March 2018

Antipsychotic (AP) Deprescribing Algorithm

Why is patient taking an antipsychotic?

• Psychosis, aggression, agitation (behavioural and • Primary insomnia treated for any duration or Schizophrenia Intellectual disability
psychological symptoms of dementia - BPSD) secondary insomnia where underlying Schizo-affective disorder Developmental delay
treated ≥ 3 months (symptoms controlled, or no comorbidities are managed Bipolar disorder Obsessive-compulsive
response to therapy). Acute delirium disorder
Tourette’s syndrome Alcoholism

Recommend Deprescribing Tic disorders Cocaine abuse

Autism Parkinson’s disease
Less than 3 months psychosis
duration of psychosis in Adjunct for treatment of
Strong Recommendation (from Systematic Review and GRADE approach)
Stop AP dementia Major Depressive
Taper and stop AP (slowly in collaboration with patient and/or Good practice Disorder
caregiver; e.g. 25%-50% dose reduction every 1–2 weeks) recommendation

Continue AP
Monitor every 1-2 weeks for duration of tapering or consult psychiatrist if
Expected benefits: Adverse drug withdrawal events (closer monitoring for those considering deprescribing
May improve alertness, gait, reduce with more severe baseline symptoms):
falls, or extrapyramidal symptoms Psychosis, aggression, agitation, delusions, hallucinations
If insomnia relapses:
Consider
If BPSD relapses: Minimize use of substances that worsen insomnia
Consider: (e.g. caffeine, alcohol)
Non-drug approaches (e.g. music therapy, behavioural management strategies) Non-drug behavioural approaches (see reverse)
Restart AP drug: Alternate drugs
Restart AP at lowest dose possible if resurgence of BPSD with re-trial of deprescribing in 3 months Other medications have been used to manage
At least 2 attempts to stop should be made insomnia. Assessment of their safety and
effectiveness is beyond the scope of this
Alternate drugs: deprescribing algorithm. See AP deprescribing
Consider change to risperidone, olanzapine, or aripiprazole guideline for details.

© Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Contact deprescribing@bruyere.org or visit deprescribing.org for more information.

Bjerre LM, Farrell B, Hogel M, Graham L, Lemay G, McCarthy L, et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia
and insomnia: Evidence-based clinical practice guideline. Can Fam Physician 2018;64:17-27 (Eng), e1-e12 (Fr).
 March 2018
Antipsychotic (AP) Deprescribing Notes
Commonly Prescribed Antipsychotics Engaging patients and caregivers
Antipsychotic Form Why is patient taking
Strength an antipsychotic?
Patients and caregivers should understand:
Chlorpromazine T • The rationale for deprescribing (risk of side effects of continued AP use)
25, 50, 100 mg
IM, IV I25 mg/mL • Withdrawal symptoms, including BPSD symptom relapse, may occur
• Psychosis, aggression, agitation (behavioural and • They
• Primary insomnia treated forare part
any of the tapering
duration or plan, Schizophrenia
and can control tapering rate and Intellectual
duration disability
Haloperidol (Haldol®) T 0.5, 1, 2, 5, 10, 20 mg
psychological symptoms of dementia
L - BPSD) 2 mg/mL secondary insomnia where underlying Schizo-affective disorder Developmental delay
treated ≥ 3 months (symptomsIR,controlled,
IM, IV or no
5 mg/mL Tapering doses
comorbidities are managed Bipolar disorder Obsessive-compulsive
response to therapy). LA IM 50, 100 mg/mL disorder
• No evidence that one tapering approachAcute delirium
is better than another
Loxapine (Xylac®, Loxapac®) T 2.5, 5, 10, 25, 50 mg Alcoholism
L 25 mg/L • Consider: Tourette’s syndrome

