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Ziprasidone

Brands and Forms

  • Geodon
    • capsule: 20mg, 40mg, 60mg, 80mg
    • powder for intramuscular injection: 20mg/ml
  • Zeldox
    • capsule: 20mg, 40mg, 60mg, 80m

Uses of Ziprasidone

Ziprasidone cen be used in the treatment of Psychotic Disorders, Bipolar Disorder, Depressive Disorders, PTSD, OCD, and Tic Disorder.

Ziprasidone can also be used in the management of behavioral disturbances, such as agitation and impulsivity, that can occur in various conditions like Impulse-Control Disorders, Disruptive Behavior Disorders, and Borderline Personality Disorder.

Unlike most other Atypical Antipsychotic, Ziprasidone tends not to cause significant weight gain or metabolic side-effects (elevated glucose, lipids and cholesterol), and for this reason may be a preferred choice in certain cases.

How Ziprasidone Works

Ziprasidone is an Atypical Antipsychotic. It is an antagonist at the dopamine D2 receptor and the serotonin 1a, 1d, 2a and 2c receptors, and also has interactions with a myriad of other receptors.

Cautions when Using Ziprasidone

In elderly individuals with Dementia, use of antipsychotics has been associated with increased rates of sudden death. It is unclear whether the antipsychotic use is a cause, or simply a marker, of deteriorating health in these individuals.

Individuals with Parkinson disease or Lewy-Body Dementia may have increased sensitivity to Ziprasidone, which may manifest as confusion, obtundation, severe extrapyramidal symptoms, and neuroleptic malignant syndrome.

Ziprasidone can prolong the QTc interval more than some other antipsychotics, which in rare cases can lead to serious heart arrhythmias. Do not use if there is a history of heart arrhythmias, recent heart attack, uncompensated heart failure, if the person has abnormal blood potassium or magnesium levels, or if the person is taking other medications that can cause QTc prolongation (such as Pimozide, Thioridazine, certain antiarrhythmic agents, Moxifloxacin, Sparfloxacin).

Use with caution in people at risk for seizures or aspiration pneumonia.

Dosing of Ziprasidone

The usual therapeutic range of Ziprasidone is 40-200mg daily. Standard practice is to prescribe it in divided doses twice daily with food, but many individuals do well with a single daily dose taken at bedtime.

Low doses of this medication can cause agitation, restlessness or anxiety, which tend to be less pronounced at higher doses. Therefore, although the manufacturer recommends starting this medication at 40mg/day, 80 or 120mg/day may be better tolerated as a starting dose for many people.

It is recommended to wait 1-2 weeks at the starting dose for therapeutic effects to occur before increasing the dose further, which can be done in increments of 40-80mg/day every week.

The intramuscular form is used to treat acute agitation, mania and psychosis. It can be given 10mg every two hours as needed, or 20mg every four hours as needed, to a maximum of 40mg per day.

When wanting to stop Ziprasidone, the dose should be decreased gradually over a period of 6-8 weeks.

Onset of action

Symptoms of mania and psychosis can improve within 1 week of use, but full therapeutic effect may take several weeks. If there is no significant effect after 4-6 weeks, including a couple of weeks at doses above 120mg/day, then it may not work at all.

Acute agitation can improve after a single dose.

For other conditions, 4-6 weeks may be needed to see a therapeutic effect.

Kidney impairment

No dose adjustment required. Intramuscular form should be used with caution.

Liver impairment

No dose adjustment required.

Side-effects of Ziprasidone

Below is a list of most of the reported side-effects of Ziprasidone. Most of these side-effects occur in only a minority of individuals, and many also resolve with time while the medication is continued.

Cardiovascular: postural hypotension; hypertension; bradycardia; tachycardia; vasodilation; fainting; QTc prolongation.

