Fluphenazine Decanoate - Uses, Dose, Side effects, MOA, Brands

Fluphenazine Decanoate is a typical antipsychotic medicine that is used in the treatment of patients with schizophrenia, psychosis, and tic disorders.

Fluphenazine Decanoate Uses:

Psychotic disorders:
- Decanoate injection is used for the treatment of patients who need prolonged therapy and is used to treat the symptoms of psychotic illnesses.
- Restrictions on use: The therapy of behavioural issues in patients with mental retardation is not proven to be successful with fluphenazine.
Use: Off-Label: Adult
- Used in the chorea of Huntington disease
- Used in chronic tic disorders
- Used in the psychosis/ agitation associated with dementia

Read: Olanzapine (Zyprexa)

Fluphenazine Decanoate Dose in Adults

Fluphenazine Decanoate Dose in the treatment of Psychosis:

Oral:
- Maintenance: 1 to 5 mg per day (may be used as a daily dose); Initial: 2.5 to 10 mg per day in 3 or 4 split doses;
- Note: For symptom control, some individuals may need as much as 40 mg daily (long-term safety of higher doses not established)
- PORT guidelines:
  - Acute therapy: 6 to 20 mg/day for up to 6 weeks;
  - Maintenance: 6 to 12 mg per day.
IM (hydrochloride):
- Initial: 1.25 mg as a single dosage; may require 2.5 to 10 mg per day in divided doses at 6- to 8-hour intervals depending on severity and duration (IM fluphenazine HCl is about comparable to 33 to 50% of the oral fluphenazine HCl dose);
- Don't exceed dosages of 10 mg per day; if symptoms have stabilised, switch to oral maintenance medication.
- Long-acting maintenance injections (decanoate):
  - Consider using a short-acting version of fluphenazine to establish response, the right dose, and tolerability prior to starting treatment.
IM, SubQ (decanoate):
- Every two weeks, 6.25 to 25 mg.
- The effects of a single injection may last for four to six weeks after they reach a steady-state; titrate dosage gradually; if dosages greater than 50 mg are required, increase in 12.5 mg increments (maximum dose: 100 mg).
Conversion from hydrochloride dosage forms to decanoate IM:
- About 10 mg of oral hydrochloride every day is comparable to 5 mg of decanoate every three weeks.

Note: After the first injection, cut the oral fluphenazine (or any antipsychotic) dosage in half; after the second injection, think about stopping oral medication.

Fluphenazine Decanoate Dose in the treatment of Chorea of Huntington disease (off-label):

Oral: Initial:
- Start with 2 mg per day and progressively raise the dose based on response and tolerance; doses as high as 7 mg per day have been documented.
IM (decanoate):
- Initial dose: 25 mg; following the first injection, the dose may be increased in increments of 12.5 to 25 mg up to 75 mg every 3 weeks, depending on response and tolerability.
To more clearly identify the function of fluphenazine in this scenario, more information could be required.

Fluphenazine Decanoate Dose in the treatment of Chronic tic disorders (off-label):

Oral:
- Initial dosage: 0.5 to 1 mg once daily; increase in 0.5 mg to 1 mg steps every week depending on response and tolerability
- There have been studies on dosages up to 24 mg divided 1–3 times daily.
- Standard daily doses are between 2.5 and 10 mg.
- To more clearly identify the function of fluphenazine in this scenario, more information could be required.

Discontinuation of therapy:

To prevent withdrawal symptoms and lower the chance of relapse, the American Psychiatric Association (APA), Canadian Psychiatric Association (CPA), and World Federation of Societies of Biological Psychiatry (WFSBP) guidelines advise reducing antipsychotics gradually.
The risk for withdrawal symptoms may be highest with highly anti-cholinergic or dopaminergic antipsychotics.
It may be possible to avoid withdrawal symptoms by continuing anti-parkinsonism medications for a limited period after stopping them.
The CPA recommendations advise a slow taper over several weeks when discontinuing antipsychotic therapy in people with schizophrenia.
The CPA guidelines advise a progressive taper over 6 to 24 months after ending antipsychotic medicine, whereas the APA standards advise a dose reduction of 10% every month.
When switching antipsychotics, 3 strategies have been suggested:
- Cross-titration (gradually discontinuing the first antipsychotic while gradually increasing the new antipsychotic),
- overlap and taper (maintaining the dose of the first antipsychotic while gradually increasing the new antipsychotic, then tapering the first antipsychotic), and
- abrupt change (abruptly discontinuing the first antipsychotic and either increasing the new antipsychotic gradually or starting it at a treatment dose).
Evidence supporting ideal switch strategies and taper rates is limited, and results are conflicting.

