SEROQUEL®
(quetiapine fumarate) Tablets
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 (eg, heart failure, sudden death) or infectious (eg, 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. SEROQUEL (quetiapine) is not approved for the treatment of patients with dementia-related psychosis [see WARNINGS AND PRECAUTIONS].
SUICIDALITY AND ANTIDEPRESSANT DRUGS
Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of SEROQUEL or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 and older. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. SEROQUEL is not approved for use in patients under ten years of age [see WARNINGS AND PRECAUTIONS].
SEROQUEL® (quetiapine fumarate) is a psychotropic agent belonging to a chemical class, the dibenzothiazepine derivatives. The chemical designation is 2-[2-(4-dibenzo [b,f][1,4]thiazepin-11-yl-1-piperazinyl)ethoxy]-ethanol fumarate (2:1) (salt). It is present in tablets as the fumarate salt. All doses and tablet strengths are expressed as milligrams of base, not as fumarate salt. Its molecular formula is C42H50N6O4S2•C4H4O4 and it has a molecular weight of 883.11 (fumarate salt). The structural formula is:
 |
Quetiapine fumarate is a white to off-white crystalline powder which is moderately soluble in water. SEROQUEL is supplied for oral administration as 25 mg (round, peach), 50 mg (round, white), 100 mg (round, yellow), 200 mg (round, white), 300 mg (capsule-shaped, white), and 400 mg (capsule-shaped, yellow) tablets.
Inactive ingredients are povidone, dibasic dicalcium phosphate dihydrate, microcrystalline cellulose, sodium starch glycolate, lactose monohydrate, magnesium stearate, hypromellose, polyethylene glycol and titanium dioxide.
The 25 mg tablets contain red ferric oxide and yellow ferric oxide and the 100 mg and 400 mg tablets contain only yellow ferric oxide.
Last updated on RxList: 12/29/2009
SEROQUEL is indicated for the treatment of schizophrenia. The efficacy of SEROQUEL in schizophrenia was established in three 6-week trials in adults and one 6-week trial in adolescents (13-17 years). The effectiveness of SEROQUEL for the maintenance treatment of schizophrenia has not been systematically evaluated in controlled clinical trials. [see Clinical Studies].
SEROQUEL is indicated for the acute treatment of manic episodes associated with bipolar I disorder, both as monotherapy and as an adjunct to lithium or divalproex. Efficacy was established in two 12-week monotherapy trials in adults, in one 3-week adjunctive trial in adults, and in one 3-week monotherapy trial in pediatric patients (10-17 years). [see Clinical Studies].
SEROQUEL is indicated as monotherapy for the acute treatment of depressive episodes associated with bipolar disorder. Efficacy was established in two 8-week monotherapy trials in adult patients with bipolar I and bipolar II disorder [see Clinical Studies].
SEROQUEL is indicated for the maintenance treatment of bipolar I disorder, as an adjunct to lithium or divalproex. Efficacy was established in two maintenance trials in adults. The effectiveness of SEROQUEL as monotherapy for the maintenance treatment of bipolar disorder has not been systematically evaluated in controlled clinical trials. [see Clinical Studies].
Pediatric schizophrenia and bipolar I disorder are serious mental disorders, however, diagnosis can be challenging. For pediatric schizophrenia, symptom profiles can be variable, and for bipolar I disorder, patients may have variable patterns of periodicity of manic or mixed symptoms. It is recommended that medication therapy for pediatric schizophrenia and bipolar 1 disorder be initiated only after a thorough diagnostic evaluation has been performed and careful consideration given to the risks associated with medication treatment. Medication treatment for both pediatric schizophrenia and bipolar I disorder is indicated as part of a total treatment program that often includes psychological, educational and social interventions.
SEROQUEL can be taken with or without food
Dose Selection—SEROQUEL should generally be administered with an initial dose of 25 mg twice daily, with increases in total daily dose of 25 mg - 50 mg divided in two or three doses on the second and third day, as tolerated, to a total dose range of 300 mg to 400 mg daily by the fourth day. Further dosage adjustments, if indicated, should generally occur at intervals of not less than 2 days, as steady-state for SEROQUEL would not be achieved for approximately 1-2 days in the typical patient. When dosage adjustments are necessary, dose increments/ decrements of 25 mg - 50 mg divided twice daily are recommended. Most efficacy data with SEROQUEL were obtained using three times daily dosing regimens, but in one controlled trial 225 mg given twice per day was also effective.
Efficacy in schizophrenia was demonstrated in a dose range of 150 mg/day to 750 mg/day in the clinical trials supporting the effectiveness of SEROQUEL. In a dose response study, doses above 300 mg/day were not demonstrated to be more efficacious than the 300 mg/day dose. In other studies, however, doses in the range of 400 mg/day - 500 mg/day appeared to be needed. The safety of doses above 800 mg/day has not been evaluated in clinical trials.
Maintenance Treatment—The effectiveness of SEROQUEL for longer than 6 weeks has not been evaluated in controlled clinical trials. While there is no body of evidence available to answer the question of how long the patient treated with SEROQUEL should be maintained, it is generally recommended that responding patients be continued beyond the acute response, but at the lowest dose needed to maintain remission. Patients should be periodically reassessed to determine the need for maintenance treatment.
Dose Selection—SEROQUEL should be administered twice daily. However, based on response and tolerability SEROQUEL may be administered three times daily where needed.
The total daily dose for the initial five days of therapy is 50 mg (Day 1), 100 mg (Day 2), 200 mg (Day 3), 300 mg (Day 4) and 400 mg (Day 5). After day 5, the dose should be adjusted within the recommended dose range of 400 mg/day to 800 mg/day based on response and tolerability. Dosage adjustments should be in increments of no greater than 100 mg/day. Efficacy was demonstrated with SEROQUEL at both 400 mg and 800 mg; however, no additional benefit was seen in the 800 mg group.
Maintenance Treatment—The effectiveness of SEROQUEL for longer than 6 weeks has not been evaluated in controlled clinical trials. While there is no body of evidence available to answer the question of how long the patient treated with SEROQUEL should be maintained, it is generally recommended that responding patients be continued beyond the acute response, but at the lowest dose needed to maintain remission. Patients should be periodically reassessed to determine the need for maintenance treatment.
Dose Selection—When used as monotherapy or adjunct therapy (with lithium or divalproex),
SEROQUEL should be initiated in twice daily doses totaling 100 mg/day on Day 1, increased to 400 mg/day on Day 4 in increments of up to 100 mg/day in twice daily divided doses. Further dosage adjustments up to 800 mg/day by Day 6 should be in increments of no greater than 200 mg/day. Data indicate that the majority of patients responded between 400 mg/day to 800 mg/day. The safety of doses above 800 mg/day has not been evaluated in clinical trials.
Dose Selection—SEROQUEL should be administered once daily at bedtime to reach 300 mg/day by Day 4.
Recommended Dosing Schedule
| Day | Day 1 | Day 2 | Day 3 | Day 4 |
| SEROQUEL | 50 mg | 100 mg | 200 mg | 300 mg |
In these clinical trials supporting effectiveness, the dosing schedule was 50 mg, 100 mg, 200 mg and 300 mg/day for Days 1-4 respectively. Patients receiving 600 mg increased to 400 mg on Day 5 and 600 mg on Day 8 (Week 1). Antidepressant efficacy was demonstrated with SEROQUEL at both 300 mg and 600 mg; however, no additional benefit was seen in the 600 mg group.
Maintenance of efficacy in bipolar I disorder was demonstrated with SEROQUEL (administered twice daily totaling 400 to 800 mg per day) as adjunct therapy to lithium or divalproex. Generally, in the maintenance phase, patients continued on the same dose on which they were stabilized during the stabilization phase [see Clinical Studies].
Dose Selection—SEROQUEL should be administered twice daily. However, based on response and tolerability SEROQUEL may be administered three times daily where needed.
The total daily dose for the initial five days of therapy is 50 mg (Day 1), 100 mg (Day 2), 200 mg (Day 3), 300 mg (Day 4) and 400 mg (Day 5). After day 5, the dose should be adjusted within the recommended dose range of 400 to 600 mg/day based on response and tolerability. Dosage adjustments should be in increments of no greater than 100 mg/day. Efficacy was demonstrated with SEROQUEL at both 400 mg and 600 mg; however, no additional benefit was seen in the 600 mg group.
The effectiveness of SEROQUEL for longer than 3 weeks has not been evaluated in controlled clinical trials of children and adolescents. While there is no body of evidence available to answer the question of how long the patient treated with SEROQUEL should be maintained, it is generally recommended that responding patients be continued beyond the acute response, but at the lowest dose needed to maintain remission. Patients should be periodically reassessed to determine the need for maintenance treatment.
Consideration should be given to a slower rate of dose titration and a lower target dose in the elderly and in patients who are debilitated or who have a predisposition to hypotensive reactions [see CLINICAL PHARMACOLOGY]. When indicated, dose escalation should be performed with caution in these patients.
Patients with hepatic impairment should be started on 25 mg/day. The dose should be increased daily in increments of 25 mg/day - 50 mg/day to an effective dose, depending on the clinical response and tolerability of the patient.
Although there are no data to specifically address reinitiation of treatment, it is recommended that when restarting patients who have had an interval of less than one week off SEROQUEL, titration of SEROQUEL is not required and the maintenance dose may be reinitiated. When restarting therapy of patients who have been off SEROQUEL for more than one week, the initial titration schedule should be followed.
There are no systematically collected data to specifically address switching patients with schizophrenia from antipsychotics to SEROQUEL, or concerning concomitant administration with antipsychotics. While immediate discontinuation of the previous antipsychotic treatment may be acceptable for some patients with schizophrenia, more gradual discontinuation may be most appropriate for others. In all cases, the period of overlapping antipsychotic administration should be minimized. When switching patients with schizophrenia from depot antipsychotics, if medically appropriate, initiate SEROQUEL therapy in place of the next scheduled injection. The need for continuing existing EPS medication should be re-evaluated periodically.
25 mg tablets, 50 mg tablets, 100 mg tablets, 200 mg tablets, 300 mg tablets, 400 mg tablets
25 mg Tablets (NDC 0310-0275) peach, round, biconvex, film coated tablets, identified with ‘SEROQUEL' and ‘25' on one side and plain on the other side, are supplied in bottles of 100 tablets and 1000 tablets, and hospital unit dose packages of 100 tablets.
50 mg Tablets (NDC 0310-0278) white, round, biconvex, film coated tablets, identified with ‘SEROQUEL' and ‘50' on one side and plain on the other side, are supplied in bottles of 100 tablets and 1000 tablets, and hospital unit dose packages of 100 tablets.
100 mg Tablets (NDC 0310-0271) yellow, round, biconvex film coated tablets, identified with ‘SEROQUEL' and ‘100' on one side and plain on the other side, are supplied in bottles of 100 tablets, and hospital unit dose packages of 100 tablets.
200 mg Tablets (NDC 0310-0272) white, round, biconvex, film coated tablets, identified with ‘SEROQUEL' and ‘200' on one side and plain on the other side, are supplied in bottles of 100 tablets, and hospital unit dose packages of 100 tablets.
300 mg Tablets (NDC 0310-0274) white, capsule-shaped, biconvex, film coated tablets, intagliated with ‘SEROQUEL' on one side and ‘300' on the other side, are supplied in bottles of 60 tablets, and hospital unit dose packages of 100 tablets.
400 mg Tablets (NDC 0310-0279) yellow, capsule-shaped, biconvex, film coated tablets, intagliated with ‘SEROQUEL' on one side and ‘400' on the other side, are supplied in bottles of 100 tablets, and hospital unit dose packages of 100 tablets.
Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [See USP].
Distributed by: AstraZeneca Pharmaceuticals LP. Wilmington, DE 19850. Made in U.S.A. Rev: 12/09.
