: Somnolence, headache, nausea.1

Interactions for Ziprasidone

Ziprasidone is metabolized by the CYP3A4 isoenzyme; CYP1A2 also may contribute but to a much lesser extent.1 Little inhibitory effect on CYP isoenzymes 1A2, 2C9, 2C19, 2D6, or 3A4; pharmacokinetic interaction unlikely with drugs metabolized by these isoenzymes.1

Drugs Affecting Hepatic Microsomal Enzymes

Potential pharmacokinetic interactions (altered metabolism) with inhibitors or inducers of CYP3A4.1

Pharmacokinetic interaction with inhibitors or inducers of CYP1A2, CYP2C9, CYP2C19, or CYP2D6 are unlikely.1

Drugs that Prolong QT Interval

Potential additive effect on QT-interval prolongation (concomitant use contraindicated) when used with drugs that prolong the QT interval.1 Ziprasidone also is contraindicated in patients receiving drugs shown to cause QT prolongation as an effect and for which this effect is described in the full prescribing information as a contraindication or boxed or bolded warning.1 (See Contraindications and Prolongation of QT Interval and Risk of Sudden Death under Cautions.)

Protein-bound Drugs

Pharmacokinetic interactions due to displacement unlikely.1

Specific Drugs

Drug

Interaction

Comments

Alcohol

Additive CNS effects1

Avoid concomitant use1

Antacids (aluminum- and magnesium-containing)

No effects on ziprasidone pharmacokinetics1 102

Antiarrhythmics (class Ia and III: e.g., amiodarone, dofetilide, procainamide, quinidine, sotalol)

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Anticholinergic agents

Possible disruption of body temperature regulation1

Use concomitantly with caution1

Arsenic trioxide

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Benztropine

Pharmacokinetic interaction unlikely1

Carbamazepine

Decreased ziprasidone AUC by approximately 35%; effect may be greater with higher dosages of carbamazepine1

Chlorpromazine

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Cimetidine

No change observed in ziprasidone pharmacokinetics1 102

CNS agents

Additive CNS effects1 12

Use concomitantly with caution1

Dextromethorphan

No change observed in dextromethorphan metabolism1

Diuretics

Possible electrolyte disturbances (e.g., hypokalemia) and increased risk of QT-interval prolongation1

Periodically monitor serum electrolytes (e.g., potassium and magnesium concentrations) when diuretic therapy is initiated during ziprasidone therapy1 (see Prolongation of QT Interval and Risk of Sudden Death under Cautions)

Dofetilide

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Dolasetron mesylate

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Dopamine agonists

Possible antagonistic effects1

Droperidol

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Gatifloxacin

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Halofantrine

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Hypotensive agents

Additive hypotensive effects1

Use with caution1

Ketoconazole

Increased AUC and peak concentrations of ziprasidone by about 35–40%1

Levodopa

Possible antagonistic effects1

Levomethadyl acetate (no longer commercially available in US)

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Lithium

No change observed in steady-state concentrations or renal clearance of lithium1

Lorazepam

Pharmacokinetic interaction unlikely1

Mefloquine

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Mesoridazine

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Moxifloxacin

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Oral contraceptives

No change observed in estradiol or levonorgestrel pharmacokinetics1

Pentamidine

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Pimozide

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Probucol

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Propranolol

Pharmacokinetic interactions due to displacement unlikely1

Quinidine

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Smoking

Pharmacokinetic interaction unlikely1

Sotalol

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Sparfloxacin

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Tacrolimus

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Thioridazine

Increased risk of QT-interval prolongation1

Concomitant use contraindicated1

Valproate

Pharmacokinetic interaction unlikely due to lack of common metabolic pathways1

Ziprasidone did not affect mean therapeutic valproate concentrations in a bipolar disorder trial1

Warfarin

Pharmacokinetic interactions due to displacement unlikely1

Ziprasidone Pharmacokinetics

Absorption

Bioavailability

Absolute bioavailability is approximately 60% following a 20-mg oral dose under fed conditions.1

Peak plasma concentrations occur 6–8 hours after oral administration or about 1 hour after IM injection or earlier.1

Food

Food increases oral absorption up to twofold.1

Special Populations

Mean AUC was 13 and 34% higher in individuals with Child-Pugh class A and B hepatic impairment, respectively, compared with that of those in the control group.1

Distribution

Extent

Manufacturer states not known whether the drug or its metabolites are distributed into milk in humans.1 However, a low concentration of ziprasidone in milk was reported in one woman; the milk/plasma ratio was 0.06 and the relative infant dose was estimated to be 1.2% of the weight-normalized maternal dose.109

Plasma Protein Binding

>99% bound to plasma proteins, principally to albumin and α1-acid glycoprotein.1

Elimination

Metabolism

Extensively metabolized in the liver. principally via reduction by aldehyde oxidase; about one-third of metabolic clearance is mediated by CYP isoenzymes, principally CYP3A4.1

Elimination Route

Approximately 20% of a dose is excreted in the urine and about 66% in feces, principally as metabolites.1 Not removed by hemodialysis.1

Half-life

Mean terminal half-life following oral administration is about 7 hours;1 following IM administration, the half-life is 2–5 hours.1

Special Populations

In patients with clinically important (Child-Pugh class A or B) cirrhosis, half-life increased by 2.3 hours compared with that of patients in the control group.1

Pharmacokinetics of oral ziprasidone similar among individuals with varying degrees of renal impairment and those with normal renal function.1 IM ziprasidone not studied in patients with renal impairment.1

Stability

Storage

Oral

Capsules

25°C (may be exposed to 15–30°C).1

Parenteral

Powder for Injection

25°C (may be exposed to 15–30°C).1 Protect from light.1

Following reconstitution, may store at 15–30°C protected from light for up to 24 hours or at 2–8°C for up to 7 days.1