Fluphenazine Decanoate Dose in Children

Fluphenazine Decanoate Dose in the treatment of Chronic tic disorders (off-label):

Children and Adolescents:
- Oral: Initial:
  - One dose of between 0.5 and 1 mg; weekly increases of between 0.5 and 1 mg dependent on response and tolerability.
  - Patients in both adult and paediatric patients have been tested with doses up to 24 mg divided 1 to 3 times day.
  - The typical daily dosing range is 0.25 to 10 mg.
- To more clearly identify the function of fluphenazine in this scenario, more information could be required.

Fluphenazine Decanoate Pregnancy Category: N

Both oxcarbazepine as well as its monohydroxy metabolite, (MHD), have pharmacological activity.
It is not known what the mechanism behind anticonvulsant effects works.
The hyperexcited neuronal membranes are stabilised by MHD and oxcarbazepine, which both limit repeated firing and lessen synaptic impulse spread.
The spread of seizures can be halted by taking these steps.
The conductance of potassium is likewise increased by MHD and oxcarbazepine, and the activity of high-voltage activated calcium channels is modulated.

Dose in Kidney Disease:

The manufacturer's labeling doesn't provide any dosage adjustments; Use with caution.

Dose in Liver disease:

Manufacturer's labeling doesn't provide any dosage adjustments

Side effects of Fluphenazine Decanoate:

Cardiovascular:
- Cardiac Arrhythmia
- Edema
- Variable Blood Pressure
- Hypertension
- Hypotension
- Tachycardia
Central Nervous System:
- Akathisia
- Drowsiness
- Dystonia
- EEG Pattern Changes
- Excitement
- Headache
- Hyperreflexia
- Lethargy
- Bizarre Dream
- Cerebral Edema
- Depression
- Disruption Of Body Temperature Regulation
- Dizziness
- Neuroleptic Malignant Syndrome
- Parkinsonian-Like Syndrome
- Restlessness
- Seizure
- Tardive Dyskinesia
Dermatologic:
- Dermatitis
- Pruritus
- Seborrhea
- Skin Photosensitivity
- Skin Pigmentation
- Skin Rash
- Eczema
- Erythema
- Urticaria
Endocrine & Metabolic:
- Galactorrhea
- Gynecomastia
- Increased Serum Prolactin
- Menstrual Disease
- Amenorrhea
- Change In Libido
- SIADH (Syndrome Of Inappropriate Antidiuretic Hormone Secretion)
- Weight Gain
Gastrointestinal:
- Anorexia
- Xerostomia
- Constipation
- Paralytic Ileus
- Salivation
Genitourinary:
- Bladder Paralysis
- Urinary Incontinence
- Ejaculatory Disorder
- Impotence
- Mastalgia
Hematologic & Oncologic:
- Agranulocytosis
- Eosinophilia
- Thrombocytopenia
- Leukopenia
- Nonthrombocytopenic Purpura
- Pancytopenia
Hepatic:
- Cholestatic Jaundice
- Hepatotoxicity
Neuromuscular & Skeletal:
- Muscle Spasm (Neck)
- Systemic Lupus Erythematosus
- Tremor (Fingers)
Ophthalmic:
- Blurred Vision
- Corneal Changes
- Glaucoma
- Lens Disease
- Retinitis Pigmentosa
Renal:
- Polyuria
Respiratory:
- Asthma
- Laryngeal Edema
- Nasal Congestion

Contraindications to Fluphenazine Decanoate:

Cross-reactivity among phenothiazines, or hypersensitivity to fluphenazine and any component of the formulation, may happen.
Grave CNS Depression
coma
Subcortical brain injury;
Blood dyscrasias
Hepatic disease
Patients who have received large amounts of hypnotics.
Children younger than 12 years old (fluphenazine canoate only)

Canadian labeling: Additional contraindications not in US labeling

Fluphenazine decanoate
- Cerebral atherosclerosis is a common condition.
- Renal insufficiency is a serious cardiovascular disorder.
- Pheochromocytoma.

