Data from FDA - Curated by EPG Health - Last updated 20 December 2016

Indication(s)

INDICATIONS AND USAGE For the management of manifestations of psychotic disorders.

For the treatment of schizophrenia.

To control nausea and vomiting.

For relief of restlessness and apprehension before surgery.

For acute intermittent porphyria.

As an adjunct in the treatment of tetanus.

To control the manifestations of the manic type of manic-depressive illness.

For relief of intractable hiccups.

For the treatment of severe behavioral problems in children (1 to 12 years of age) marked by combativeness and/or explosive hyperexcitable behavior (out of proportion to immediate provocations), and in the short-term treatment of hyperactive children who show excessive motor activity with accompanying conduct disorders consisting of some or all of the following symptoms: impulsivity, difficulty sustaining attention, aggressivity, mood lability and poor frustration tolerance.

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Advisory information

contraindications
CONTRAINDICATIONS Do not use in patients with known hypersensitivity to phenothiazines. Do not use in comatose states or in the presence of large amounts of central nervous system depressants (alcohol, barbiturates, narcotics, etc.).
Special warnings and precautions

PRECAUTIONS Leukopenia, Neutropenia and Agranulocytosis In clinical trial and postmarketing experience, events of leukopenia/neutropenia and agranulocytosis have been reported temporally related to antipsychotic agents.

Possible risk factors for leukopenia/neutropenia include preexisting low white blood cell count (WBC) and history of drug induced leukopenia/neutropenia.

Patients with a preexisting low WBC or a history of drug induced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy and should discontinue chlorpromazine hydrochloride tablets USP at the first sign of a decline in WBC in the absence of other causative factors.

Patients with neutropenia should be carefully monitored for fever or other symptoms or signs of infection and treated promptly if such symptoms or signs occur.

Patients with severe neutropenia (absolute neutrophil count <1000/ mm3) should discontinue chlorpromazine hydrochloride tablets

USP and have their WBC followed until recovery.

General Given the likelihood that some patients exposed chronically to antipsychotics will develop tardive dyskinesia, it is advised that all patients in whom chronic use is contemplated be given, if possible, full information about this risk.

The decision to inform patients and/or their guardians must obviously take into account the clinical circumstances and the competency of the patient to understand the information provided.

Chlorpromazine should be administered cautiously to persons with cardiovascular, liver or renal disease.

There is evidence that patients with a history of hepatic encephalopathy due to cirrhosis have increased sensitivity to the CNS effects of chlorpromazine (i.e., impaired cerebration and abnormal slowing of the EEG).

Because of its CNS depressant effect, chlorpromazine should be used with caution in patients with chronic respiratory disorders such as severe asthma, emphysema and acute respiratory infections, particularly in children (1 to 12 years of age).

Because chlorpromazine can suppress the cough reflex, aspiration of vomitus is possible.

Chlorpromazine prolongs and intensifies the action of CNS depressants such as anesthetics, barbiturates and narcotics.

When chlorpromazine is administered concomitantly, about 1/4 to 1/2 the usual dosage of such agents is required.

When chlorpromazine is not being administered to reduce requirements of CNS depressants, it is best to stop such depressants before starting chlorpromazine treatment.

These agents may subsequently be reinstated at low doses and increased as needed.

Note:

Chlorpromazine does not intensify the anti-convulsant action of barbiturates.

Therefore, dosage of anticonvulsants, including barbiturates, should not be reduced if chlorpromazine is started.

Instead, start chlorpromazine at low doses and increase as needed.

Use with caution in persons who will be exposed to extreme heat, organophosphorus insecticides, and in persons receiving atropine or related drugs.

Antipsychotic drugs elevate prolactin levels; the elevation persists during chronic administration.

Tissue culture experiments indicate that approximately one-third of human breast cancers are prolactin-dependent in_vitro, a factor of potential importance if the prescribing of these drugs is contemplated in a patient with a previously detected breast cancer.

Although disturbances such as galactorrhea, amenorrhea, gynecomastia and impotence have been reported, the clinical significance of elevated serum prolactin levels is unknown for most patients.

An increase in mammary neoplasms has been found in rodents after chronic administration of antipsychotic drugs.

