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Tips for tapering off Risperdal (risperidone)


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#1 Altostrata

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Posted 02 February 2012 - 02:41 PM

Risperdal aka risperidone, an atypical antipsychotic often prescribed off-label as a "shut-up" pill for whatever, comes in these forms:

from Risperdal Official FDA Information

  • Risperdal® Tablets are available in 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, and 4 mg.
  • Risperdal® Oral Solution is available in a 1 mg/mL strength.
  • Risperdal® M-TAB® Orally Disintegrating Tablets are available in 0.5 mg, 1 mg, 2 mg, 3 mg, and 4 mg. The range of available dosages and existence of the liquid makes slow tapering relatively easy.
  • Plus, from http://www.drugs.com...dal-consta.html, Risperdal Consta injections of 12.5 mg, 25 mg, 37.5 mg, or 50 mg risperidone every 2 weeks

http://www.drugs.com...isperidone.html
The psychoactive effect is due to risperidone plus its active metabolite paliperidone (9-hydroxy-Risperidone).
 

Following oral administration of solution or tablet, mean peak plasma concentrations of Risperidone occurred at about 1 hour. Peak concentrations of 9-hydroxyRisperidone occurred at about 3 hours in extensive metabolizers, and 17 hours in poor metabolizers.....

The pharmacokinetics of Risperidone and 9-hydroxyRisperidone combined, after single and multiple doses, were similar in extensive and poor metabolizers, with an overall mean elimination half-life of about 20 hours.

Also see the journal article Howland, 2010 Potential adverse effects of discontinuing psychotropic drugs. Part 3: Antipsychotic, dopaminergic, and mood-stabilizing drugs. http://survivinganti...ndpost__p__7840
 

Abrupt discontinuation of antipsychotic drugs in patients with schizophrenia is associated with earlier, and often more severe, illness episodes than are seen with gradual discontinuation. Antipsychotic drugs can cause various abnormal motor syndromes, but abruptly stopping them has been associated with the seemingly paradoxical development of similar motor syndromes, such as withdrawal dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome.

Dopamine-releasing and dopamine-agonist drugs are used to treat some of the motor syndromes caused by antipsychotic drugs, but their abrupt discontinuation can also be associated with abnormal syndromes. When antipsychotic drugs, lithium, or certain anticonvulsant drugs are used for treatment of bipolar disorder, rapid versus gradual discontinuation is more likely to lead to greater mood instability and manic relapse.

If necessary, these medications should be gradually tapered to minimize all types of adverse discontinuation effects. Patients should be educated about the possible adverse effects of abrupt medication discontinuation.

As with other psychiatric drugs, do not taper Risperdal by taking a dose every other day! This causes a fluctuating level of the drug in your nervous system and can make you very sick.

A conservative taper is a drop of 10% from the previous dosage every few weeks. Some people find they can go faster and some people find they have to go slower -- they can only tolerate decreases of a fraction of a milligram at a time. See Why taper by 10% of my dosage?
 
Tapering off injectable Risperdal Consta
Risperdal may be administered via injection every 2 weeks. This form is called Risperdal Consta. It comes in a range of dosages: 12.5 mg, 25 mg, 37.5 mg, or 50 mg.
 
One can taper the injections simply by reducing the amount of liquid injected. This is probably the safest way to go off Risperdal Consta -- but it requires the cooperation of a doctor.
 
If you wish to switch to the tablet form to taper (see below), the following is important http://www.drugs.com...onsta.html#S2.8 :
 

Pharmacokinetics
Absorption
After a single intramuscular (gluteal) injection of RISPERDAL® CONSTA®, there is a small initial release of the drug (< 1% of the dose), followed by a lag time of 3 weeks. The main release of the drug starts from 3 weeks onward, is maintained from 4 to 6 weeks, and subsides by 7 weeks following the intramuscular (IM) injection. Therefore, oral antipsychotic supplementation should be given during the first 3 weeks of treatment with RISPERDAL® CONSTA® to maintain therapeutic levels until the main release of risperidone from the injection site has begun [see Dosage and Administration (2)]. Following single doses of RISPERDAL® CONSTA®, the pharmacokinetics of risperidone, 9-hydroxyrisperidone (the major metabolite), and risperidone plus 9-hydroxyrisperidone were linear in the dosing range of 12.5 mg to 50 mg.
 
The combination of the release profile and the dosage regimen (IM injections every 2 weeks) of RISPERDAL® CONSTA® results in sustained therapeutic concentrations. Steady-state plasma concentrations are reached after 4 injections and are maintained for 4 to 6 weeks after the last injection....
 
Excretion
....The apparent half-life of risperidone plus 9-hydroxyrisperidone following RISPERDAL® CONSTA® administration is 3 to 6 days, and is associated with a monoexponential decline in plasma concentrations. This half-life of 3–6 days is related to the erosion of the microspheres and subsequent absorption of risperidone. The clearance of risperidone and risperidone plus 9-hydroxyrisperidone was 13.7 L/h and 5.0 L/h in extensive CYP 2D6 metabolizers, and 3.3 L/h and 3.2 L/h in poor CYP 2D6 metabolizers, respectively. No accumulation of risperidone was observed during long-term use (up to 12 months) in patients treated every 2 weeks with 25 mg or 50 mg RISPERDAL® CONSTA®. The elimination phase is complete approximately 7 to 8 weeks after the last injection....