Warnings and precautions

Modified cardiac conduction
- Potentially affect cardiac conduction (life-threatening arrhythmias have been reported with therapeutic doses antipsychotics).
Anticholinergic effects
- There could be anticholinergic effects (constipation, urinary retention, xerostomia and blurred vision).
- Patients with reduced gastrointestinal motility, paralytic and ileus, urinary retentions, BPH, xerostomia, and visual impairments should be cautious.
- Fluphenazine is a lower-potency antipsychotic than other antipsychotics.
Blood dyscrasias
- Antipsychotic usage has been linked to reports of leukopenia, neutropenia, and even fatal agranulocytosis in clinical trials and postmarketing reports.
- Periodic blood count assessments should be done if there are any risk factors, such as low WBC or a history of drug-induced neutropenia/neutropenia.
- If you have blood dyscrasias or if your absolute neutrophil count reaches 1000/mm3, stop treatment.
Depression in the CNS:
- CNS depression can lead to mental or physical impairments. Patients should be cautious about driving or operating machinery that requires mental alertness.
Esophageal dysmotility/aspiration
- Antipsychotic use has been linked to esophageal dysmotility, aspiration, and increased risk with age.
- Patients at high risk of aspiration pneumonia (ie Alzheimer's disease) should be treated with caution, especially if they are older than 75 years.
Extrapyramidal symptoms
- Extrapyramidal symptoms (EPS).
  - Extrapyramidal symptoms may include tardive dyskinesia, pseudo-parkinsonism and akathisia.
- Higher doses of antipsychotics and use of conventional antipsychotics may increase the risk of dystonia (and other EPS), in younger patients.
- There are several factors that increase the vulnerability to tardive dyskinesia, including older age, female gender, postmenopausal status and pseudo-parkinsonism symptoms.
- You may consider discontinuing therapy if you experience tardive dyskinesia symptoms.
Falls
- Patients with certain diseases or medications that can increase fall risk should have their fall risk assessed at baseline and again periodically throughout treatment.
- May increase the chance of falling due to somnolence and orthostatic hypotension.
Hepatic effects
- Use has been linked to jaundice and liver damage in cases of cholestatic hepatitis.
Hyperprolactinemia
- Hyperprolactinemia is a condition that results in an increase in prolactin levels. Clinical significance of hyperprolactinemia for patients with breast cancer or other prolactin dependent tumors is not known.
Neuroleptic malignant Syndrome (NMS).
- This may be related to NMS. Monitor for changes in mental status, fever, rigidity of the muscles, and/or other signs that could indicate NMS.
Ocular effects
- Extended therapy may cause pigmentary retinopathy and lenticular or corneal deposits.
Orthostatic hypotension
- Orthostatic hypotension may occur; caution is advised in patients who are at high risk or those who cannot tolerate temporary hypotension (cerebrovascular disease and hypovolemia), or for people taking concurrent medication that could lead to hypotension/bradycardia.
Temperature regulation
- It is possible to have impaired core body temperature regulation. Be aware of heat exposure, dehydration and any concomitant anticholinergic medication.
Cardiovascular disease
- Patients with severe cardiovascular disease should be cautious.
Dementia: [US Boxed Warning]
- Antipsychotics have a higher death rate than placebo for dementia-related psychosis in the elderly.
- Patients with Parkinson disease dementia or Lewy body dementia should be cautious due to the increased risk of adverse effects and increased sensitivity for extrapyramidal effects. Also, there is an association with irreversible cognitive decline or death.
- The APA recommends that second-generation antipsychotics be preferred to first generation antipsychotics for elderly patients with dementia-related schizophrenia (APA [Reus 2016]). This is because there is a greater risk of harm than second generation antipsychotics.
- The majority of deaths were either from cardiovascular disease (eg heart failure, sudden death, etc.) or from infectious diseases (eg pneumonia).
- For the treatment of dementia-related psychosis, fluphenazine has not been approved.
Hepatic impairment
- Patients with hepatic impairment should be cautious; patients with liver damage should not be used.
Renal impairment
- Patients with impaired renal function should be cautious; stop therapy if the BUN is abnormal.
Seizure disorder
- Patients with seizures history should be cautious.