Neither clinical nor epidemiologic studies conducted to date, however, have shown an association between chronic administration of these drugs and mammary tumorigenesis; the available evidence is considered too limited to be conclusive at this time.

Chromosomal aberrations in spermatocytes and abnormal sperm have been demonstrated in rodents treated with certain neuroleptics.

As with all drugs which exert an anticholinergic effect, and/or cause mydriasis, chlorpromazine should be used with caution in patients with glaucoma.

Chlorpromazine diminishes the effect of oral anticoagulants.

Phenothiazines can produce alpha-adrenergic blockade.

Chlorpromazine may lower the convulsive threshold; dosage adjustments of anticonvulsants may be necessary.

Potentiation of anticonvulsant effects does not occur.

However, it has been reported that chlorpromazine may interfere with the metabolism of phenytoin and thus precipitate phenytoin toxicity.

Concomitant administration with propranolol results in increased plasma levels of both drugs.

Thiazide diuretics may accentuate the orthostatic hypotension that may occur with phenothiazines.

The presence of phenothiazines may produce false-positive phenylketonuria (PKU) test results.

Drugs which lower the seizure threshold, including phenothiazine derivatives, should not be used with metrizamide.

As with other phenothiazine derivatives, chlorpromazine should be discontinued at least 48 hours before myelography, should not be resumed for at least 24 hours postprocedure, and should not be used for the control of nausea and vomiting occurring either prior to myelography or postprocedure with metrizamide.

Long-Term Therapy To lessen the likelihood of adverse reactions related to cumulative drug effect, patients with a history of long-term therapy with chlorpromazine and/or other antipsychotics should be evaluated periodically to decide whether the maintenance dosage could be lowered or drug therapy discontinued.

Antiemetic Effect The antiemetic action of chlorpromazine may mask the signs and symptoms of overdosage of other drugs and may obscure the diagnosis and treatment of other conditions such as intestinal obstruction, brain tumor and Reye 's syndrome.

(See WARNINGS.

) When chlorpromazine is used with cancer chemotherapeutic drugs, vomiting as a sign of the toxicity of these agents may be obscured by the antiemetic effect of chlorpromazine.

Abrupt Withdrawal Like other phenothiazines, chlorpromazine is not known to cause psychic dependence and does not produce tolerance or addiction.

There may be, however, following abrupt withdrawal of high-dose therapy, some symptoms resembling those of physical dependence such as gastritis, nausea and vomiting, dizziness and tremulousness.

These symptoms can usually be avoided or reduced by gradual reduction of the dosage or by continuing concomitant anti-parkinsonism agents for several weeks after chlorpromazine is withdrawn.

Adverse reactions

ADVERSE REACTIONS Note:

Some adverse effects of chlorpromazine may be more likely to occur, or occur with greater intensity, in patients with special medical problems; e.g., patients with mitral insufficiency or pheochromocytoma have experienced severe hypotension following recommended doses.

Drowsiness Usually mild to moderate may occur, particularly during the first or second week, after which it generally disappears.

If troublesome, dosage may be lowered.

Jaundice Overall incidence has been low, regardless of indication or dosage.

Most investigators conclude it is a sensitivity reaction.

Most cases occur between the second and fourth weeks of therapy.

The clinical picture resembles infectious hepatitis, with laboratory features of obstructive jaundice, rather than those of parenchymal damage.

It is usually promptly reversible on withdrawal of the medication; however, chronic jaundice has been reported.

There is no conclusive evidence that preexisting liver disease makes patients more susceptible to jaundice.

Alcoholics with cirrhosis have been successfully treated with chlorpromazine without complications.

Nevertheless, the medication should be used cautiously in patients with liver disease.

Patients who have experienced jaundice with a phenothiazine should not, if possible, be reexposed to chlorpromazine or other phenothiazines.

If fever with grippe-like symptoms occurs, appropriate liver studies should be conducted.

If tests indicate an abnormality, stop treatment.

Liver function tests in jaundice induced by the drug may mimic extrahepatic obstruction; withhold exploratory laparotomy until extrahepatic obstruction is confirmed.

Hematologic Disorders Including agranulocytosis, eosinophilia, leukopenia, hemolytic anemia, aplastic anemia, thrombocytopenic purpura and pancytopenia have been reported.

Agranulocytosis Warn patients to report the sudden appearance of sore throat or other signs of infection.