Recommend Deprescribing
IM 25, 50 mg/mL • R
educe to 75%, 50%, 25% of original dose on
Tic disorders a weekly or bi-weekly Cocaine
basis abuse
and then stop; or
• Consider slower tapering and frequent monitoring in those with severe baseline BPSD
Parkinson’s disease
Aripiprazole (Abilify®) T 2, 5, 10, 15, 20, 30 mg Autism
• Tapering may not be needed if low dose for insomnia only psychosis
IM 300, 400 mg Less than 3 months
Clozapine (Clozaril®) T 25, 100 mg duration of psychosis in Adjunct for treatment of
Strong Recommendation (from Systematic Review and GRADE approach)
Stop
Sleep AP
management dementia Major Depressive
Taper and stop AP
Olanzapine (Zyprexa®) T 2.5, 5, 7.5, 10, 15, 20 mg
D (slowly in collaboration
5, 10, 15, with
20 mg patient and/or Good practice Disorder
Primary care: Institutional care:
IM 10mg per vial
caregiver; e.g. 25%-50% dose reduction every 1–2 weeks) 1. recommendation
Go to bed only when sleepy 1. Pull up curtains during the day to obtain
Paliperidone (Invega®) ER T 3, 6, 9 mg 2. Do not use your bed or bedroom for bright light exposure
PR IM 50mg/0.5mL, 75mg/0.75mL,
100mg/1mL, 150mg/1.5mL
anything but sleep (or intimacy) 2. Keep alarm noises to a minimum
Continue AP
Monitor every 1-2 weeks for duration of tapering
Quetiapine (Seroquel®) IR T 25, 100, 200, 300 mg
3. If you do not fall asleep within about 20-30
min at the beginning of the night or after
3. Increase daytime activity and discourage
or consult psychiatrist if
daytime sleeping
Expected benefits: ER T 50, 150,
Adverse 200,withdrawal
drug 300, 400 mgevents (closer monitoring for those
an awakening, exit the bedroom 4. Reduce number of napsdeprescribing
considering (no more than
Risperidone (Risperdal®) T with0.25,
more0.5,severe
1, 2, 3,baseline
4 mg symptoms): 4. If you do not fall asleep within 20-30 min 30 mins and no naps after 2pm)
May improve alertness, gait, reduce
S 1 mg/mL on returning to bed, repeat #3 5. Offer warm decaf drink, warm milk at night
falls, or extrapyramidal symptoms
D Psychosis,
0.5, 1, 2, 3, 4aggression,
mg agitation, delusions, hallucinations
5. Use your alarm to awaken at the same 6. Restrict food, caffeine, smoking before
PR IM 12.5, 25, 37.5, 50 mg time every morning If insomnia relapses:bedtime
6. Do not nap 7. Have the resident toilet before going to bed
IM = intramuscular, IV = intravenous, L = liquid, S = suppository, SL = sublingual, Consider
7. Avoid caffeine after noon 8. Encourage regular bedtime and rising times
T=If tablet,
BPSD relapses:
D = disintegrating tablet, ER = extended release, IR = immediate release, 8. Avoid exercise, nicotine, alcohol, andMinimize
big use of
9. substances
Avoid wakingthat worsen
at night insomnia
to provide direct care
LA = long-acting, PR = prolonged release meals within 2 hrs of bedtime (e.g. caffeine, alcohol)
10. Offer backrub, gentle massage
Consider:
Non-drug approaches (e.g. music therapy, behavioural management strategies) Non-drug behavioural approaches (see reverse)
Antipsychotic side effects BPSD management
Alternate drugs
Restart AP drug:
• APsRestart AP atwith
associated lowest dose risk
increased possible
of: if resurgence of BPSD with re-trial of deprescribing in 3 interventions
• Consider months Other
such as: relaxation, medications
social have(music
contact, sensory beenorused to manage
aroma-therapy),
• Metabolic disturbances, weight gain,
At least 2 attempts to stop should be madedry mouth, dizziness structured activities and behavioural insomnia.
therapy Assessment of their safety and
• Somnolence, drowsiness, injury or falls, hip fractures, EPS, abnormal gait, • Address physical and other disease factors: e.g. pain, infection,
effectiveness is beyond constipation,
the scope depression
of this
Alternate
urinarydrugs:
tract infections, cardiovascular adverse events, death • Consider environment: e.g. light, noisedeprescribing algorithm. See AP deprescribing
Consider change to risperidone, olanzapine, or aripiprazole • Review medications that might be worsening symptoms
guideline for details.
• Risk factors: higher dose, older age, Parkinsons’, Lewy Body Dementia

© Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Contact deprescribing@bruyere.org or visit deprescribing.org for more information.

Bjerre LM, Farrell B, Hogel M, Graham L, Lemay G, McCarthy L, et al. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia
and insomnia: Evidence-based clinical practice guideline. Can Fam Physician 2018;64:17-27 (Eng), e1-e12 (Fr).