Last updated on RxList: 12/29/2009
Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
The information below is derived from a clinical trial database for SEROQUEL consisting of over 4300 patients. This database includes 698 patients exposed to SEROQUEL for the treatment of bipolar depression, 405 patients exposed to SEROQUEL for the treatment of acute bipolar mania (monotherapy and adjunct therapy), 646 patients exposed to SEROQUEL for the maintenance treatment of bipolar I disorder as adjunct therapy, and approximately 2600 patients and/or normal subjects exposed to 1 or more doses of SEROQUEL for the treatment of schizophrenia.
Of these approximately 4300 subjects, approximately 4000 (2300 in schizophrenia, 405 in acute bipolar mania, 698 in bipolar depression, and 646 for the maintenance treatment of bipolar I disorder) were patients who participated in multiple dose effectiveness trials, and their experience corresponded to approximately 2400 patient-years. The conditions and duration of treatment with SEROQUEL varied greatly and included (in overlapping categories) open-label and double-blind phases of studies, inpatients and outpatients, fixed-dose and dose-titration studies, and short-term or longer-term exposure.
Adverse reactions were assessed by collecting adverse events, results of physical examinations, vital signs, weights, laboratory analyses, ECGs, and results of ophthalmologic examinations. Adverse reactions during exposure were obtained by general inquiry and recorded by clinical investigators using terminology of their own choosing. Consequently, it is not possible to provide a meaningful estimate of the proportion of individuals experiencing adverse reactions without first grouping similar types of reactions into a smaller number of standardized reaction categories.
In the tables and tabulations that follow, standard COSTART terminology has been used to classify reported adverse reactions for schizophrenia and bipolar mania. MedDRA terminology has been used to classify reported adverse reactions for bipolar depression.
The stated frequencies of adverse reactions represent the proportion of individuals who experienced, at least once, a treatment-emergent adverse reaction of the type listed. A reaction was considered treatment emergent if it occurred for the first time or worsened while receiving therapy following baseline evaluation.
Adverse Reactions Associated with Discontinuation of Treatment in Short-Term, Placebo-Controlled Trials:
Schizophrenia: Overall, there was little difference in the incidence of discontinuation due to adverse reactions (4% for SEROQUEL vs. 3% for placebo) in a pool of controlled trials. However, discontinuations due to somnolence (0.8% SEROQUEL vs. 0% placebo) and hypotension (0.4% SEROQUEL vs. 0% placebo) were considered to be drug related [see WARNINGS AND PRECAUTIONS].
Bipolar Disorder:
Mania: Overall, discontinuations due to adverse reactions were 5.7% for SEROQUEL vs. 5.1% for placebo in monotherapy and 3.6% for SEROQUEL vs. 5.9% for placebo in adjunct therapy.
Depression: Overall, discontinuations due to adverse reactions were 12.3% for SEROQUEL 300 mg vs. 19.0% for SEROQUEL 600 mg and 5.2% for placebo.
Commonly Observed Adverse Reactions in Short-Term, Placebo-Controlled Trials:
In the acute therapy of schizophrenia (up to 6 weeks) and bipolar mania (up to 12 weeks) trials, the most commonly observed adverse reactions associated with the use of SEROQUEL monotherapy (incidence of 5% or greater) and observed at a rate on SEROQUEL at least twice that of placebo were somnolence (18%), dizziness (11%), dry mouth (9%), constipation (8%), ALT increased (5%), weight gain (5%), and dyspepsia (5%).
Adverse Reactions Occurring at an Incidence of 1% or More Among SEROQUEL Treated Patients in Short-Term, Placebo-Controlled Trials:
The prescriber should be aware that the figures in the tables and tabulations cannot be used to predict the incidence of side effects in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical trials. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving different treatments, uses, and investigators. The cited figures, however, do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the side effect incidence in the population studied.
Table 7 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse reactions that occurred during acute therapy of schizophrenia (up to 6 weeks) and bipolar mania (up to 12 weeks) in 1% or more of patients treated with SEROQUEL (doses ranging from 75 to 800 mg/day) where the incidence in patients treated with SEROQUEL was greater than the incidence in placebo-treated patients.
Table 7: Treatment-Emergent Adverse Reaction Incidence in
3- to 12-Week Placebo-Controlled Clinical Trials for the Treatment of Schizophrenia
and Bipolar Mania (Monotherapy)1
| Body System/Preferred Term | SEROQUEL (n=719) |
PLACEBO (n=404) |
| Body as a Whole | ||
| Headache | 21% | 14% |
| Pain | 7% | 5% |
| Asthenia | 5% | 3% |
| Abdominal Pain | 4% | 1% |
| Back Pain | 3% | 1% |
| Fever | 2% | 1% |
| Cardiovascular | ||
| Tachycardia | 6% | 4% |
| Postural Hypotension | 4% | 1% |
| Digestive | ||
| Dry Mouth | 9% | 3% |
| Constipation | 8% | 3% |
| Vomiting | 6% | 5% |
| Dyspepsia | 5% | 1% |
| Gastroenteritis Gamma Glutamyl | 2% | 0% |
| Transpeptidase Increased | 1% | 0% |
| Metabolic and Nutritional | ||
| Weight Gain | 5% | 1% |
| ALT Increased | 5% | 1% |
| AST Increased | 3% | 1% |
| Nervous | ||
| Agitation | 20% | 17% |
| Somnolence | 18% | 8% |
| Dizziness | 11% | 5% |
| Anxiety | 4% | 3% |
| Respiratory | ||
| Pharyngitis | 4% | 3% |
| Rhinitis | 3% | 1% |
| Skin and Appendages | ||
| Rash | 4% | 2% |
| Special Senses | ||
| Amblyopia | 2% | 1% |
| 1 Reactions for which the SEROQUEL incidence was equal to or less than placebo are not listed in the table, but included the following: accidental injury, akathisia, chest pain, cough increased, depression, diarrhea, extra-pyramidal syndrome, hostility, hypertension, hypertonia, hypotension, increased appetite, infection, insomnia, leukopenia, malaise, nausea, nervousness, paresthesia, peripheral edema, sweating, tremor, and weight loss. | ||
In the acute adjunct therapy of bipolar mania (up to 3 weeks) studies, the most commonly observed adverse reactions associated with the use of SEROQUEL (incidence of 5% or greater) and observed at a rate on SEROQUEL at least twice that of placebo were somnolence (34%), dry mouth (19%), asthenia (10%), constipation (10%), abdominal pain (7%), postural hypotension (7%), pharyngitis (6%), and weight gain (6%).
Table 8 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse reactions that occurred during therapy (up to 3 weeks) of acute mania in 1% or more of patients treated with SEROQUEL (doses ranging from 100 to 800 mg/day) used as adjunct therapy to lithium and divalproex where the incidence in patients treated with SEROQUEL was greater than the incidence in placebo-treated patients.
Table 8: Treatment-Emergent Adverse Reaction Incidence in
3-Week Placebo-Controlled Clinical Trials for the Treatment of Bipolar Mania
(Adjunct Therapy)1
| Body System/Preferred Term | SEROQUEL (n=196) |
PLACEBO (n=203) |
| Body as a Whole | ||
| Headache | 17% | 13% |
| Asthenia | 10% | 4% |
| Abdominal Pain | 7% | 3% |
| Back Pain | 5% | 3% |
| Hormone Level Altered | 3% | 0% |
| Heaviness | 2% | 1% |
| Infection | 2% | 1% |
| Fever | 2% | 1% |
| Neck Rigidity | 1% | 0% |
| Cardiovascular | ||
| Postural Hypotension | 7% | 2% |
| Hypotension | 3% | 1% |
| Hypertension | 2% | 1% |
| Tachycardia | 2% | 1% |
| Hemorrhage | 1% | 0% |
| Digestive | ||
| Dry Mouth | 19% | 3% |
| Constipation | 10% | 5% |
| Dyspepsia | 4% | 3% |
| Increased Appetite | 2% | 1% |
| Flatulence | 2% | 0% |
| Gastrointestinal Disorder | 2% | 0% |
| Endocrine | ||
| Hypothyroidism | 2% | 1% |
| Hemic and Lymphatic | ||
| Lymphadenopathy | 1% | 0% |
| Metabolic and Nutritional | ||
| Weight Gain | 6% | 3% |
| Peripheral Edema | 4% | 2% |
| Musculoskeletal | ||
| Twitching | 4% | 0% |
| Joint Disorder | 1% | 0% |
| Nervous | ||
| Somnolence | 34% | 9% |
| Dizziness | 9% | 6% |
| Tremor | 8% | 7% |
| Agitation | 6% | 4% |
| Hypertonia | 4% | 3% |
| Depression | 3% | 2% |
| Speech Disorder | 3% | 1% |
| Incoordination | 2% | 1% |
| Thinking Abnormal | 2% | 0% |
| Anxiety | 2% | 0% |
| Ataxia | 2% | 0% |
| Respiratory | ||
| Pharyngitis | 6% | 3% |
| Rhinitis | 4% | 2% |
| Sinusitis | 2% | 1% |
| Skin and Appendages | ||
| Sweating | 2% | 1% |
| Special Senses | ||
| Amblyopia | 3% | 2% |
| Ear Disorder | 1% | 0% |
| Ear Pain | 1% | 0% |
| Urogenital | ||
| Urinary Tract Infection | 2% | 1% |
| Female Lactation | 1% | 0% |
| Impotence | 1% | 0% |
| Urinary Tract Disorder | 1% | 0% |
| 1 Reactions for which the SEROQUEL incidence was equal to or less than placebo are not listed in the table, but included the following: akathisia, diarrhea, insomnia, nausea, accidental injury, chest pain, face edema, flu syndrome, electrocardiogram abnormal, vomiting, gastritis, SGPT increased, weight loss, nervousness, pares-thesia, extrapyramidal syndrome, confusion, cough increased, rash and urinary incontinence. | ||
In bipolar depression studies (up to 8 weeks), the most commonly observed treatment emergent adverse reactions associated with the use of SEROQUEL (incidence of 5% or greater) and observed at a rate on SEROQUEL at least twice that of placebo were somnolence (57%) dry mouth (44%), dizziness (18%), and constipation (10%), and lethargy (5%).
Table 9 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse reactions that occurred during therapy (up to 8 weeks) of bipolar depression in 1% or more of patients treated with SEROQUEL (doses of 300 and 600 mg/day) where the incidence in patients treated with SEROQUEL was greater than the incidence in placebo-treated patients.
Table 9: Treatment-Emergent Adverse Reaction Incidence in
8-Week Placebo-Controlled Clinical Trials for the Treatment of Bipolar Depression1
| Body System/Preferred Term | SEROQUEL (n=698) |
PLACEBO (n=347 |
| Cardiac Disorders | ||
| Palpitations | 4% | 2% |
| Tachycardia | 1% | 0% |
| Ear and Labyrinth Disorders | ||
| Vision Blurred | 4% | 2% |
| Gastrointestinal Disorders | ||
| Dry Mouth | 44% | 13% |
| Constipation | 10% | 4% |
| Dyspepsia | 7% | 4% |
| Vomiting | 5% | 4% |
| Gastroesophagea lreflux disease | 2% | 1% |
| Dysphagia | 2% | 0% |
| General Disorders and Administrative Site Conditions | ||
| Fatigue | 10% | 8% |
| Asthenia | 2% | 1% |
| Injury, poisoning and procedural complications | ||
| Injury | 1% | 0% |
| Investigations | ||
| Weight increased | 4% | 1% |
| Metabolism and Nutrition Disorders | ||
| Increased Appetite | 5% | 3% |
| Musculoskeletal and Connective Tissue Disorders | ||
| Arthralgia | 3% | 2% |
| Pain in extremity | 2% | 1% |
| Nervous System Disorders | ||
| Somnolence2 | 57% | 15% |
| Dizziness | 18% | 7% |
| Lethargy | 5% | 2% |
| Akathisia | 4% | 1% |
| Extrapyramidal Disorder | 3% | 1% |
| Paraesthesia | 3% | 2% |
| Dysarthria | 3% | 0% |
| Hypersomnia | 3% | 0% |
| Tremor | 2% | 1% |
| Restless Legs Syndrome | 2% | 0% |
| Balance Disorder | 2% | 1% |
| Hypoaesthesia | 2% | 1% |
| Dystonia | 1% | 0% |
| Dizziness, postural | 1% | 0% |
| Dyskinesia | 1% | 0% |
| Dysgeusia | 1% | 0% |
| Psychiatric disorders | ||
| Irritability | 3% | 1% |
| Abnormal Dreams | 2% | 1% |
| Confusional State | 1% | 0% |
| Respiratory, Thoracic, and Mediastinal Disorders | ||
| Nasal Congestion | 5% | 3% |
| Cough | 3% | 1% |
| Sinus Congestion | 2% | 1% |
| Vascular Disorders | ||
| Orthostatic Hypotension | 4% | 3% |
| Hypertension | 1% | 0% |
| 1 Reactions for which the SEROQUEL
incidence was equal to or less than placebo are not listed in the table,
but included the following: nausea, upper respiratory tract infection,
headache, tinnitus, diarrhea, flatulence, toothache, stomach discomfort,
abdominal pain, pyrexia, peripheral edema, nasopharyngitis, influenza,
bronchitis, viral gastroenteritis, accidental overdose, decreased appetite,
back pain, muscle twitching, myalgia, muscle cramp, headache, insomnia,
anxiety, nightmare, libido decreased, suicidal ideation, pollakiuria,
dyspnoea, .pharyngolaryngeal pain, night sweats and hot flush. 2 Somnolence combines adverse reaction terms somnolence and sedation. |
||
Explorations for interactions on the basis of gender, age, and race did not reveal any clinically meaningful differences in the adverse reaction occurrence on the basis of these demographic factors.