If white blood cell and differential counts indicate cellular depression, stop treatment and start antibiotic and other suitable therapy.

Most cases have occurred between the 4th and 10th weeks of therapy; patients should be watched closely during that period.

Moderate suppression of white blood cells is not an indication for stopping treatment unless accompanied by the symptoms described above.

Cardiovascular Hypotensive Effects Postural hypotension, simple tachycardia, momentary fainting and dizziness may occur rarely, after the first oral dose.

Usually recovery is spontaneous and symptoms disappear within 1/2 to 2 hours.

Occasionally, these effects may be more severe and prolonged, producing a shock-like condition.

To control hypotension, place patient in head-low position with legs raised.

If a vasoconstrictor is required, norepinephrine and phenylephrine are the most suitable.

Other pressor agents, including epinephrine, should not be used as they may cause a paradoxical further lowering of blood pressure.

EKG

Changes Particularly nonspecific, usually reversible Q and T wave distortions - have been observed in some patients receiving phenothiazine tranquilizers, including chlorpromazine.

Note:

Sudden death, apparently due to cardiac arrest, has been reported.

CNS Reactions Extrapyramidal Symptoms Neuromuscular reactions include dystonias, motor restlessness, pseudo-parkinsonism and tardive dyskinesia, and appear to be dose-related.

They are discussed in the following paragraphs: Dystonia Class effect: Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment.

Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue.

While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first generation antipsychotic drugs.

An elevated risk of acute dystonia is observed in males and younger age groups.

Motor Restlessness Symptoms may include agitation or jitteriness and sometimes insomnia.

These symptoms often disappear spontaneously.

At times, these symptoms may be similar to the original neurotic or psychotic symptoms.

Dosage should not be increased until these side effects have subsided.

If these symptoms become too troublesome, they can usually be controlled by a reduction of dosage or change of drug.

Treatment with anti-parkinsonian agents , benzodiazepines or propranolol may be helpful.

Pseudo-parkinsonism Symptoms may include: mask-like facies, drooling, tremors, pillrolling motion, cogwheel rigidity and shuffling gait.

In most cases, these symptoms are readily controlled when an anti-parkinsonism agent is administered concomitantly.

Anti-parkinsonism agents should be used only when required.

Generally, therapy of a few weeks to 2 or 3 months will suffice.

After this time patients should be evaluated to determine their need for continued treatment.

(Note:

Levodopa has not been found effective in antipsychotic-induced pseudo-parkinsonism.)

Occasionally, it is necessary to lower the dosage of chlorpromazine or to discontinue the drug.

Tardive Dyskinesia As with all antipsychotic agents, tardive dyskinesia may appear in some patients on long-term therapy or may appear after drug therapy has been discontinued.

The syndrome can also develop, although much less frequently, after relatively brief treatment periods at low doses.

This syndrome appears in all age groups.

Although its prevalence appears to be highest among elderly patients, especially elderly women, it is impossible to rely upon prevalence estimates to predict at the inception of antipsychotic treatment which patients are likely to develop the syndrome.

The symptoms are persistent and in some patients appear to be irreversible.

The syndrome is characterized by rhythmical involuntary movements of the tongue, face, mouth or jaw (e.g., protrusion of tongue, puffing of cheeks, puckering of mouth, chewing movements).

Sometimes these may be accompanied by involuntary movements of extremities.

In rare instances, these involuntary movements of the extremities are the only manifestations of tardive dyskinesia.

A variant of tardive dyskinesia, tardive dystonia, has also been described.

There is no known effective treatment for tardive dyskinesia; anti-parkinsonism agents do not alleviate the symptoms of this syndrome.

If clinically feasible, it is suggested that all antipsychotic agents be discontinued if these symptoms appear.

Should it be necessary to reinstitute treatment, or increase the dosage of the agent, or switch to a different antipsychotic agent, the syndrome may be masked.

It has been reported that fine vermicular movements of the tongue may be an early sign of the syndrome and if the medication is stopped at that time, the syndrome may not develop.

Adverse Behavioral Effects

Psychotic symptoms and catatonic-like states have been reported rarely.

Other CNS Effects Neuroleptic Malignant Syndrome (NMS) has been reported in association with antipsychotic drugs.

(See WARNINGS.