 
If you are switching from the injection to the extended-release tablets, you need to be careful about the overlap -- you could be taking a high dose if you have recently had an injection and you add tablets. Probably the safest time to make the switch to a lower-dosage daily tablet would be in the 5th week, when the injection is wearing off.
 
This reference, from the UK Psychiatric Pharmacy Group (now College of Mental Health Pharmacy), is the only one I could find regarding switching from the Consta injection to a risperidone tablet:
 
http://www.ukppg.org...idance-avon.rtf

It takes about 6 weeks following an injection for the levels in the blood to fall below a sub-therapeutic level. Switching a patient to an oral preparation should be started about 5 weeks after the final injection. The manufacturer suggests starting at a dose of 2mg/day of risperidone and gradually increasing if necessary according to response over the following week. 

 

Cutting up the tablets with a pill splitter
This can work, but if you are sensitive to small variations in dosage, cutting up pills is not very exact. For more exact doses, weigh fragments with an electronic digital scale.

Keep the pieces you don't use in a clean pill bottle labeled with the dosage for future use.

Use an electronic digital jeweler's scale to weigh small amounts
If you are sensitive to dosage changes, you may wish to be more precise in your measurements so you can taper at a measured rate. A digital scale, which can be bought for about $30, is useful. Instructions here.

Have risperidone made into smaller dosage capsules by a compounding pharmacy
Compounding pharmacies can crush the tablets and put the powder into smaller capsules by weight. You will need a doctor's prescription for this telling the pharmacy exactly how much to put in a capsule and how many capsules to make.

See http://survivinganti...-and-elsewhere/

Use the Risperdal liquid solution
Titrating using a liquid is very good for very small measured decreases in dosage, allowing more precise measurements.

from Risperdal Official FDA Information


 

Risperdal® Oral Solution can be administered directly from the calibrated pipette, or can be mixed with a beverage prior to administration. Risperdal® Oral Solution is compatible in the following beverages: water, coffee, orange juice, and low-fat milk; it is NOT compatible with either cola or tea.

If you mix it with liquid to titrate, you may find you need to slightly adjust the dose up or down. Those adjustments would be by tenths or even hundredths of a milligram.

For tips about using an oral syringe for doses of liquid medication, see http://survivinganti...ring-techniques

Use a tiny 1mL syringe to measure dosages less than 1mg, to hundredths of a milligram.


Edited by Altostrata, 14 October 2014 - 01:42 PM.
updated

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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#2 Altostrata

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Posted 22 January 2013 - 09:42 AM

From official FDA information http://www.drugs.com.../risperdal.html

Warnings and Precautions

....
Neuroleptic Malignant Syndrome

Antipsychotic drugs including Risperdal® can cause a potentially fatal symptom complex referred to as Neuroleptic Malignant Syndrome (NMS). Clinical manifestations of NMS include hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Additional signs may include elevated creatine phosphokinase (CPK), myoglobinuria, rhabdomyolysis, and acute renal failure.

The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is important to identify cases in which the clinical presentation includes both serious medical illness (e.g., pneumonia, systemic infection, etc.) and untreated or inadequately treated extrapyramidal signs and symptoms (EPS). Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, drug fever, and primary central nervous system pathology.

The management of NMS should include: (1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy; (2) intensive symptomatic treatment and medical monitoring; and (3) treatment of any concomitant serious medical problems for which specific treatments are available. There is no general agreement about specific pharmacological treatment regimens for uncomplicated NMS.

If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported.

Tardive Dyskinesia

A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs. The risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase. However, the syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses.

There is no known treatment for established cases of tardive dyskinesia, although the syndrome may remit, partially or completely, if antipsychotic treatment is withdrawn. Antipsychotic treatment, itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome and thereby may possibly mask the underlying process. The effect that symptomatic suppression has upon the long-term course of the syndrome is unknown.

Given these considerations, prescribe Risperdal® in a manner that is most likely to minimize the occurrence of tardive dyskinesia. Chronic antipsychotic treatment should generally be reserved for patients who suffer from a chronic illness that: (1) is known to respond to antipsychotic drugs, and (2) for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate. In patients who do require chronic treatment, the smallest dose and the shortest duration of treatment producing a satisfactory clinical response should be sought. The need for continued treatment should be reassessed periodically.

If signs and symptoms of tardive dyskinesia appear in a patient treated with Risperdal®, consider drug discontinuation. However, some patients may require treatment with Risperdal® despite the presence of the syndrome.

Metabolic Changes

​Atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular/cerebrovascular risk. These metabolic changes include hyperglycemia, dyslipidemia, and body weight gain. While all of the drugs in the class have been shown to produce some metabolic changes, each drug has its own specific risk profile.

Hyperglycemia and Diabetes Mellitus

Hyperglycemia and diabetes mellitus, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, have been reported in patients treated with atypical antipsychotics including Risperdal®. Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders, the relationship between atypical antipsychotic use and hyperglycemia-related adverse events is not completely understood. However, epidemiological studies suggest an increased risk of treatment-emergent hyperglycemia-related adverse events in patients treated with the atypical antipsychotics. Precise risk estimates for hyperglycemia-related adverse events in patients treated with atypical antipsychotics are not available.

Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics, including Risperdal®, should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics, including Risperdal®, should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics, including Risperdal®, should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics, including Risperdal®, should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic, including Risperdal®, was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of Risperdal®....


This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

#3 rispmed

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Posted 06 September 2014 - 11:29 AM

this info is helpful...