Dose-related Adverse Reactions: Spontaneously elicited adverse reaction data from a study of schizophrenia comparing five fixed doses of SEROQUEL (75 mg, 150 mg, 300 mg, 600 mg, and 750 mg/day) to placebo were explored for dose-relatedness of adverse reactions. Logistic regression analyses revealed a positive dose response (p < 0.05) for the following adverse reactions: dyspepsia, abdominal pain, and weight gain.
Adverse Reactions in clinical trials with quetiapine and not listed elsewhere in the label: The following adverse reactions have also been reported with quetiapine: abnormal dreams and nightmares, hypersensitivity, restless legs syndrome, and elevations in serum creatine phosphokinase (not associated with NMS).
Extrapyramidal Symptoms:
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.
Adults: Data from one 6-week clinical trial of schizophrenia comparing five fixed doses of SEROQUEL (75, 150, 300, 600, 750 mg/day) provided evidence for the lack of treatment-emergent extrapyramidal symptoms (EPS) and dose-relatedness for EPS associated with SEROQUEL treatment. Three methods were used to measure EPS: (1) Simpson-Angus total score (mean change from baseline) which evaluates Parkinsonism and akathisia, (2) incidence of spontaneous complaints of EPS (akathisia, akinesia, cogwheel rigidity, extrapyramidal syndrome, hypertonia, hypokinesia, neck rigidity, and tremor), and (3) use of anticholinergic medications to treat emergent EPS.
Table 10: Adverse experiences potentially associated with
EPS in a short-term, placebo controlled multiple fixed-dose Phase III schizophrenia
trial (6 weeks duration)
| Preferred term | Placebo (N=51) |
SEROQUEL 75 mg/day (N=53) |
SEROQUEL 150 mg/day (N=48) |
SEROQUEL 300 mg/day (N=52) |
SEROQUEL 600 mg/day (N=51) |
SEROQUEL 750 mg/day (N=54) |
||||||
| n | % | n | % | n | % | n | % | n | % | n | % | |
| Dystonic eventa | 4 | 7.8 | 2 | 3.8 | 2 | 4.2 | 0 | 0.0 | 2 | 3.9 | 3 | 5.6 |
| Parkinsonismb | 4 | 7.8 | 2 | 3.8 | 0 | 0.0 | 1 | 1.9 | 1 | 2.0 | 1 | 1.9 |
| Akathisiac | 4 | 7.8 | 1 | 1.9 | 1 | 2.1 | 0 | 0.0 | 0 | 0.0 | 1 | 1.9 |
| Dyskinetic eventd | 0 | 0.0 | 2 | 3.8 | 0 | 0.0 | 0 | 0.0 | 1 | 2.0 | 0 | 0.0 |
| Other extrapyramidal evente | 4 | 7.8 | 2 | 3.8 | 0 | 0.0 | 3 | 5.8 | 3 | 5.9 | 1 | 1.9 |
| a: Patients with the following terms were counted in this
category: nuchal rigidity, hypertonia, dystonia, muscle rigidity b: Patients with the following terms were counted in this category: cogwheel rigidity, tremor c: Patients with the following terms were counted in this category: akathisia d: Patients with the following terms were counted in this category: tardive dyskinesia, dyskinesia, choreoathetosis e: Patients with the following terms were counted in this category: restlessness; extrapyramidal disorder |
||||||||||||
Parkinsonism incidence rates as measured by the Simpson-Angus total score for placebo and the five fixed doses (75, 150, 300, 600, 750 mg/day) were: -0.6; -1.0, -1.2; -1.6; -1.8 and -1.8. The rate of anticholinergic medication use to treat emergent EPS for placebo and the five fixed doses was: 14%; 11%; 10%; 8%; 12% and 11%.
In six additional placebo-controlled clinical trials (3 in acute mania and 3 in schizophrenia) using variable doses of SEROQUEL, there were no differences between the SEROQUEL and placebo treatment groups in the incidence of EPS, as assessed by Simpson-Angus total scores, spontaneous complaints of EPS and the use of concomitant anticholinergic medications to treat EPS.
In two placebo-controlled clinical trials for the treatment of bipolar depression using 300 mg and 600 mg of SEROQUEL, the incidence of adverse reactions potentially related to EPS was 12% in both dose groups and 6% in the placebo group. In these studies, the incidence of the individual adverse reactions (akathisia, extrapyramidal disorder, tremor, dyskinesia, dystonia, restlessness, muscle contractions involuntary, psychomotor hyperactivity and muscle rigidity) were generally low and did not exceed 4% in any treatment group.
The 3 treatment groups were similar in mean change in SAS total score and BARS Global Assessment score at the end of treatment. The use of concomitant anticholinergic medications was infrequent and similar across the three treatment groups.
Children and Adolescents:
The information below is derived from a clinical trial database for SEROQUEL consisting of over 1000 pediatric patients. This database includes 677 patients exposed to SEROQUEL for the treatment of schizophrenia and 393 patients exposed to SEROQUEL for the treatment of acute bipolar mania.
The following findings were based on a 6-week placebo-controlled trial in which quetiapine was administered in either doses of 400 or 800 mg/day.
Adverse Reactions Associated with Discontinuation of Treatment
The incidence of discontinuation due to adverse reactions for quetiapine-treated and placebo-treated patients was 8.2% and 2.7%, respectively. The adverse event leading to discontinuation in 1% or more of patients on SEROQUEL and at a greater incidence than placebo was somnolence (2.7% and 0% for placebo).
Commonly Observed Adverse Reactions
In therapy for schizophrenia (up to 6 weeks), the most commonly observed adverse reactions associated with the use of quetiapine in adolescents (incidence of 5% or greater and quetiapine incidence at least twice that for placebo) were somnolence (34%), dizziness (12%), dry mouth (7%), tachycardia ( 7%).
Table 11 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse reactions that occurred during therapy (up to 6-weeks) of schizophrenia in 5% or more of patients treated with SEROQUEL (doses of 400 or 800 mg/day) where the incidence in patients treated with SEROQUEL was at least twice the incidence in placebo-treated patients. Adverse events that were potentially dose-related with higher frequency in the 800 mg group compared to the 400 mg group included dizziness (8.2% vs. 14.9%), dry mouth (4.1% vs. 9.5%), and tachycardia (5.5% vs. 8.1%).
Table 11: Treatment-Emergent Adverse Reaction Incidence in
a 6-Week Placebo-Controlled Clinical Trial for the Treatment of Schizophrenia
in Adolescent Patients
| Body System/Preferred Term | SEROQUEL (n=147) |
PLACEBO (n=75) |
| Central Nervous System Disorders | ||
| Somnolence1 | 34% | 11% |
| Digestive | ||
| Dry Mouth | 7% | 1% |
| Cardiovascular Disorders | ||
| Tachycardia | 7% | 0% |
| Nervous System Disorder | ||
| Dizziness | 12% | 5% |
| 1 Somnolence combines adverse event terms somnolence and sedation | ||
The following findings were based on a 3-week placebo-controlled trial in which quetiapine was administered in either doses of 400 or 600 mg/day.
Adverse Reactions Associated with Discontinuation of Treatment
The incidence of discontinuation due to adverse reactions for quetiapine-treated and placebo-treated patients was 11.4% and 4.4%, respectively. The adverse events leading to discontinuation in 1% of more of patients on SEROQUEL and at a greater incidence than placebo were somnolence (4.1% vs. 1.1%), fatigue (2.1% vs. 0), irritability (1.6% vs. 0) and syncope (1% vs. 0).
Commonly Observed Adverse Reactions
In bipolar mania therapy (up to 3-weeks) the most commonly observed adverse reactions associated with the use of quetiapine in children and adolescents (incidence of 5% or greater and quetiapine incidence at least twice that for placebo) were somnolence (53%), dizziness (18%), fatigue (11%), increased appetite (9%), nausea (8%), vomiting (8%), tachycardia (7%), dry mouth (7%), and weight increased (6%).
Table 12 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse reactions that occurred during therapy (up to 3-weeks) of bipolar mania in 5% or more of patients treated with SEROQUEL (doses of 400 or 600 mg/day) where the incidence in patients treated with SEROQUEL was at least twice the incidence in placebo-treated patients. Adverse events that were potentially dose-related with higher frequency in the 600 mg group compared to the 400 mg group included somnolence (49% vs. 57%), nausea (6.3% vs. 10.2%) and tachycardia (5.3% vs. 8.2%).
Table 12: Treatment-Emergent Adverse Reaction Incidence in
a 3-Week Placebo-Controlled Clinical Trial for the Treatment of Bipolar Mania
in Children and Adolescent Patients
| Body System/Preferred Term | SEROQUEL (n=193) |
PLACEBO (n=90) |
| Nervous System Disorders | ||
| Somnolence1 | 53% | 14% |
| Dizziness | 18% | 2% |
| Fatigue | 11% | 4% |
| Metabolism and Nutrition Disorders | ||
| Increased Appetite | 9% | 1% |
| Weight Increased | 6% | 0% |
| Gastrointestinal Disorders | ||
| Nausea | 8% | 4% |
| Vomiting | 8% | 3% |
| Dry Mouth | 7% | 0% |
| Cardiac Disorders | ||
| Tachycardia | 7% | 0% |
| 1 Somnolence combines adverse event terms somnolence and sedation | ||
In acute therapy for schizophrenia and bipolar mania (up to 6 weeks in schizophrenia and up to 3 weeks in bipolar mania) the most commonly observed adverse reactions associated with the use of quetiapine in children and adolescents (incidence of 5% or greater and quetiapine incidence at least twice that for placebo) were somnolence (47%), dizziness (15%), fatigue (9%), increased appetite (8%), dry mouth (7%), tachycardia (7%), and weight increased (5%). Table 13 enumerates the pooled incidence of adverse reactions that occurred during acute therapy of children and adolescents (up to 6 weeks in Schizophrenia and up to 3 weeks in Bipolar Mania). The table includes only those reactions that occurred in 1% or more of patients treated with quetiapine (doses of 400, 600, or 800 mg/day) and for which the incidence in patients treated with quetiapine was greater than the incidence in patients treated with placebo.