) Cerebral edema has been reported.

Convulsive seizures (petit mal and grand mal) have been reported, particularly in patients with EEG abnormalities or history of such disorders.

Abnormality of the cerebrospinal fluid proteins has also been reported.

Allergic Reactions of a mild urticarial type or photosensitivity are seen.

Avoid undue exposure to sun.

More severe reactions, including exfoliative dermatitis, have been reported occasionally.

Contact dermatitis has been reported in nursing personnel; accordingly, the use of rubber gloves when administering chlorpromazine liquid or injectable is recommended.

In addition, asthma, laryngeal edema, angioneurotic edema and anaphylactoid reactions have been reported.

Endocrine Disorders Lactation and moderate breast engorgement may occur in females on large doses.

If persistent, lower dosage or withdraw drug.

False-positive pregnancy tests have been reported, but are less likely to occur when a serum test is used.

Amenorrhea and gynecomastia have also been reported.

Hyperglycemia, hypoglycemia and glycosuria have been reported.

Autonomic Reactions Occasional dry mouth; nasal congestion; nausea; obstipation; constipation; adynamic ileus; urinary retention, priapism, miosis and mydriasis, atonic colon, ejaculatory disorders/impotence.

Special Consideration in Long-Term Therapy Skin pigmentation and ocular changes have occurred in some patients taking substantial doses of chlorpromazine for prolonged periods.

Skin Pigmentation Rare instances of skin pigmentation have been observed in hospitalized mental patients, primarily females who have received the drug usually for 3 years or more in dosages ranging from 500 mg to 1500 mg daily.

The pigmentary changes, restricted to exposed areas of the body, range from an almost imperceptible darkening of the skin to a slate gray color, sometimes with a violet hue.

Histological examination reveals a pigment, chiefly in the dermis, which is probably a melanin-like complex.

The pigmentation may fade following discontinuance of the drug.

Ocular Changes Ocular changes have occurred more frequently than skin pigmentation and have been observed both in pigmented and nonpigmented patients receiving chlorpromazine, usually for 2 years or more in dosages of 300 mg daily and higher.

Eye changes are characterized by deposition of fine particulate matter in the lens and cornea.

In more advanced cases, star-shaped opacities have also been observed in the anterior portion of the lens.

The nature of the eye deposits has not yet been determined.

A small number of patients with more severe ocular changes have had some visual impairment.

In addition to these corneal and lenticular changes, epithelial keratopathy and pigmentary retinopathy have been reported.

Reports suggest that the eye lesions may regress after withdrawal of the drug.

Since the occurrence of eye changes seems to be related to dosage levels and/or duration of therapy, it is suggested that long-term patients on moderate to high dosage levels have periodic ocular examinations.

Etiology The etiology of both of these reactions is not clear, but exposure to light, along with dosage/duration of therapy, appears to be the most significant factor.

If either of these reactions is observed, the physician should weigh the benefits of continued therapy against the possible risks and, on the merits of the individual case, determine whether or not to continue present therapy, lower the dosage, or withdraw the drug.

Other Adverse Reactions Mild fever may occur after large I.M. doses.

Hyperpyrexia has been reported.

Increases in appetite and weight sometimes occur.

Peripheral edema and a systemic lupus erythematosus-like syndrome have been reported.

Note:

There have been occasional reports of sudden death in patients receiving phenothiazines.

In some cases, the cause appeared to be cardiac arrest or asphyxia due to failure of the cough reflex..

Usage information

Dosing and administration

DOSAGE AND ADMINISTRATION Adults Adjust dosage to individual and the severity of his condition, recognizing that the milligram for milligram potency relationship among all dosage forms has not been precisely established clinically.

It is important to increase dosage until symptoms are controlled.

Dosage should be increased more gradually in debilitated or emaciated patients.

In continued therapy, gradually reduce dosage to the lowest effective maintenance level, after symptoms have been controlled for a reasonable period.

The 100 mg and 200 mg tablets are for use in severe neuropsychiatric conditions.

Elderly Patients In general, dosages in the lower range are sufficient for most elderly patients.

Since they appear to be more susceptible to hypotension and neuromuscular reactions, such patients should be observed closely.

Dosage should be tailored to the individual, response carefully monitored, and dosage adjusted accordingly.