Fluphenazine: Drug Interaction

Risk Factor C (Monitor therapy)
Acetylcholinesterase Inhibitors	May diminish the therapeutic effect of Anticholinergic Agents. Anticholinergic Agents may diminish the therapeutic effect of Acetylcholinesterase Inhibitors.
Acetylcholinesterase Inhibitors (Central)	May enhance the neurotoxic (central) effect of Antipsychotic Agents. Severe extrapyramidal symptoms have occurred in some patients.
Ajmaline	May elevate CYP2D6 Substrates' serum concentration (High risk with Inhibitors).
Alcohol (Ethyl)	Alcohol's CNS depressing effect may be amplified by CNS depressants (Ethyl).
Alizapride	May enhance the CNS depressant effect of CNS Depressants.
Amifampridine	Agents With Seizure Threshold Lowering Potential may enhance the neuroexcitatory and/or seizure-potentiating effect of Amifampridine.
Aminolevulinic Acid (Topical)	Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Topical).
Amphetamines	Antipsychotic Agents may diminish the stimulatory effect of Amphetamines.
Antacids	May decrease the absorption of Antipsychotic Agents (Phenothiazines).
Anticholinergic Agents	May enhance the adverse/toxic effect of other Anticholinergic Agents.
Antimalarial Agents	May increase the serum concentration of Antipsychotic Agents (Phenothiazines).
Beta-Blockers	Antipsychotic Agents (Phenothiazines) may enhance the hypotensive effect of Beta-Blockers. Beta-Blockers may decrease the metabolism of Antipsychotic Agents (Phenothiazines). Antipsychotic Agents (Phenothiazines) may decrease the metabolism of BetaBlockers. Exceptions: Atenolol; Levobunolol; Metipranolol; Nadolol.
Botulinum Toxin-Containing Products	May enhance the anticholinergic effect of Anticholinergic Agents.
Brexanolone	CNS Depressants may enhance the CNS depressant effect of Brexanolone.
Brimonidine (Topical)	May enhance the CNS depressant effect of CNS Depressants.
Cannabidiol	May enhance the CNS depressant effect of CNS Depressants.
Cannabis	May enhance the CNS depressant effect of CNS Depressants.
Chloral Betaine	May enhance the adverse/toxic effect of Anticholinergic Agents.
Chlorphenesin Carbamate	May enhance the adverse/toxic effect of Antipsychotic Agents (Phenothiazines).
Chlorphenesin Carbamate	May enhance the adverse/toxic effect of CNS Depressants.
CloBAZam	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
CNS Depressants	May enhance the adverse/toxic effect of other CNS Depressants.
Cobicistat	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
CYP2D6 Inhibitors (Moderate)	May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors).
Darunavir	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Deutetrabenazine	May enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, the risk for akathisia, parkinsonism, or neuroleptic malignant syndrome may be increased.
Dimethindene (Topical)	May enhance the CNS depressant effect of CNS Depressants.
Doxylamine	May enhance the CNS depressant effect of CNS Depressants. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with other CNS depressants is not recommended.
Dronabinol	May enhance the CNS depressant effect of CNS Depressants.
Esketamine	May enhance the CNS depressant effect of CNS Depressants.
Gastrointestinal Agents (Prokinetic)	Anticholinergic Agents may diminish the therapeutic effect of Gastrointestinal Agents (Prokinetic).
Glucagon	Anticholinergic Agents may enhance the adverse/toxic effect of Glucagon. Specifically, the risk of gastrointestinal adverse effects may be increased.
Guanethidine	Antipsychotic Agents may diminish the therapeutic effect of Guanethidine.
HydrOXYzine	May enhance the CNS depressant effect of CNS Depressants.
Imatinib	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Itopride	Anticholinergic Agents may diminish the therapeutic effect of Itopride.
Kava Kava	May enhance the adverse/toxic effect of CNS Depressants.
Lithium	May enhance the neurotoxic effect of Antipsychotic Agents. Lithium may decrease the serum concentration of Antipsychotic Agents. Specifically noted with chlorpromazine.
Lofexidine	May enhance the CNS depressant effect of CNS Depressants. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs.
Lumefantrine	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Magnesium Sulfate	May enhance the CNS depressant effect of CNS Depressants.
Methylphenidate	Antipsychotic Agents may enhance the adverse/toxic effect of Methylphenidate. Methylphenidate may enhance the adverse/toxic effect of Antipsychotic Agents.
MetyroSINE	CNS Depressants may enhance the sedative effect of MetyroSINE.
MetyroSINE	May enhance the adverse/toxic effect of Antipsychotic Agents.
Mianserin	May enhance the anticholinergic effect of Anticholinergic Agents.