Table 13: Adverse Reactions (incidence ≥ 1% and greater
than placebo) in Short-Term, Placebo-Controlled Trials of Children and Adolescents
(10 to 17 years of age) with Bipolar Mania or Schizophrenia1
| Body System/ Preferred Term | SEROQUEL (n=340) |
PLACEBO (n=165 |
| Central/Nervous System Disorder | ||
| Somnolence2 | 47% | 15% |
| Dizziness | 15% | 4% |
| Fatigue | 9% | 4% |
| Irritability | 4% | 1% |
| Tremor | 3% | 2% |
| Akathisia | 2% | 1% |
| Syncope | 2% | 0% |
| Lethargy | 1% | 0% |
| Metabolism and Nutrition Disorders | ||
| Increased Appetite | 8% | 2% |
| Weight Increased | 5% | 1% |
| Digestive | ||
| Dry Mouth | 7% | 1% |
| Cardiovascular Disorders | ||
| Tachycardia | 8% | 0% |
| Musculoskeletal and Connective Tissue Disorders | ||
| Arthralgia | 3% | 1% |
| Back Pain | 2% | 1% |
| Musculoskeletal Stiffness | 2% | 1% |
| Respiratory, Thoracic and Mediastinal Disorder | ||
| Nasal Congestion | 3% | 2% |
| Epistaxis | 2% | 2% |
| Upper Respiratory Tract Infection | 2% | 2% |
| Gastrointestinal Disorder | ||
| Vomiting | 7% | 6% |
| Constipation | 2% | 2% |
| Stomach Discomfort | 2% | 1% |
| Dyspepsia | 2% | 2% |
| Skin and subcutaneous Tissue Disorders | ||
| Acne | 2% | 1% |
| General Disorders and Administration Site Conditions | ||
| Pyrexia | 2% | 1% |
| Asthenia | 2% | 1% |
| Psychiatric Disorders | ||
| Aggression | 2% | 1% |
| Restlessness | 1% | 0% |
| Eye Disorders | ||
| Vision Blurred | 2% | 1% |
| Infections and Infestations | ||
| Tooth Abscess | 1% | 0% |
| 1 Threshold criteria were applied
before rounding to the nearest integer 2 Somnolence combines adverse event terms somnolence and sedation |
||
Extrapyramidal Symptoms:
In a short-term placebo-controlled monotherapy trial in adolescent patients with schizophrenia (6-week duration), the aggregated incidence of extrapyramidal symptoms was 12.9% for SEROQUEL and 5.3% for placebo, though the incidence of the individual adverse events (eg, akathisia, tremor, extrapyramidal disorder, hypokinesia, restlessness, psychomotor hyperac-tivity, muscle rigidity, dyskinesia) did not exceed 4.1% in any treatment group. In a short-term placebo-controlled monotherapy trial in children and adolescent patients with bipolar mania (3-week duration), the aggregated incidence of extrapyramidal symptoms was 3.6% for SEROQUEL and 1.1% for placebo.
Table 14 below presents a listing of patients with AEs potentially associated with EPS in the short-term placebo-controlled monotherapy trial in adolescent patients with schizophrenia (6-week duration).
Table 14: Adverse experiences potentially associated with
EPS in the short-term placebo-controlled monotherapy trial in adolescent patients
with schizophrenia (6-week duration).
| Preferred term | Placebo (N=75) |
Quetiapine 400 mg/day (N=73) |
Quetiapine 800 mg/day (N=74) |
All Quetiapine (N=147) |
||||
| n | % | n | % | n | % | n | % | |
| Dystonic eventa | 0 | 0.0 | 2 | 2.7 | 0 | 0.0 | 2 | 1.4 |
| Parkinsonismb | 2 | 2.7 | 4 | 5.5 | 4 | 5.4 | 8 | 5.4 |
| Akathisiac | 3 | 4.0 | 3 | 4.1 | 4 | 5.4 | 7 | 4.8 |
| Dyskinetic eventd | 0 | 0.0 | 2 | 2.7 | 0 | 0.0 | 2 | 1.4 |
| Other extrapyramidal evente | 0 | 0.0 | 2 | 2.7 | 2 | 2.7 | 4 | 2.7 |
| a: Patients with the following terms were counted in this
category: nuchal rigidity, hypertonia, dystonia, muscle rigidity b: Patients with the following terms were counted in this category: cogwheel rigidity, tremor c: Patients with the following terms were counted in this category: akathisia d: Patients with the following terms were counted in this category: tardive dyskinesia, dyskinesia, choreoathetosis e: Patients with the following terms were counted in this category: restlessness; extrapyramidal disorder |
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Table 15 below presents a listing of patients with Adverse Experiences potentially associated with EPS in a short-term placebo-controlled monotherapy trial in children and adolescent patients with bipolar mania (3-week duration).
Table 15: Adverse experiences potentially associated with
EPS in a short-term placebo-controlled monotherapy trial in children and adolescent
patients with bipolar mania (3-week duration)
| Preferred term* | Placebo (N=90) |
Quetiapine 400 mg (N=95) |
Quetiapine 600 mg (N=98) |
All Quetiapine (N=193) |
||||
| n | % | n | % | n | % | n | % | |
| Parkinsonisma | 1 | 1.1 | 2 | 2.1 | 1 | 1.0 | 3 | 1.6 |
| Akathisiab | 0 | 0.0 | 1 | 1.0 | 1 | 1.0 | 2 | 1.0 |
| Other extrapyramidal eventc | 0 | 0.0 | 1 | 1.1 | 1 | 1.0 | 2 | 1.0 |
| *: There were no adverse experiences with the preferred term
of dystonic or dyskinetic events. a: Patients with the following terms were counted in this category: cogwheel rigidity, tremor b: Patients with the following terms were counted in this category: akathisia c: Patients with the following terms were counted in this category: restlessness; extrapyramidal disorder |
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The adverse reactions reported in a 26-week, open label trial with SEROQUEL in 5% or greater of the children and adolescent patients with schizophrenia or bipolar mania were somnolence (30%), headache (19%), vomiting (11%), increased weight (13%), insomnia (8%), nausea (10%), fatigue (8%), dizziness (9%), increased appetite (7%), upper respiratory tract infection (7%), agitation (5%), tachycardia (5%), and irritability (5%).
Following is a list of COSTART terms that reflect treatment-emergent adverse reactions as defined in the introduction to the ADVERSE REACTIONS section reported by patients treated with SEROQUEL at multiple doses ≥ 75 mg/day during any phase of a trial within the premar-keting database of approximately 2200 patients treated for schizophrenia. All reported reactions are included except those already listed in the tables or elsewhere in labeling, those reactions for which a drug cause was remote, and those reaction terms which were so general as to be uninformative. It is important to emphasize that, although the reactions reported occurred during treatment with SEROQUEL, they were not necessarily caused by it.
Reactions are further categorized by body system and listed in order of decreasing frequency according to the following definitions: frequent adverse reactions are those occurring in at least 1/100 patients (only those not already listed in the tabulated results from placebo-controlled trials appear in this listing); infrequent adverse reactions are those occurring in 1/100 to 1/1000 patients; rare reactions are those occurring in fewer than 1/1000 patients.
Nervous System: Infrequent: abnormal dreams, dyskinesia, thinking abnormal, tardive dyskinesia, vertigo, involuntary movements, confusion, amnesia, psychosis, hallucinations, hyperkinesia, libido increased*, urinary retention, incoordination, paranoid reaction, abnormal gait, myoclonus, delusions, manic reaction, apathy, ataxia, depersonalization, stupor, bruxism, catatonic reaction, hemiplegia; Rare: aphasia, buccoglossal syndrome, choreoathetosis, delirium, emotional lability, euphoria, libido decreased*, neuralgia, stuttering, subdural hematoma.
Body as a Whole: Frequent: flu syndrome; Infrequent: neck pain, pelvic pain*, suicide attempt, malaise, photosensitivity reaction, chills, face edema, moniliasis; Rare: abdomen enlarged.
Digestive System: Frequent: anorexia; Infrequent: increased salivation, increased appetite, gamma glutamyl transpeptidase increased, gingivitis, dysphagia, flatulence, gastroenteritis, gastritis, hemorrhoids, stomatitis, thirst, tooth caries, fecal incontinence, gastroesophageal reflux, gum hemorrhage, mouth ulceration, rectal hemorrhage, tongue edema; Rare: glossitis, hematemesis, intestinal obstruction, melena, pancreatitis.
Cardiovascular System: Infrequent: vasodilatation, QT interval prolonged, migraine, bradycardia, cerebral ischemia, irregular pulse, T wave abnormality, bundle branch block, cerebrovascular accident, deep thrombophlebitis, T wave inversion; Rare: angina pectoris, atrial fibrillation, AV block first degree, congestive heart failure, ST elevated, thrombophlebitis, T wave flattening, ST abnormality, increased QRS duration.
Respiratory System: Frequent: cough increased, dyspnea; Infrequent: pneumonia, epistaxis, asthma; Rare: hiccup, hyperventilation.
Metabolic and Nutritional System: Infrequent: weight loss, alkaline phosphatase increased, hyperlipemia, alcohol intolerance, dehydration, hyperglycemia, creatinine increased, hypoglycemia; Rare: glycosuria, gout, hand edema, hypokalemia, water intoxication.
Skin and Appendages System: Infrequent: pruritus, acne, eczema, contact dermatitis, maculopapular rash, seborrhea, skin ulcer; Rare: exfoliative dermatitis, psoriasis, skin discoloration.
Urogenital System: Infrequent: dysmenorrhea*, vaginitis*, urinary incontinence, metrorrhagia*, impotence*, dysuria, vaginal moniliasis*, abnormal ejaculation*, cystitis, urinary frequency, amenorrhea*, female lactation*, leukorrhea*, vaginal hemorrhage*, vulvovaginitis* orchitis*; Rare: gynecomastia*, nocturia, polyuria, acute kidney failure.
Special Senses: Infrequent: conjunctivitis, abnormal vision, dry eyes, tinnitus, taste perversion, blepharitis, eye pain; Rare: abnormality of accommodation, deafness, glaucoma.
Musculoskeletal System: Infrequent: pathological fracture, myasthenia, twitching, arthralgia, arthritis, leg cramps, bone pain.
Hemic and Lymphatic System: Infrequent: leukocytosis, anemia, ecchymosis, eosinophilia, hypochromic anemia; lymphadenopathy, cyanosis; Rare: hemolysis, thrombocytopenia.
Endocrine System: Infrequent: hypothyroidism, diabetes mellitus; Rare: hyperthyroidism.
*adjusted for gender
Hyperglycemia, hyperlipidemia, weight gain, orthostatic hypotension have been reported with quetiapine. Increases in blood pressure have also been reported with quetiapine in children and adolescents [see WARNINGS AND PRECAUTIONS].
In placebo-controlled monotherapy clinical trials involving 3368 patients on quetiapine fumarate and 1515 on placebo, the incidence of at least one occurrence of neutrophil count < 1.0 x 109/L among patients with a normal baseline neutrophil count and at least one available follow up laboratory measurement was 0.3% (10/2967) in patients treated with quetiapine fumarate, compared to 0.1% (2/1349) in patients treated with placebo. 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 SEROQUEL at the first sign of a decline in WBC in absence of other causative factors [see WARNINGS AND PRECAUTIONS].
Adults: Between-group comparisons for pooled placebo-controlled trials revealed no statistically significant SEROQUEL/placebo differences in the proportions of patients experiencing potentially important changes in ECG parameters, including QT, QTc, and PR intervals. However, the proportions of patients meeting the criteria for tachycardia were compared in four 3- to 6-week placebo-controlled clinical trials for the treatment of schizophrenia revealing a 1% (4/399) incidence for SEROQUEL compared to 0.6% (1/156) incidence for placebo. In acute (monotherapy) bipolar mania trials the proportions of patients meeting the criteria for tachycardia was 0.5% (1/192) for SEROQUEL compared to 0% (0/178) incidence for placebo. In acute bipolar mania (adjunct) trials the proportions of patients meeting the same criteria was 0.6% (1/166) for SEROQUEL compared to 0% (0/171) incidence for placebo. In bipolar depression trials, no patients had heart rate increases to > 120 beats per minute. SEROQUEL use was associated with a mean increase in heart rate, assessed by ECG, of 7 beats per minute compared to a mean increase of 1 beat per minute among placebo patients. This slight tendency to tachycardia in adults may be related to SEROQUEL's potential for inducing ortho-static changes [see WARNINGS AND PRECAUTIONS].