Central Nervous System: extrapyramidal symptoms; somnolence; headache; dizziness; weakness; insomnia; hypesthesia; speech disorder; abnormal gait; slowed movements; memory difficulties; unsteadiness; confusion; delirium; dysarthria; hypotonia; incoordination; neuropathy; paresthesia; tremor; twitching; vertigo; serotonin syndrome (very rare); seizures (very rare).

Dermatologic: rash; fungal dermatitis; excessive sweating; allergic dermatitis; angioedema; orofacial edema; urticaria.

Ears, Eyes, Nose and Throat: vision abnormalities; rhinitis; pharyngitis.

Endocrine/Metabolic: elevated prolactin; breast pain, enlargement, or milk production in men and women; trouble conceiving; hyperthermia; weight gain; metabolic syndrome (insulin resistance, elevated blood sugars, hyperlipidemia and hypercholesterolemia);

Gastrointestinal: nausea; constipation; dyspepsia; diarrhea; dry mouth; vomiting; increased salivation; tongue swelling; loss of appetite; dysphagia; rectal hemorrhage; tooth disorder.

Genitourinary: dysmenorrhea; priapism; enuresis; urinary incontinence.

Musculoskeletal: muscle stiffness; muscle pains; neuroleptic malignant syndrome (rare).

Psychiatric: anxiety; agitation; depressed mood; obsessive-compulsive symptoms; psychosis (rare); mania (rare).

Respiratory: upper respiratory tract infection; increased cough; shortness of breath; aspiration pneumonia (due to esophageal dysmotility; rare).

Common side-effects of Ziprasidone

Somnolence, extrapyramidal symptoms, headache, dizziness, nausea, constipation.

Rare but serious side-effects of note of Ziprasidone

Ziprasidone overdose

Anxiety, extrapyramidal symptoms, sedation, slurred speech, somnolence, hypertension, tremor, QTc prolongation, neuroleptic malignant syndrome.

Ziprasidone, weight gain and metabolic syndrome

A small percentage of people taking Ziprasidone will gain about 7% of their total body weight within 8 weeks of starting the medication [ref, ref]. Metabolic side-effects, including elevated glucose and lipids can also occur, which in the long-term increase the risk for heart disease and vascular problem.

See here for further information on these side-effects, and how they can be managed.

Ziprasidone and pregnancy

Category C: some animal studies show adverse effects at very high doses, but no controlled human studies have been done; should only be used in pregnancy if clearly needed and if benefits outweigh potential risks.

Medical Monitoring for Ziprasidone

Perform an electrocardiogram prior to starting the medication, and then a couple of weeks after starting it and after every dose increase, in order to monitor for the development of QTc prolongation. Discontinue treatment in patients who have persistent QTc measurements of more than 500 msec.

Ensure that patients at risk of electrolyte disturbances have baseline and periodic serum potassium and magnesium measurements, as this can increase the risk of cardiac arrhythmias.

Monitoring for weight gain and a metabolic syndrome requires the following measures to be taken prior to starting the medication, then monthly for the first 3 months of use, and then every 3 months:

  • Body Mass Index (BMI)
  • waistline circumference at umbilicus
  • blood pressure
  • fasting blood glucose
  • fasting blood lipids and cholesterol

To monitor for elevated prolactin, prolactin levels should be measured prior to starting the medication, and then one month after starting it and after every dose increase.

Drug Interactions with Ziprasidone

  • Given the increased risk of cardiac arrhythmias, do not combine Ziprasidone with any of the following medications: Amiodarone, Arsenic Trioxide, Cisapride, Dofetilide, Dolasetron, Droperidol, Halofantrine, Levomethadyl, Mefloquine, Moxifloxacin, Pentamidine, Pimozide, Quinidine, Ranolazine, Sotalol, Sparfloxacin, Tacrolimus, Thioridazine.
  • Ziprasidone may enhance the effects of some antihypertensives.
  • Ziprasidone blood concentrations can be reduced by Carbamazepine.
  • Ziprasidone blood concentrations can be increased by Ketoconazole.