Minocycline	May enhance the CNS depressant effect of CNS Depressants.
Mirabegron	Anticholinergic Agents may enhance the adverse/toxic effect of Mirabegron.
Mirtazapine	CNS Depressants may enhance the CNS depressant effect of Mirtazapine.
Nabilone	May enhance the CNS depressant effect of CNS Depressants.
Nitroglycerin	Anticholinergic Agents may decrease the absorption of Nitroglycerin. Specifically, anticholinergic agents may decrease the dissolution of sublingual nitroglycerin tablets, possibly impairing or slowing nitroglycerin absorption.
Panobinostat	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Peginterferon Alfa-2b	May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Perhexiline	CYP2D6 Substrates (High risk with Inhibitors) may increase the serum concentration of Perhexiline. Perhexiline may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Porfimer	Photosensitizing Agents may enhance the photosensitizing effect of Porfimer.
Quinagolide	Antipsychotic Agents may diminish the therapeutic effect of Quinagolide.
QuiNINE	May elevate CYP2D6 Substrates' serum concentration (High risk with Inhibitors).
Ramosetron	Anticholinergic Agents may enhance the constipating effect of Ramosetron.
Rufinamide	May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced.
Selective Serotonin Reuptake Inhibitors	CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced.
Serotonin Modulators	May enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Exceptions: Nicergoline.
Serotonin Reuptake Inhibitor/Antagonists	Antipsychotic Agents (Phenothiazines) may enhance the adverse/toxic effect of Serotonin Reuptake Inhibitor/Antagonists. Specifically, this may be manifest as symptoms consistent with serotonin syndrome or neuroleptic malignant syndrome. Serotonin Reuptake Inhibitor/Antagonists may enhance the hypotensive effect of Antipsychotic Agents (Phenothiazines).
Tetrabenazine	May enhance the adverse/toxic effect of Antipsychotic Agents.
Tetrahydrocannabinol	May enhance the CNS depressant effect of CNS Depressants.
Tetrahydrocannabinol and Cannabidiol	May enhance the CNS depressant effect of CNS Depressants.
Thiazide and Thiazide-Like Diuretics	Anticholinergic Agents may increase the serum concentration of Thiazide and Thiazide-Like Diuretics.
Thiopental	Antipsychotic Agents (Phenothiazines) may enhance the adverse/toxic effect of Thiopental.
Topiramate	Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate.
Trimeprazine	May enhance the CNS depressant effect of CNS Depressants.
Verteporfin	Photosensitizing Agents may enhance the photosensitizing effect of Verteporfin.
Risk Factor D (Consider therapy modification)
Abiraterone Acetate	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of abiraterone with CYP2D6 substrates that have a narrow therapeutic index whenever possible. When concurrent use is not avoidable, monitor patients closely for signs/symptoms of toxicity.
Anti-Parkinson Agents (Dopamine Agonist)	May reduce the therapeutic benefit of antipsychotic medications (First Generation [Typical]). The therapeutic benefit of first-generation [typical] antipsychotic agents may be reduced (Dopamine Agonist). Management: If concurrent therapy cannot be avoided, monitor for diminished effects of both medications and avoid it as much as you can. It may be less likely for atypical antipsychotics like clozapine and quetiapine to lessen the effects of anti-Parkinson medications.
Asunaprevir	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Blonanserin	CNS Depressants may enhance the CNS depressant effect of Blonanserin.
Buprenorphine	CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine patches (Butrans brand) at 5 mcg/hr in adults when used with other CNS depressants.
Chlormethiazole	May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used.
CYP2D6 Inhibitors (Strong)	May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors).
Dacomitinib	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of dacomitinib with CYP2D6 subtrates that have a narrow therapeutic index.
Droperidol	May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Exceptions to this monograph are discussed in further detail in separate drug interaction monographs.
Flunitrazepam	CNS Depressants may enhance the CNS depressant effect of Flunitrazepam.
HYDROcodone	CNS Depressants may enhance the CNS depressant effect of HYDROcodone. Management: Avoid concomitant use of hydrocodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
Iohexol	Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iohexol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iohexol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants.