Dosage should be increased more gradually in elderly patients.

Psychotic Disorders Increase dosage gradually until symptoms are controlled.

Maximum improvement may not be seen for weeks or even months.

Continue optimum dosage for 2 weeks; then gradually reduce dosage to the lowest effective maintenance level.

Daily dosage of 200 mg is not unusual.

Some patients require higher dosages (e.g., 800 mg daily is not uncommon in discharged mental patients).

Hospitalized Patients Acute Schizophrenic or Manic States It is recommended that initial treatment be with chlorpromazine injection until patient is controlled.

Usually patient becomes quiet and cooperative within 24 to 48 hours and oral doses may be substituted and increased until the patient is calm.

500 mg a day is generally sufficient.

While gradual increases to 2000 mg a day or more may be necessary, there is usually little therapeutic gain to be achieved by exceeding 1000 mg a day for extended periods.

In general, dosage levels should be lower in the elderly, the emaciated and the debilitated.

Less Acutely Disturbed 25 mg t.i.d. Increased gradually until effective dose is reached - usually 400 mg daily.

Outpatients 10 mg t.i.d. or q.i.d., or 25 mg b.i.d. or t.i.d.

More Severe Cases 25 mg t.i.d.

After 1 or 2 days, daily dosage may be increased by 20 to 50 mg at semi-weekly intervals until patient becomes calm and cooperative.

Prompt Control of Severe Symptoms Initial treatment should be with intramuscular chlorpromazine.

Subsequent doses should be oral, 25 to 50 mg t.i.d. Nausea and Vomiting 10 to 25 mg q4 to 6h, p.r.n., increased, if necessary.

Presurgical Apprehension 25 to 50 mg, 2 to 3 hours before the operation.

Intractable Hiccups 25 to 50 mg t.i.d. or q.i.d.

If symptoms persist for 2 to 3 days, parenteral therapy is indicated.

Acute Intermittent Porphyria 25 to 50 mg t.i.d. or q.i.d. Can usually be discontinued after several weeks, but maintenance therapy may be necessary for some patients.

Pediatric Patients (6 months to 12 years of age) Chlorpromazine should generally not be used in pediatric patients under 6 months of age except where potentially lifesaving.

It should not be used in conditions for which specific pediatric dosages have not been established.

Severe Behavioral Problems Outpatients Select route of administration according to severity of patient 's condition and increase dosage gradually as required.

Oral: 1/4 mg/lb body weight q4 to 6h, p.r.n. (e.g., for 40 lb child - 10 mg q4 to 6h).

Hospitalized Patients As with outpatients, start with low doses and increase dosage gradually.

In severe behavior disorders higher dosages (50 to 100 mg daily and in older children, 200 mg daily or more) may be necessary.

There is little evidence that behavior improvement in severely disturbed mentally retarded patients is further enhanced by doses beyond 500 mg per day.

Nausea and Vomiting Dosage and frequency of administration should be adjusted according to the severity of the symptoms and response of the patient.

The duration of activity following intramuscular administration may last up to 12 hours.

Subsequent doses may be given by the same route if necessary.

Oral: 1/4 mg/lb body weight (e.g., 40 lb child - 10 mg q4 to 6h).

Presurgical Apprehension 1/4 mg/lb body weight orally 2 to 3 hours before operation.

Pregnancy and lactation
Nursing Mothers There is evidence that chlorpromazine is excreted in the breast milk of nursing mothers. Because of the potential for serious adverse reactions in nursing infants from chlorpromazine, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

More information

Category Value
Authorisation number ANDA080439
Orphan designation No
Product NDC 0615-1546,0615-1547,0615-1548
Date Last Revised 26-02-2013
Type HUMAN PRESCRIPTION DRUG
RXCUI 991336
Storage and handling Store at 20°-25°C (68°-77°F) (see USP Controlled Room Temperature). Protect from moisture. Dispense in a tight, light-resistant container.
Marketing authorisation holder NCS HealthCare of KY, Inc dba Vangard Labs
Warnings

WARNING Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.

Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients.

Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5 %, compared to a rate of about 2.6 % in the placebo group.

Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature.

Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality.

The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear.

Chlorpromazine hydrochloride is not approved for the treatment of patients with dementia-related psychosis (see WARNINGS).