Children and Adolescents: In the acute (6 week) schizophrenia trial in adolescents, potentially clinically significant increases in heart rate ( > 110 bpm) occurred in 5.2% (3/73) of patients receiving SEROQUEL 400 mg and 8.5% (5/74) of patients receiving SEROQUEL 800 mg compared to 0% (0/75) of patients receiving placebo. Mean increases in heart rate were 3.8 bpm and 11.2 bpm for SEROQUEL 400 mg and 800 mg groups, respectively, compared to a decrease of 3.3 bpm in the placebo group [see WARNINGS AND PRECAUTIONS].
In the acute (3 week) bipolar mania trial in children and adolescents, potentially clinically significant increases in heart rate ( > 110 bpm) occurred in 1.1% (1/95) of patients receiving SEROQUEL 400 mg and 2.4% (2/98) of patients receiving SEROQUEL 600 mg compared to 0% (0/98) of patients receiving placebo. Mean increases in heart rate were 12.8 bpm and 13.4 bpm for SEROQUEL 400 mg and 600 mg groups, respectively, compared to a decrease of 1.7 bpm in the placebo group [see WARNINGS AND PRECAUTIONS].
The following adverse reactions were identified during post approval of SEROQUEL. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Adverse reactions reported since market introduction which were temporally related to SEROQUEL therapy include: anaphylactic reaction and galactorrhea.
Other adverse reactions reported since market introduction, which were temporally related to SEROQUEL therapy, but not necessarily causally related, include the following: agranulocytosis, cardiomyopathy, hyponatremia, myocarditis, rhabdomyolysis, syndrome of inappropriate antidi-uretic hormone secretion (SIADH), Stevens-Johnson syndrome (SJS), and decreased platelets. In post-marketing clinical trials, elevations in total cholesterol (predominantly LDL cholesterol) have been reported.
The risks of using SEROQUEL in combination with other drugs have not been extensively evaluated in systematic studies. Given the primary CNS effects of SEROQUEL, caution should be used when it is taken in combination with other centrally acting drugs. SEROQUEL potentiated the cognitive and motor effects of alcohol in a clinical trial in subjects with selected psychotic disorders, and alcoholic beverages should be avoided while taking SEROQUEL. Because of its potential for inducing hypotension, SEROQUEL may enhance the effects of certain antihypertensive agents.
SEROQUEL may antagonize the effects of levodopa and dopamine agonists.
Phenytoin: Coadministration of quetiapine (250 mg three times daily) and phenytoin (100 mg three times daily) increased the mean oral clearance of quetiapine by 5-fold. Increased doses of SEROQUEL may be required to maintain control of symptoms of schizophrenia in patients receiving quetiapine and phenytoin, or other hepatic enzyme inducers (e.g., carbamazepine, barbiturates, rifampin, glucocorticoids). Caution should be taken if phenytoin is withdrawn and replaced with a non-inducer (e.g., valproate) [see DOSAGE AND ADMINISTRATION].
Divalproex: Coadministration of quetiapine (150 mg twice daily) and divalproex (500 mg twice daily) increased the mean maximum plasma concentration of quetiapine at steady state by 17% without affecting the extent of absorption or mean oral clearance.
Thioridazine: Thioridazine (200 mg twice daily) increased the oral clearance of quetiapine (300 mg twice daily) by 65%.
Cimetidine: Administration of multiple daily doses of cimetidine (400 mg three times daily for 4 days) resulted in a 20% decrease in the mean oral clearance of quetiapine (150 mg three times daily). Dosage adjustment for quetiapine is not required when it is given with cimetidine.
P450 3A Inhibitors: Coadministration of ketoconazole (200 mg once daily for 4 days), a potent inhibitor of cytochrome P450 3A, reduced oral clearance of quetiapine by 84%, resulting in a 335% increase in maximum plasma concentration of quetiapine. Caution (reduced dosage) is indicated when SEROQUEL is administered with ketoconazole and other inhibitors of cytochrome P450 3A (e.g., itraconazole, fluconazole, erythromycin, and protease inhibitors).
Fluoxetine, Imipramine, Haloperidol, and Risperidone: Coadministration of fluoxetine (60 mg once daily), imipramine (75 mg twice daily), haloperidol (7.5 mg twice daily), or risperidone (3 mg twice daily) with quetiapine (300 mg twice daily) did not alter the steady-state pharmacokinetics of quetiapine.
Lorazepam: The mean oral clearance of lorazepam (2 mg, single dose) was reduced by 20% in the presence of quetiapine administered as 250 mg three times daily dosing.
Divalproex: The mean maximum concentration and extent of absorption of total and free valproic acid at steady state were decreased by 10 to 12% when divalproex (500 mg twice daily) was administered with quetiapine (150 mg twice daily). The mean oral clearance of total valproic acid (administered as divalproex 500 mg twice daily) was increased by 11% in the presence of quetiapine (150 mg twice daily). The changes were not significant.
Lithium: Concomitant administration of quetiapine (250 mg three times daily) with lithium had no effect on any of the steady-state pharmacokinetic parameters of lithium.
Antipyrine: Administration of multiple daily doses up to 750 mg/day (on a three times daily schedule) of quetiapine to subjects with selected psychotic disorders had no clinically relevant effect on the clearance of antipyrine or urinary recovery of antipyrine metabolites. These results indicate that quetiapine does not significantly induce hepatic enzymes responsible for cytochrome P450 mediated metabolism of antipyrine.
SEROQUEL is not a controlled substance.
SEROQUEL has not been systematically studied, in animals or humans, for its potential for abuse, tolerance or physical dependence. While the clinical trials did not reveal any tendency for any drug-seeking behavior, these observations were not systematic and it is not possible to predict on the basis of this limited experience the extent to which a CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, patients should be evaluated carefully for a history of drug abuse, and such patients should be observed closely for signs of misuse or abuse of SEROQUEL, e.g., development of tolerance, increases in dose, drug-seeking behavior.
Last updated on RxList: 12/29/2009
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL (quetiapine fumarate) is not approved for the treatment of patients with dementia-related psychosis (see Boxed Warning).
Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. There has been a long-standing concern, however, that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18-24) with major depressive disorder (MDD) and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction with antidepressants compared to placebo in adults aged 65 and older.
The pooled analyses of placebo-controlled trials in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders included a total of 24 short-term trials of 9 antidepressant drugs in over 4400 patients. The pooled analyses of placebo-controlled trials in adults with MDD or other psychiatric disorders included a total of 295 short-term trials (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients. There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied. There were differences in absolute risk of suicidality across the different indications, with the highest incidence in MDD. The risk differences (drug vs. placebo), however, were relatively stable within age strata and across indications. These risk differences (drug-placebo difference in the number of cases of suicidality per 1000 patients treated) are provided in Table 1.
Table 1
| Age Range | Drug-Placebo Difference in Numberof Cases of Suicidality per 1000 Patients Treated |
| Increases Compared to Placebo | |
| < 18 | 14 additional cases |
| 18-24 | 5 additional cases |
| Decreases Compared to Placebo | |
| 25-64 | 1 fewer case |
| ≥ 65 | 6 fewer cases |
No suicides occurred in any of the pediatric trials. There were suicides in the adult trials, but the number was not sufficient to reach any conclusion about drug effect on suicide.
It is unknown whether the suicidality risk extends to longer-term use, i.e., beyond several months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with depression that the use of antidepressants can delay the recurrence of depression.
All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.
The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric. Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.
Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms.
Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to healthcare providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for SEROQUEL should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.
Screening Patients for Bipolar Disorder: A major depressive episode may be the initial presentation of bipolar disorder. It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown. However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. It should be noted that SEROQUEL is approved for use in treating adult bipolar depression.
A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with administration of antipsychotic drugs, including SEROQUEL. Rare cases of NMS have been reported with SEROQUEL. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status, and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Additional signs may include elevated creatine phosphokinase, 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 exclude cases where 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 (CNS) 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 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.
Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics, including quetiapine. 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 reactions is not completely understood. However, epidemiological studies suggest an increased risk of treatment-emergent hyperglycemia-related adverse reactions in patients treated with the atypical antipsychotics. Precise risk estimates for hyperglycemia-related adverse reactions in patients treated with atypical antipsychotics are not available.
Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (eg, obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of antidiabetic treatment despite discontinuation of the suspect drug.
Table 2: Fasting Glucose-Proportion of Patients Shifting
to ≥ 126 mg/dL in short-term ( ≤ 12 weeks) Placebo Controlled Studies
| Laboratory Analyte | Category Change (At Least Once) from Baseline | Treatment Arm | N | Patients n (%) |
| Fasting Glucose | Normal to High ( < 100 mg/dL to ≥ 126 mg/dL) | Quetiapine | 2907 | 71 (2.4%) |
| Placebo | 1346 | 19 (1.4%) | ||
| Borderline to High ( ≥ 100 mg/dL and < 126 mg/dL) to ≥ 126 mg/dL | Quetiapine | 572 | 67 (11.7%) | |
| Placebo | 279 | 33 (11.8%) |
In a 24-week trial (active-controlled, 115 patients treated with SEROQUEL) designed to evaluate glycemic status with oral glucose tolerance testing of all patients, at week 24 the incidence of a treatment-emergent post-glucose challenge glucose level ≥ 200 mg/dL was 1.7% and the incidence of a fasting treatment-emergent blood glucose level ≥ 126 mg/dL was 2.6%. The mean change in fasting glucose from baseline was 3.2 mg/dL and mean change in 2 hour glucose from baseline was -1.8 mg/dL for quetiapine.
In 2 long-term placebo-controlled randomized withdrawal clinical trials for bipolar maintenance, mean exposure of 213 days for SEROQUEL (646 patients) and 152 days for placebo (680 patients), the mean change in glucose from baseline was +5.0 mg/dL for SEROQUEL and –0.05 mg/dL for placebo. The exposure-adjusted rate of any increased blood glucose level ( ≥ 126 mg/dL) for patients more than 8 hours since a meal (however, some patients may not have been precluded from calorie intake from fluids during fasting period) was 18.0 per 100 patient years for SEROQUEL (10.7% of patients; n=556) and 9.5 for placebo per 100 patient years (4.6% of patients; n=581).
In a placebo-controlled SEROQUEL monotherapy study of adolescent patients (13–17 years of age) with schizophrenia (6 weeks duration), the mean change in fasting glucose levels for SEROQUEL (n=138) compared to placebo (n=67) was –0.75 mg/dL versus –1.70 mg/dL. In a placebo-controlled SEROQUEL monotherapy study of children and adolescent patients (10–17 years of age) with bipolar mania (3 weeks duration), the mean change in fasting glucose level for SEROQUEL (n=170) compared to placebo (n=81) was 3.62 mg/dL versus –1.17 mg/dL. No patient in either study with a baseline normal fasting glucose level ( < 100 mg/dL) or a baseline borderline fasting glucose level ( ≥ 100 mg/dL and < 126 mg/dL) had a treatment-emergent blood glucose level of ≥ 126 mg/dL.
Adults: Undesirable alterations in lipids have been observed with quetiapine use. Clinical monitoring, including baseline and periodic follow-up lipid evaluations in patients using quetiapine is recommended.