Iomeprol	Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iomeprol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iomeprol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants.
Iopamidol	Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iopamidol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iopamidol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants.
Mequitazine	Antipsychotic Agents may enhance the arrhythmogenic effect of Mequitazine. Management: Consider alternatives to one of these agents when possible. While this combination is not specifically contraindicated, mequitazine labeling describes this combination as discouraged.
Methotrimeprazine	CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established.
Opioid Agonists	CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
OxyCODONE	CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
Perampanel	May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination.
Pramlintide	May enhance the anticholinergic effect of Anticholinergic Agents. These effects are specific to the GI tract.
Secretin	Anticholinergic Agents may diminish the therapeutic effect of Secretin. Management: Avoid concomitant use of anticholinergic agents and secretin. Discontinue anticholinergic agents at least 5 half-lives prior to administration of secretin.
Sodium Oxybate	May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to combined use. When combined use is needed, consider minimizing doses of one or more drugs. Use of sodium oxybate with alcohol or sedative hypnotics is contraindicated.
Suvorexant	CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended.
Tapentadol	May enhance the CNS depressant effect of CNS Depressants. Management: Avoid concomitant use of tapentadol and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
Zolpidem	CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol.
Risk Factor X (Avoid combination)
Aclidinium	May enhance the anticholinergic effect of Anticholinergic Agents.
Aminolevulinic Acid (Systemic)	Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Systemic).
Amisulpride	Antipsychotic Agents may enhance the adverse/toxic effect of Amisulpride. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs.
Azelastine (Nasal)	CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal).
Bromopride	May enhance the adverse/toxic effect of Antipsychotic Agents.
Bromperidol	May enhance the CNS depressant effect of CNS Depressants.
Cimetropium	Anticholinergic Agents may enhance the anticholinergic effect of Cimetropium.
Dronedarone	Antipsychotic Agents (Phenothiazines) may enhance the arrhythmogenic effect of Dronedarone.
Eluxadoline	Anticholinergic Agents may enhance the constipating effect of Eluxadoline.
Glycopyrrolate (Oral Inhalation)	Anticholinergic Agents may enhance the anticholinergic effect of Glycopyrrolate (Oral Inhalation).
Glycopyrronium (Topical)	May enhance the anticholinergic effect of Anticholinergic Agents.
Ipratropium (Oral Inhalation)	May enhance the anticholinergic effect of Anticholinergic Agents.
Levosulpiride	Anticholinergic Agents may diminish the therapeutic effect of Levosulpiride.
Metoclopramide	May enhance the adverse/toxic effect of Antipsychotic Agents.
Orphenadrine	CNS Depressants may enhance the CNS depressant effect of Orphenadrine.
Oxatomide	May enhance the anticholinergic effect of Anticholinergic Agents.
Oxomemazine	May enhance the CNS depressant effect of CNS Depressants.
Paraldehyde	CNS Depressants may enhance the CNS depressant effect of Paraldehyde.
Piribedil	Antipsychotic Agents may diminish the therapeutic effect of Piribedil. Piribedil may diminish the therapeutic effect of Antipsychotic Agents. Management: Use of piribedil with antiemetic neuroleptics is contraindicated, and use with antipsychotic neuroleptics, except for clozapine, is not recommended.
Potassium Chloride	Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Chloride. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium chloride.
Potassium Citrate	Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Citrate.
Revefenacin	Anticholinergic Agents may enhance the anticholinergic effect of Revefenacin.
Saquinavir	Saquinavir's ability to induce arrhythmias may be enhanced by antipsychotic drugs (phenothiazines). Management: Separate drug interaction monographs go into further detail about the medications indicated as exceptions to this book.
Sulpiride	Antipsychotic Agents may enhance the adverse/toxic effect of Sulpiride.
Thalidomide	CNS Depressants may enhance the CNS depressant effect of Thalidomide.
Tiotropium	Anticholinergic Agents may enhance the anticholinergic effect of Tiotropium.
Umeclidinium	May enhance the anticholinergic effect of Anticholinergic Agents.