Actions

  • Exact mechanism of antipsychotic action has not been fully elucidated; may involve antagonism of central type 2 serotonergic (5-HT2) receptors and central dopamine D2 receptors.1 8 9

  • Precise mechanism of antimanic action has not been fully elucidated.1

  • Exhibits high in vitro binding affinity for dopamine D2 and D3 receptors; serotonin 5-HT2A, 5-HT2C, 5-HT1A, and 5-HT1D receptors; and α1-adrenergic receptors.1 Blockade of α1-adrenergic receptors may explain the occasional orthostatic hypotension associated with the drug.1

  • Functions as an antagonist at D2, 5-HT2A, and 5-HT1D receptors, and as an agonist at the 5-HT1A receptor.1

  • Exhibits moderate affinity for the histamine H1 receptor, which may cause the somnolence associated with the drug.1

  • Inhibits synaptic reuptake of serotonin and norepinephrine.1

  • Does not possess appreciable affinity for other receptors or binding sites, including muscarinic receptors.1

Advice to Patients

  • Importance of providing a copy of written patient information (medication guide) each time oral ziprasidone is dispensed.1 Importance of advising patients to read the patient information before taking ziprasidone.1

  • Importance of taking ziprasidone exactly as prescribed.1 Importance of informing patients to swallow ziprasidone capsules whole and to take with food for optimal absorption, preferably at the same time each day.1

  • Importance of advising patients and caregivers that geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death.1 29 68 78 Inform patients and caregivers that ziprasidone is not approved for treating geriatric patients with dementia-related psychosis.1 68

  • Importance of patients informing their clinician if they have the following: history of QT-interval prolongation or cardiac arrhythmia, recent AMI, uncompensated heart failure, risk for clinically important electrolyte abnormalities, or are receiving other drugs that may prolong the QT interval.1 (See Contraindications under Cautions and see Drugs that Prolong QT Interval and Specific Drugs under Interactions.)

  • Importance of patients informing their clinician of the onset of conditions that may increase the risk for clinically important electrolyte disturbances (e.g., hypokalemia) such as the initiation of diuretic therapy or prolonged diarrhea or vomiting; importance of reporting symptoms possibly associated with torsades de pointes (e.g., dizziness, palpitations, syncope) to the clinician.1

  • Risk of severe cutaneous adverse reactions, such as DRESS or Stevens-Johnson syndrome.1 108 Importance of advising patients to notify their clinician at the earliest onset of any manifestations, including rash, fever, swollen face, or swollen lymph nodes.1 108

  • Risk of hyperglycemia in patients receiving atypical antipsychotics.1 Importance of patients and caregivers being aware of the symptoms of hyperglycemia and diabetes mellitus (e.g., increased thirst, increased urination, increased appetite, weakness) and monitoring all patients receiving ziprasidone for these symptoms.1 Importance of informing patients with diabetes or those with risk factors for diabetes (e.g., obesity, family history of diabetes) that they should have their blood glucose monitored at the beginning of and periodically during ziprasidone therapy; patients who develop symptoms of hyperglycemia during therapy should have their blood glucose assessed.1

  • Risk of leukopenia/neutropenia.1 Importance of advising patients with a preexisting low WBC count or history of drug-induced leukopenia/neutropenia of the need for CBC monitoring during ziprasidone therapy.1

  • Importance of clinicians informing patients in whom chronic ziprasidone use is contemplated about the risk of tardive dyskinesia.1 107 Importance of informing patients to report any abnormal muscle movements to a healthcare professional.107

  • Risk of NMS, which can cause high fever, stiff muscles, sweating, fast or irregular heart beat, change in BP, confusion, and kidney damage.1

  • Risk of somnolence.1 Importance of advising patients to exercise caution when performing activities requiring mental alertness (e.g., driving, operating hazardous machinery) until they gain experience with the drug’s effects.1 Importance of avoiding alcohol during ziprasidone therapy.1

  • Importance of informing patients that the effects of oral ziprasidone may take a few weeks to be evident and to continue ziprasidone therapy even if improvement is not noticed immediately.1 Importance of patients continuing to take oral ziprasidone even if improvement is seen, unless directed otherwise by their clinician.1

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription (see Drugs that Prolong QT Interval and Specific Drugs under Interactions) or OTC drugs, dietary supplements, and/or herbal products, as well as any concomitant illnesses (e.g., cardiovascular disease, diabetes mellitus, seizures, dementia).1

  • Risk of orthostatic hypotension and dizziness or syncope (fainting), particularly during the initial dosage titration period or when the dosage is increased.1 Importance of informing patients about interventions that may help to reduce the occurrence of orthostatic hypotension (e.g., slowly rising from a seated position) and to contact their clinician if dizziness or fainting occurs.1

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 106 Importance of clinicians informing patients about the benefits and risks of taking antipsychotics during pregnancy (see Pregnancy under Cautions).1 106 Importance of advising patients not to stop taking ziprasidone if they become pregnant without consulting their clinician; abruptly stopping antipsychotic agents may cause complications.106 Importance of advising patients not to breast-feed during ziprasidone therapy.1

  • Importance of avoiding overheating or dehydration.1

  • Importance of informing patients of other important precautionary information.1 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Ziprasidone Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Capsules

20 mg*

Geodon

Pfizer

40 mg*

Geodon

Pfizer

60 mg*

Geodon

Pfizer

80 mg*

Geodon

Pfizer

Ziprasidone Mesylate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection, for IM use only

20 mg (of ziprasidone) per mL

Geodon

Pfizer

AHFS DI Essentials. © Copyright, 2016, American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814. Review Date: September 06, 2016.

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