Table 3 shows the percentage of adult patients with changes in total cholesterol, triglycerides, LDL-cholesterol and HDL-cholesterol from baseline by indication in clinical trials with SEROQUEL
Table 3: Percentage of Adult Patients with Shifts in Total
Cholesterol, Triglycerides, LDL-Cholesterol and HDL-Cholesterol from Baseline
to Clinically Significant Levels by Indication
| Laboratory Analyte | Indication | Treatment Arm | N | Patients n (%) |
| Total Cholesterol ≥ 240 mg/dL | Schizophreniaa | Quetiapine | 137 | 24 (18%) |
| Placebo | 92 | 6 (7%) | ||
| Bipolar Depressionb | Quetiapine | 463 | 41 (9%) | |
| Placebo | 250 | 15 (6%) | ||
| Triglycerides ≥ 200 mg/dL | Schizophreniaa | Quetiapine | 120 | 26(22%) |
| Placebo | 70 | 11 (16%) | ||
| Bipolar Depressionb | Quetiapine | 436 | 59 (14%) | |
| Placebo | 232 | 20 (9%) | ||
| LDL-Cholesterol ≥ 160 mg/dL | Schizophreniaa | Quetiapine | nac | nac |
| Placebo | nac | nac | ||
| Bipolar Depressionb | Quetiapine | 465 | 29 (6%) | |
| Placebo | 256 | 12 (5%) | ||
| HDL-Cholesterol ≤ 40 mg/dL | Schizophreniaa | Quetiapine | nac | nac |
| Placebo | nac | nac | ||
| Bipolar Depressionb | Quetiapine | 393 | 56 (14%) | |
| Placebo | 214 | 29 (14%) | ||
| a: 6 weeks duration b: 8 weeks duration c: Parameters not measured in the SEROQUEL registration studies for schizophrenia. Lipid parameters also were not measured in the bipolar mania registration studies. |
||||
Children and Adolescents: Table 4 shows the percentage of children and adolescents with changes in total cholesterol, triglycerides, LDL-cholesterol and HDL-cholesterol from baseline in clinical trials with SEROQUEL.
Table 4: Percentage of Children and Adolescents with Shifts
in Total Cholesterol, Triglycerides, LDL-Cholesterol and HDL-Cholesterol from
Baseline to Clinically Significant Levels
| Laboratory Analyte | Indication | Treatment Arm | N | Patients n (%) |
| Total Cholesterol ≥ 200 mg/dL | Schizophreniaa | Quetiapine | 107 | 13 (12%) |
| Placebo | 56 | 1 (2%) | ||
| Bipolar Maniab | Quetiapine | 159 | 16 (10%) | |
| Placebo | 66 | 2 (3%) | ||
| Triglycerides ≥ 150 mg/dL | Schizophreniaa | Quetiapine | 103 | 17 (17%) |
| Placebo | 51 | 4 (8%) | ||
| Bipolar Maniab | Quetiapine | 149 | 32 (22%) | |
| Placebo | 60 | 8 (13%) | ||
| LDL-Cholesterol ≥ 130 mg/dL | Schizophreniaa | Quetiapine | 112 | 4 (4%) |
| Placebo | 60 | 1 (2%) | ||
| Bipolar Maniab | Quetiapine | 169 | 13 (8%) | |
| Placebo | 74 | 4 (5%) | ||
| HDL-Cholesterol ≤ 40 mg/dL | Schizophreniaa | Quetiapine | 104 | 16 (15%) |
| Placebo | 54 | 10 (19%) | ||
| Bipolar Maniab | Quetiapine | 154 | 16 (10%) | |
| Placebo | 61 | 4 (7%) | ||
| a: 13-17 years, 6 weeks duration b: 10-17 years, 3 weeks duration |
||||
Increases in weight have been observed in clinical trials. Patients receiving quetiapine should receive regular monitoring of weight [see Patient Counseling Information].
Adults: In clinical trials with SEROQUEL the following increases in weight have been reported.
Table 5: Proportion of Patients with Weight Gain ≥ 7% of
Body Weight (Adults)
| Vital sign | Indication | Treatment Arm | N | Patients n (%) |
| Weight Gain ≥ 7% of body weight | Schizophreniaa | SEROQUEL | 391 | 89 (23%) |
| Placebo | 206 | 11 (6%) | ||
| Bipolar Mania (montherapy)b | SEROQUEL | 209 | 44 (21%) | |
| Placebo | 198 | 13 (7%) | ||
| Bipolar Mania (adjunct therapy)c | SEROQUEL | 196 | 25 (13%) | |
| Placebo | 203 | 8 (4%) | ||
| Bipolar Depressiond | SEROQUEL | 554 | 47 (8%) | |
| Placebo | 295 | 7 (2%) | ||
| a: up to 6 weeks duration b: up to 12 weeks duration c: up to 3 weeks duration d: up to 8 weeks duration |
||||
Children and Adolescents: In two clinical trials with SEROQUEL, one in bipolar mania and one in schizophrenia, reported increases in weight are included in the table below.
Table 6: Proportion of Patients with Weight Gain ≥ 7% of
Body Weight (Children and Adolescents)
| Vital sign | Indication | Treatment Arm | N | Patients n (%) |
| Weight gain ≥ 7% of body weight | Schizophreniaa | SEROQUEL | 111 | 23 (21%) |
| Placebo | 44 | 3 (7%) | ||
| Bipolar Maniab | SEROQUEL | 157 | 18 (12%) | |
| Placebo | 68 | 0 (0%) | ||
| a: 6 weeks duration b: 3 weeks duration |
||||
The mean change in body weight in the schizophrenia trial was 2.0 kg in the SEROQUEL group and -0.4 kg in the placebo group and in the bipolar mania trial it was 1.7 kg in the SEROQUEL group and 0.4 kg in the placebo group.
In an open-label study that enrolled patients from the above two pediatric trials, 63% of patients (241/380) completed 26 weeks of therapy with SEROQUEL. After 26 weeks of treatment, the mean increase in body weight was 4.4 kg. Forty-five percent of the patients gained ≥ 7% of their body weight, not adjusted for normal growth. In order to adjust for normal growth over 26 weeks an increase of at least 0.5 standard deviation from baseline in BMI was used as a measure of a clinically significant change; 18.3% of patients on SEROQUEL met this criterion after 26 weeks of treatment.
When treating pediatric patients with SEROQUEL for any indication, weight gain should be assessed against that expected for normal growth.
A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs including quetiapine. Although the prevalence of the syndrome appears to be highest among the elderly, 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. Whether antipsychotic drug products differ in their potential to cause tardive dyskinesia is unknown.
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. Anti-psychotic 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, SEROQUEL should be prescribed in a manner that is most likely to minimize the occurrence of tardive dyskinesia. Chronic antipsychotic treatment should generally be reserved for patients who appear to 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 on SEROQUEL, drug discontinuation should be considered. However, some patients may require treatment with SEROQUEL despite the presence of the syndrome.
Quetiapine may induce orthostatic hypotension associated with dizziness, tachycardia and, in some patients, syncope, especially during the initial dose-titration period, probably reflecting its a1-adrenergic antagonist properties. Syncope was reported in 1% (28/3265) of the patients treated with SEROQUEL, compared with 0.2% (2/954) on placebo and about 0.4% (2/527) on active control drugs. Orthostatic hypotension, dizziness, and syncope may lead to falls.
SEROQUEL should be used with particular caution in patients with known cardiovascular disease (history of myocardial infarction or ischemic heart disease, heart failure or conduction abnormalities), cerebrovascular disease or conditions which would predispose patients to hypotension (dehydration, hypovolemia and treatment with antihypertensive medications) [see ADVERSE REACTIONS]. The risk of orthostatic hypotension and syncope may be minimized by limiting the initial dose to 25 mg twice daily [see DOSAGE AND ADMINISTRATION]. If hypotension occurs during titration to the target dose, a return to the previous dose in the titration schedule is appropriate.
In placebo-controlled trials in children and adolescents with schizophrenia (6-week duration) or bipolar mania (3-week duration), the incidence of increases at any time in systolic blood pressure ( ≥ 20 mmHg) was 15.2% (51/335) for SEROQUEL and 5.5% (9/163) for placebo; the incidence of increases at any time in diastolic blood pressure ( ≥ 10 mmHg) was 40.6% (136/335) for SEROQUEL and 24.5% (40/163) for placebo. In the 26-week open-label clinical trial, one child with a reported history of hypertension experienced a hypertensive crisis. Blood pressure in children and adolescents should be measured at the beginning of, and periodically during treatment.
In clinical trials and postmarketing experience, events of leukopenia/neutropenia have been reported temporally related to atypical antipsychotic agents, including SEROQUEL. Agranulocytosis (including fatal cases) has also been reported.
Possible risk factors for leukopenia/neutropenia include pre-existing low white cell count (WBC) and history of drug induced leukopenia/neutropenia. Patients with a pre-existing 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 SEROQUEL at the first sign of a decline in WBC in 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 SEROQUEL and have their WBC followed until recovery [see ADVERSE REACTIONS].
The development of cataracts was observed in association with quetiapine treatment in chronic dog studies [see Nonclinical Toxicology, Animal Toxicology]. Lens changes have also been observed in adults, children, and adolescents during long-term SEROQUEL treatment, but a causal relationship to SEROQUEL use has not been established. Nevertheless, the possibility of lenticular changes cannot be excluded at this time. Therefore, examination of the lens by methods adequate to detect cataract formation, such as slit lamp exam or other appropriately sensitive methods, is recommended at initiation of treatment or shortly thereafter, and at 6-month intervals during chronic treatment.
During clinical trials, seizures occurred in 0.5% (20/3490) of patients treated with SEROQUEL compared to 0.2% (2/954) on placebo and 0.7% (4/527) on active control drugs. As with other antipsychotics, SEROQUEL should be used cautiously in patients with a history of seizures or with conditions that potentially lower the seizure threshold, eg, Alzheimer's dementia. Conditions that lower the seizure threshold may be more prevalent in a population of 65 years or older.
Adults: Clinical trials with SEROQUEL demonstrated a dose-related decrease in total and free thyroxine (T4) of approximately 20% at the higher end of the therapeutic dose range and was maximal in the first two to four weeks of treatment and maintained without adaptation or progression during more chronic therapy. Generally, these changes were of no clinical significance and thyroid stimulating hormone (TSH) was unchanged in most patients and levels of thyroid binding globulin (TBG) were unchanged. In nearly all cases, cessation of SEROQUEL treatment was associated with a reversal of the effects on total and free T4, irrespective of the duration of treatment. About 0.7% (26/3489) of SEROQUEL patients did experience TSH increases in monotherapy studies. Six of the patients with TSH increases needed replacement thyroid treatment. In the mania adjunct studies, where SEROQUEL was added to lithium or divalproex, 12% (24/196) of SEROQUEL treated patients compared to 7% (15/203) of placebo-treated patients had elevated TSH levels. Of the SEROQUEL treated patients with elevated TSH levels, 3 had simultaneous low free T4 levels.
Children and Adolescents: In acute placebo-controlled trials in children and adolescent patients with schizophrenia (6-week duration) or bipolar mania (3-week duration), the incidence of shifts to potentially clinically important thyroid function values at any time for SEROQUEL treated patients and placebo-treated patients for elevated TSH was 2.9% (8/280) vs 0.7% (1/138), respectively and for decreased total thyroxine was 2.8% (8/289) vs 0% (0/145, respectively). Of the SEROQUEL treated patients with elevated TSH levels, 1 had simultaneous low free T4 level at end of treatment.
Adults: During clinical trials with quetiapine, the incidence of shifts in prolactin levels to a clinically significant value occurred in 3.6% (158/4416) of patients treated with quetiapine compared to 2.6% (51/1968) on placebo.
Children and Adolescents: In acute placebo-controlled trials in children and adolescent patients with bipolar mania (3-week duration) or schizophrenia (6-week duration), the incidence of shifts in prolactin levels to a clinically significant value ( > 20 µg/L males; > 26 µg/L females at any time) was 13.4% (18/134) for SEROQUEL compared to 4% (3/75) for placebo in males and 8.7% (9/104) for SEROQUEL compared to 0% (0/39) for placebo in females.
Like other drugs that antagonize dopamine D2 receptors, SEROQUEL elevates prolactin levels in some patients and the elevation may persist during chronic administration. Hyper prolactinemia, regardless of etiology, may suppress hypothalamic GnRH, resulting in reduced pituitary gonadotrophin secretion. This, in turn, may inhibit reproductive function by impairing gonadal steroidogenesis in both female and male patients. Galactorrhea, amenorrhea, gyneco-mastia, and impotence have been reported in patients receiving prolactin-elevating compounds. Long-standing hyperprolactinemia when associated with hypogonadism may lead to decreased bone density in both female and male subjects.