Monitoring parameters:

Mental health;
Vital signs (as indicated by a doctor);
Weight, height, waist circumference, and BMI (baseline) at each visit for the first six months. Visits are made quarterly with stable antipsychotic medication.
CBC (as indicated by the doctor; patients who have a history of drug-induced leukopenia/neutropenia or low WBC should be monitored frequently in the first few months.
Electrolytes, renal function and liver function (yearlyly and as indicated by the doctor; discontinue treatment if BUN is abnormal).
Fasting plasma glucose level/HbA
lipid panel (baseline, repeat every 2 years if your LDL level has not increased; repeat every 6 month if it is higher than 130 mg/dL).
Changes in menstruation, galactorrhea development, libido and ejaculatory functions (at each visit during the first 12 weeks following the antipsychotic's administration or until the dose becomes stable; thereafter, annually).
Parkinsonian signs or abnormal involuntary movements (baseline; continue weekly until dose stabilization for at least 2 week after introduction, and 2 weeks after any significant dose rise);
Visual changes (enquire annually);
Lateive dyskinesia occurs every 6 months
High-risk patients should be seen every 3 months
Ocular examinations (annually for patients over 40 years old; once every 2 years for younger patients).

How to administer Fluphenazine Decanoate?

IM:

You can inject the hydrochloride/decanoate formulation intramuscularly.
Hypotension should be monitored.

Solution: Injection of decanoate

Use a dry, >=21 gauge needle and syringe to deliver fluphenazine. A moist needle or syringe could obscure the fluid.
To prevent leakage, Ztrack injection techniques should be used. Fluphenazine injection by deltoid is recommended by experts.

Oral:

To ensure stability and palatability, oral liquid concentrate must be dilute immediately before administration.
Mix at least 60mL (2 fl. oz.) of milk, tomato juice or uncaffeinated soft drink, or juices with fruit juices.
Do not mix caffeine-containing beverages (coffee, tea, cola), tannins or apple juice (tea), pectinate (apple cider) with any other beverage.

SubQ

Subcutaneous administration of the decanoate formulation is not permitted.
Use a dry needle and a syringe with a gauge greater than 21 to inject fluphenazine. A moist syringe or needle could obscure the fluid.

Mechanism of action of Fluphenazine Decanoate:

In the brain, nonselectively postsynaptic dopaminergic D2 neurons are blocked by the antipsychotic fluphenazine, a piperazine-phenothiazine.
Fluphenazine, however, only has a little amount of action at histaminergic and muscarinic receptors.