Tissue culture experiments indicate that approximately one-third of human breast cancers are prolactin dependent in vitro, a factor of potential importance if the prescription of these drugs is considered in a patient with previously detected breast cancer. As is common with compounds which increase prolactin release, mammary gland, and pancreatic islet cell neoplasia (mammary adenocarcinomas, pituitary and pancreatic adenomas) was observed in carcinogenicity studies conducted in mice and rats. Neither clinical studies nor epidemiologic studies conducted to date have shown an association between chronic administration of this class of drugs and tumorigenesis in humans, but the available evidence is too limited to be conclusive [see Carcinogenesis, Mutagenesis, Impairment of Fertility].
Asymptomatic, transient and reversible elevations in serum transaminases (primarily ALT) have been reported. In schizophrenia trials in adults, the proportions of patients with transam-inase elevations of > 3 times the upper limits of the normal reference range in a pool of 3- to 6-week placebo controlled trials were approximately 6% (29/483) for SEROQUEL compared to 1% (3/194) for placebo. In acute bipolar mania trials in adults, the proportions of patients with transaminase elevations of > 3 times the upper limits of the normal reference range in a pool of 3- to 12-week placebo controlled trials were approximately 1% for both SEROQUEL (3/560) and placebo (3/294). These hepatic enzyme elevations usually occurred within the first 3 weeks of drug treatment and promptly returned to pre-study levels with ongoing treatment with SEROQUEL. In bipolar depression trials, the proportions of patients with transaminase elevations of > 3 times the upper limits of the normal reference range in two 8-week placebo controlled trials was 1% (5/698) for SEROQUEL and 2% (6/347) for placebo.
Somnolence was a commonly reported adverse event reported in patients treated with SEROQUEL especially during the 3-5 day period of initial dose titration. In schizophrenia trials, somnolence was reported in 18% (89/510) of patients on SEROQUEL compared to 11% (22/206) of placebo patients. In acute bipolar mania trials using SEROQUEL as monotherapy, somnolence was reported in 16% (34/209) of patients on SEROQUEL compared to 4% of placebo patients. In acute bipolar mania trials using SEROQUEL as adjunct therapy, somnolence was reported in 34% (66/196) of patients on SEROQUEL compared to 9% (19/203) of placebo patients. In bipolar depression trials, somnolence was reported in 57% (398/698) of patients on SEROQUEL compared to 15% (51/347) of placebo patients. Since SEROQUEL has the potential to impair judgment, thinking, or motor skills, patients should be cautioned about performing activities requiring mental alertness, such as operating a motor vehicle (including automobiles) or operating hazardous machinery until they are reasonably certain that SEROQUEL therapy does not affect them adversely. Somnolence may lead to falls.
One case of priapism in a patient receiving SEROQUEL has been reported prior to market introduction. While a causal relationship to use of SEROQUEL has not been established, other drugs with alpha-adrenergic blocking effects have been reported to induce priapism, and it is possible that SEROQUEL may share this capacity. Severe priapism may require surgical intervention.
Although not reported with SEROQUEL, disruption of the body's ability to reduce core body temperature has been attributed to antipsychotic agents. Appropriate care is advised when prescribing SEROQUEL for patients who will be experiencing conditions which may contribute to an elevation in core body temperature, e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity, or being subject to dehydration.
Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients, in particular those with advanced Alzheimer's dementia. SEROQUEL and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia.
The possibility of a suicide attempt is inherent in bipolar disorder and schizophrenia; close supervision of high risk patients should accompany drug therapy. Prescriptions for SEROQUEL should be written for the smallest quantity of tablets consistent with good patient management in order to reduce the risk of overdose.
In 2 eight-week clinical studies in patients with bipolar depression (N=1048), the incidence of treatment emergent suicidal ideation or suicide attempt was low and similar to placebo (SEROQUEL 300 mg, 6/350, 1.7%; SEROQUEL 600 mg, 9/348, 2.6%; Placebo, 7/347, 2.0%).
Clinical experience with SEROQUEL in patients with certain concomitant systemic illnesses is limited [see Pharmacokinetics].
SEROQUEL has not been evaluated or used to any appreciable extent in patients with a recent history of myocardial infarction or unstable heart disease. Patients with these diagnoses were excluded from premarketing clinical studies. Because of the risk of orthostatic hypotension with SEROQUEL, caution should be observed in cardiac patients [see WARNINGS AND PRECAUTIONS].
Acute withdrawal symptoms, such as nausea, vomiting, and insomnia have very rarely been described after abrupt cessation of atypical antipsychotic drugs, including SEROQUEL. Gradual withdrawal is advised.
[see Medication Guide]
Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with SEROQUEL and should counsel them in its appropriate use. A patient Medication Guide about “Antidepressant Medicines, Depression and other Serious Mental Illness, and Suicidal Thoughts or Actions” is available for SEROQUEL. The prescriber or health professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document.
Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking SEROQUEL.
Patients and caregivers should be advised that elderly patients with dementia-related psychoses treated with atypical antipsychotic drugs are at increased risk of death compared with placebo. Quetiapine is not approved for elderly patients with dementia-related psychosis [see WARNINGS AND PRECAUTIONS].
Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should be advised to look for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt. Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication [see WARNINGS AND PRECAUTIONS].
Patients should be advised to report to their physician any signs or symptoms that may be related to NMS. These may include muscle stiffness and high fever [see WARNINGS AND PRECAUTIONS].
Patients should be aware of the symptoms of hyperglycemia (high blood sugar) and diabetes mellitus. Patients who are diagnosed with diabetes, those with risk factors for diabetes, or those that develop these symptoms during treatment should have their blood glucose monitored at the beginning of and periodically during treatment [see WARNINGS AND PRECAUTIONS].
Patients should be advised that elevations in total cholesterol, LDL-cholesterol and triglyc-erides and decreases in HDL-cholesterol may occur. Patients should have their lipid profile monitored at the beginning of and periodically during treatment [see WARNINGS AND PRECAUTIONS].
Patients should be advised that they may experience weight gain. Patients should have their weight monitored regularly [see WARNINGS AND PRECAUTIONS].
Patients should be advised of the risk of orthostatic hypotension (symptoms include feeling dizzy or lightheaded upon standing, which may lead to falls), especially during the period of initial dose titration, and also at times of re-initiating treatment or increases in dose [see WARNINGS AND PRECAUTIONS].
Blood pressure should be measured at the beginning of, and periodically during, treatment [see WARNINGS AND PRECAUTIONS].
Patients with a pre-existing low WBC or a history of drug induced leukopenia/neutropenia should be advised that they should have their CBC monitored while taking SEROQUEL [see WARNINGS AND PRECAUTIONS].
Patients should be advised of the risk of somnolence or sedation (which may lead to falls), especially during the period of initial dose titration. Patients should be cautioned about performing any activity requiring mental alertness, such as operating a motor vehicle (including automobiles) or operating machinery, until they are reasonably certain quetiapine therapy does not affect them adversely. Patients should limit consumption of alcohol during treatment with quetiapine [see WARNINGS AND PRECAUTIONS].
Patients should be advised regarding appropriate care in avoiding overheating and dehydration [see WARNINGS AND PRECAUTIONS].
As with other medications, patients should be advised to notify their physicians if they are taking, or plan to take, any prescription or over-the-counter drugs [see WARNINGS AND PRECAUTIONS].
Patients should be advised to notify their physician if they become pregnant or intend to become pregnant during therapy. Patients should be advised not to breast feed if they are taking quetiapine [see Use in Specific Populations].
SEROQUEL is indicated as an integral part of a total treatment program for adolescents with schizophrenia and pediatric bipolar disorder that may include other measures (psychological, educational, and social). Effectiveness and safety of SEROQUEL have not been established in pediatric patients less than 13 years of age for schizophrenia or less than 10 years of age for bipolar mania. Appropriate educational placement is essential and psychosocial intervention is often helpful. The decision to prescribe atypical antipsychotic medication will depend upon the physician's assessment of the chronicity and severity of the patient's symptoms.
Carcinogenicity studies were conducted in C57BL mice and Wistar rats. Quetiapine was administered in the diet to mice at doses of 20, 75, 250, and 750 mg/kg and to rats by gavage at doses of 25, 75, and 250 mg/kg for two years. These doses are equivalent to 0.1, 0.5, 1.5, and 4.5 times the maximum human dose (800 mg/day) on a mg/m2 basis (mice) or 0.3, 0.9, and 3.0 times the maximum human dose on a mg/m2 basis (rats). There were statistically significant increases in thyroid gland follicular adenomas in male mice at doses of 250 and 750 mg/kg or 1.5 and 4.5 times the maximum human dose on a mg/m2 basis and in male rats at a dose of 250 mg/kg or 3.0 times the maximum human dose on a mg/m2 basis. Mammary gland adenocarcinomas were statistically significantly increased in female rats at all doses tested (25, 75, and 250 mg/kg or 0.3, 0.9, and 3.0 times the maximum recommended human dose on a mg/m2 basis).
Thyroid follicular cell adenomas may have resulted from chronic stimulation of the thyroid gland by thyroid stimulating hormone (TSH) resulting from enhanced metabolism and clearance of thyroxine by rodent liver. Changes in TSH, thyroxine, and thyroxine clearance consistent with this mechanism were observed in subchronic toxicity studies in rat and mouse and in a 1-year toxicity study in rat; however, the results of these studies were not definitive. The relevance of the increases in thyroid follicular cell adenomas to human risk, through whatever mechanism, is unknown.
Antipsychotic drugs have been shown to chronically elevate prolactin levels in rodents. Serum measurements in a 1-year toxicity study showed that quetiapine increased median serum prolactin levels a maximum of 32- and 13-fold in male and female rats, respectively. Increases in mammary neoplasms have been found in rodents after chronic administration of other antipsychotic drugs and are considered to be prolactin-mediated. The relevance of this increased incidence of prolactin-mediated mammary gland tumors in rats to human risk is unknown [see WARNINGS AND PRECAUTIONS].
The mutagenic potential of quetiapine was tested in six in vitro bacterial gene mutation assays and in an in vitro mammalian gene mutation assay in Chinese Hamster Ovary cells. However, sufficiently high concentrations of quetiapine may not have been used for all tester strains. Quetiapine did produce a reproducible increase in mutations in one Salmonella typhimurium tester strain in the presence of metabolic activation. No evidence of clastogenic potential was obtained in an in vitro chromosomal aberration assay in cultured human lymphocytes or in the in vivo micronucleus assay in rats.
Quetiapine decreased mating and fertility in male Sprague-Dawley rats at oral doses of 50 and 150 mg/kg or 0.6 and 1.8 times the maximum human dose on a mg/m2 basis. Drug-related effects included increases in interval to mate and in the number of matings required for successful impregnation. These effects continued to be observed at 150 mg/kg even after a two-week period without treatment. The no-effect dose for impaired mating and fertility in male rats was 25 mg/kg, or 0.3 times the maximum human dose on a mg/m2 basis. Quetiapine adversely affected mating and fertility in female Sprague-Dawley rats at an oral dose of 50 mg/kg, or 0.6 times the maximum human dose on a mg/m2 basis. Drug-related effects included decreases in matings and in matings resulting in pregnancy, and an increase in the interval to mate. An increase in irregular estrus cycles was observed at doses of 10 and 50 mg/kg, or 0.1 and 0.6 times the maximum human dose on a mg/m2 basis. The no-effect dose in female rats was 1 mg/kg, or 0.01 times the maximum human dose on a mg/m2 basis.