The onset of action:

Decanoate: 24 to 72 hours

Peak effect:

Decanoate: 48 to 96 hours

Duration:

Decanoate: ~4 to 6 weeks

Metabolism:

Hepatic via CYP 2D6.

Bioavailability:

35 percent.

Half-life elimination (derivative dependent):

Oral: 14.4 to 16.4 hours.
Decanoate: ~14 days.

Time to peak, serum:

Oral: 2.8 hours;
Decanoate: 8 to 10 hours.

International Brand Names of Fluphenazine:

APO-Fluphenazine
FluPHENAZine Omega
Modecate Concentrate
Fenazine
Flenazine
Fludecasine
Fludecate
Fludecate Multidose
Flufenan
Fluvita
Funazine
FunazineS
PMS-Fluphenazine
PMS-Fluphenazine Decanoate
Anatensol
Anatensol Decanoate
Cenilene
Dapotum
Dapotum D
Dapotum d
Deca
Lyogen
Lyogen Depot
Modecate
Modicate
Moditen
Moditen Depot
Shrizine 1
Sikzonoate
Siqualone
Sydepres
Monasan
Moody
Omca
Pharnazine
Prolixin-D
Shrizine
Ziphen

Fluphenazine Brand Names in Pakistan:

Fluphenazine Injection 25 mg in Pakistan
Flufiwan	Swan Pharmaceuticals(Pvt) Ltd
Synocate	Polyfine Chempharma (Pvt) Ltd.

Fluphenazine Injection 25 mg/ml in Pakistan
Fenarax	Mediceena Pharma (Pvt) Ltd.
Flitzin	Fynk Pharmaceuticals
Flucate	Akhai Pharmaceuticals.
Fluphan	Pharmedic (Pvt) Ltd.
Fluphen	Haji Medicine Co.
Gencate	Genetics Pharmaceuticals
M-Kate	Ophth-Pharma (Pvt) Ltd.
Modecate	Glaxosmithkline
Saviget	Cirin Pharmaceuticals (Pvt) Ltd.

Fluphenazine Decanoate - Uses, Dose, Side effects, MOA, Brands

Fluphenazine Decanoate Uses:

Psychotic disorders:

Use: Off-Label: Adult

Fluphenazine Decanoate Dose in Adults

Fluphenazine Decanoate Dose in the treatment of Psychosis:

Conversion from hydrochloride dosage forms to decanoate IM:

Fluphenazine Decanoate Dose in the treatment of Chorea of Huntington disease (off-label):

Fluphenazine Decanoate Dose in the treatment of Chronic tic disorders (off-label):

Discontinuation of therapy:

Fluphenazine Decanoate Dose in Children

Fluphenazine Decanoate Dose in the treatment of Chronic tic disorders (off-label):

Children and Adolescents:

Fluphenazine Decanoate Pregnancy Category: N

Dose in Kidney Disease:

Dose in Liver disease:

Side effects of Fluphenazine Decanoate:

Cardiovascular:

Central Nervous System:

Dermatologic:

Endocrine & Metabolic:

Gastrointestinal:

Genitourinary:

Hematologic & Oncologic:

Hepatic:

Neuromuscular & Skeletal:

Ophthalmic:

Renal:

Respiratory:

Contraindications to Fluphenazine Decanoate:

Warnings and precautions

Modified cardiac conduction

Anticholinergic effects

Blood dyscrasias

Depression in the CNS:

Esophageal dysmotility/aspiration

Extrapyramidal symptoms

Falls

Hepatic effects

Hyperprolactinemia

Neuroleptic malignant Syndrome (NMS).

Ocular effects

Orthostatic hypotension

Temperature regulation

Cardiovascular disease

Dementia: [US Boxed Warning]

Hepatic impairment

Renal impairment

Seizure disorder

Monitoring parameters:

How to administer Fluphenazine Decanoate?

Mechanism of action of Fluphenazine Decanoate:

International Brand Names of Fluphenazine:

Fluphenazine Brand Names in Pakistan:

Fluphenazine Injection 25 mg in Pakistan

Fluphenazine Injection 25 mg/ml in Pakistan

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