The teratogenic potential of quetiapine was studied in Wistar rats and Dutch Belted rabbits dosed during the period of organogenesis. No evidence of a teratogenic effect was detected in rats at doses of 25 to 200 mg/kg or 0.3 to 2.4 times the maximum human dose on a mg/m2 basis or in rabbits at 25 to 100 mg/kg or 0.6 to 2.4 times the maximum human dose on a mg/m2 basis. There was, however, evidence of embryo/fetal toxicity. Delays in skeletal ossification were detected in rat fetuses at doses of 50 and 200 mg/kg (0.6 and 2.4 times the maximum human dose on a mg/m2 basis) and in rabbits at 50 and 100 mg/kg (1.2 and 2.4 times the maximum human dose on a mg/m2 basis). Fetal body weight was reduced in rat fetuses at 200 mg/kg and rabbit fetuses at 100 mg/kg (2.4 times the maximum human dose on a mg/m2 basis for both species). There was an increased incidence of a minor soft tissue anomaly (carpal/tarsal flexure) in rabbit fetuses at a dose of 100 mg/kg (2.4 times the maximum human dose on a mg/m2 basis). Evidence of maternal toxicity (i.e., decreases in body weight gain and/or death) was observed at the high dose in the rat study and at all doses in the rabbit study. In a peri/postnatal reproductive study in rats, no drug-related effects were observed at doses of 1, 10, and 20 mg/kg or 0.01, 0.12, and 0.24 times the maximum human dose on a mg/m2 basis. However, in a preliminary peri/postnatal study, there were increases in fetal and pup death, and decreases in mean litter weight at 150 mg/kg, or 3.0 times the maximum human dose on a mg/m2 basis.
There are no adequate and well-controlled studies in pregnant women and quetiapine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
The effect of SEROQUEL on labor and delivery in humans is unknown.
SEROQUEL was excreted in milk of treated animals during lactation. It is not known if SEROQUEL is excreted in human milk. It is recommended that women receiving SEROQUEL should not breast feed.
In general, the adverse reactions observed in children and adolescents during the clinical trials were similar to those in the adult population with few exceptions. Increases in systolic and diastolic blood pressure occurred in children and adolescents and did not occur in adults. Orthostatic hypotension occurred more frequently in adults (4-7%) compared to children and adolescents ( < 1%).
The efficacy and safety of SEROQUEL in the treatment of schizophrenia in adolescents aged 13 to 17 years were demonstrated in one six week, double-blind, placebo-controlled trial [see INDICATIONS, DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS, and Clinical Studies].
Safety and effectiveness of SEROQUEL in pediatric patients less than 13 years of age with schizophrenia have not been established.
The safety and effectiveness of SEROQUEL in the maintenance treatment of bipolar disorder has not been established in pediatric patients less than 18 years of age. The safety and effectiveness of SEROQUEL in the maintenance treatment of schizophrenia has not been established in any patient population, including pediatric patients.
The efficacy and safety of SEROQUEL in the treatment of mania in children and adolescents ages 10 to 17 years with Bipolar I disorder was demonstrated in a 3-week, double-blind, placebo controlled, multicenter trial. [see INDICATIONS, DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS, and Clinical Studies].
Safety and effectiveness of SEROQUEL in pediatric patients less than 10 years of age with bipolar mania have not been established.
Safety and effectiveness of SEROQUEL in pediatric patients less than 18 years of age with bipolar depression have not been established.
Some differences in the pharmacokinetics of quetiapine were noted between children/adolescents (10 to 17 years of age) and adults. When adjusted for weight, the AUC and Cmax of quetiapine were 41% and 39% lower, respectively, in children and adolescents compared to adults. The pharmacokinetics of the active metabolite, norquetiapine, were similar between children/adolescents and adults after adjusting for weight [see CLINICAL PHARMACOLOGY].
Of the approximately 3700 patients in clinical studies with SEROQUEL, 7% (232) were 65 years of age or over. In general, there was no indication of any different tolerability of SEROQUEL in the elderly compared to younger adults. Nevertheless, the presence of factors that might decrease pharmacokinetic clearance, increase the pharmacodynamic response to SEROQUEL, or cause poorer tolerance or orthostasis, should lead to consideration of a lower starting dose, slower titration, and careful monitoring during the initial dosing period in the elderly. The mean plasma clearance of SEROQUEL was reduced by 30% to 50% in elderly patients when compared to younger patients [see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION].
Last updated on RxList: 12/29/2009
In clinical trials, survival has been reported in acute overdoses of up to 30 grams of quetiapine. Most patients who overdosed experienced no adverse reactions or recovered fully from the reported reactions. Death has been reported in a clinical trial following an overdose of 13.6 grams of quetiapine alone. In general, reported signs and symptoms were those resulting from an exaggeration of the drugs known pharmacological effects, ie, drowsiness and sedation, tachycardia and hypotension. Patients with pre-existing severe cardiovascular disease may be at an increased risk of the effects of overdose [see WARNINGS AND PRECAUTIONS]. One case, involving an estimated overdose of 9600 mg, was associated with hypokalemia and first degree heart block. In post-marketing experience, there have been very rare reports of overdose of SEROQUEL alone resulting in death, coma, or QTc prolongation.
In case of acute overdosage, establish and maintain an airway and ensure adequate oxygenation and ventilation. Gastric lavage (after intubation, if patient is unconscious) and administration of activated charcoal together with a laxative should be considered. The possibility of obtundation, seizure or dystonic reaction of the head and neck following overdose may create a risk of aspiration with induced emesis. Cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring to detect possible arrhythmias. If antiarrhythmic therapy is administered, disopyramide, procainamide and quinidine carry a theoretical hazard of additive QT-prolonging effects when administered in patients with acute overdosage of SEROQUEL. Similarly it is reasonable to expect that the alpha-adrenergic-blocking properties of bretylium might be additive to those of quetiapine, resulting in problematic hypotension.
There is no specific antidote to SEROQUEL. Therefore, appropriate supportive measures should be instituted. The possibility of multiple drug involvement should be considered. Hypotension and circulatory collapse should be treated with appropriate measures such as intravenous fluids and/or sympathomimetic agents (epinephrine and dopamine should not be used, since beta stimulation may worsen hypotension in the setting of quetiapine-induced alpha blockade). In cases of severe extrapyramidal symptoms, anticholinergic medication should be administered. Close medical supervision and monitoring should continue until the patient recovers.
The mechanism of action of SEROQUEL, as with other drugs having efficacy in the treatment of schizophrenia and bipolar disorder, is unknown. However, it has been proposed that the efficacy of SEROQUEL in schizophrenia and its mood stabilizing properties in bipolar depression and mania are mediated through a combination of dopamine type 2 (D2) and serotonin type 2 (5HT2) antagonism. Antagonism at receptors other than dopamine and 5HT2 with similar receptor affinities may explain some of the other effects of SEROQUEL. SEROQUEL's antagonism of histamine H1 receptors may explain the somnolence observed with this drug.
SEROQUEL's antagonism of adrenergic α1 receptors may explain the orthostatic hypotension observed with this drug.
SEROQUEL is an antagonist at multiple neurotransmitter receptors in the brain: serotonin 5HT1A and 5HT2 (IC50s=717 & 148nM, respectively), dopamine D1 and D2 (IC50s=1268 & 329nM, respectively), histamine H1 (IC50=30nM), and adrenergic α1 and α2 receptors (IC50s=94 & 271nM, respectively). SEROQUEL has no appreciable affinity at cholinergic muscarinic and benzodiazepine receptors (IC50s > 5000 nM).
Quetiapine fumarate activity is primarily due to the parent drug. The multiple-dose pharmaco-kinetics of quetiapine are dose-proportional within the proposed clinical dose range, and quetiapine accumulation is predictable upon multiple dosing. Elimination of quetiapine is mainly via hepatic metabolism with a mean terminal half-life of about 6 hours within the proposed clinical dose range. Steady-state concentrations are expected to be achieved within two days of dosing. Quetiapine is unlikely to interfere with the metabolism of drugs metabolized by cytochrome P450 enzymes.
At steady-state the pharmacokinetics of the parent compound, in children and adolescents (10-17 years of age), were similar to adults. However, when adjusted for dose and weight, AUC and Cmax of the parent compound were 41% and 39% lower, respectively, in children and adolescents than in adults. For the active metabolite, norquetiapine, AUC and Cmax were 45% and 31% higher, respectively, in children and adolescents than in adults. When adjusted for dose and weight, the pharmacokinetics of the metabolite, norquetiapine, was similar between children and adolescents and adults [see Use in Specific Populations].
Quetiapine fumarate is rapidly absorbed after oral administration, reaching peak plasma concentrations in 1.5 hours. The tablet formulation is 100% bioavailable relative to solution. The bioavailability of quetiapine is marginally affected by administration with food, with Cmax and AUC values increased by 25% and 15%, respectively.
Quetiapine is widely distributed throughout the body with an apparent volume of distribution of 10±4 L/kg. It is 83% bound to plasma proteins at therapeutic concentrations. In vitro, quetiapine did not affect the binding of warfarin or diazepam to human serum albumin. In turn, neither warfarin nor diazepam altered the binding of quetiapine.
Following a single oral dose of 14C-quetiapine, less than 1% of the administered dose was excreted as unchanged drug, indicating that quetiapine is highly metabolized. Approximately 73% and 20% of the dose was recovered in the urine and feces, respectively.
Quetiapine is extensively metabolized by the liver. The major metabolic pathways are sulfoxidation to the sulfoxide metabolite and oxidation to the parent acid metabolite; both metabolites are pharmacologically inactive. In vitro studies using human liver microsomes revealed that the cytochrome P450 3A4 isoenzyme is involved in the metabolism of quetiapine to its major, but inactive, sulfoxide metabolite and in the metabolism of its active metabolite N-desalkyl quetiapine.
Oral clearance of quetiapine was reduced by 40% in elderly patients ( ≥ 65 years, n=9) compared to young patients (n=12), and dosing adjustment may be necessary [see DOSAGE AND ADMINISTRATION].
There is no gender effect on the pharmacokinetics of quetiapine.
There is no race effect on the pharmacokinetics of quetiapine.
Smoking has no effect on the oral clearance of quetiapine.
Patients with severe renal impairment (Clcr=10-30 mL/min/1.73 m2, n=8) had a 25% lower mean oral clearance than normal subjects (Clcr > 80 mL/min/1.73 m2, n=8), but plasma quetiapine concentrations in the subjects with renal insufficiency were within the range of concentrations seen in normal subjects receiving the same dose. Dosage adjustment is therefore not needed in these patients.
Hepatically impaired patients (n=8) had a 30% lower mean oral clearance of quetiapine than normal subjects. In two of the 8 hepatically impaired patients, AUC and Cmax were 3 times higher than those observed typically in healthy subjects. Since quetiapine is extensively metabolized by the liver, higher plasma levels are expected in the hepatically impaired population, and dosage adjustment may be needed [see DOSAGE AND ADMINISTRATION].
In vitro enzyme inhibition data suggest that quetiapine and 9 of its metabolites would have little inhibitory effect on in vivo metabolism mediated by cytochromes P450 1A2, 2C9, 2C19, 2D6 and 3A4.
Quetiapine oral clearance is increased by the prototype cytochrome P450 3A4 inducer, phenytoin, and decreased by the prototype cytochrome P450 3A4 inhibitor, ketoconazole. Dose adjustment of quetiapine will be necessary if it is coadministered with phenytoin or ketoconazole [see DRUG INTERACTIONS].
Quetiapine oral clearance is not inhibited by the non-specific enzyme inhibitor, cimetidine. Quetiapine at doses of 750 mg/day did not affect the single dose pharmacokinetics of antipyrine, lithium or lorazepam [see DRUG INTERACTIONS].
Quetiapine caused a dose-related increase in pigment deposition in thyroid gland in rat toxicity studies which were 4 weeks in duration or longer and in a mouse 2-year carcinogenicity study. Doses were 10-250 mg/kg in rats, 75-750 mg/kg in mice; these doses are 0.1-3.0, and 0.1-4.5 times the maximum recommended human dose (on a mg/m2 basis), respectively. Pigment deposition was shown to be irreversible in rats. The identity of the pigment could not be determined, but was found to be co-localized with quetiapine in thyroid gland follicular epithelial cells. The functional effects and the relevance of this finding to human risk are unknown.
In dogs receiving quetiapine for 6 or 12 months, but not for 1 month, focal triangular cataracts occurred at the junction of posterior sutures in the outer cortex of the lens at a dose of 100 mg/kg, or 4 times the maximum recommended human dose on a mg/m2 basis. This finding may be due to inhibition of cholesterol biosynthesis by quetiapine. Quetiapine caused a dose-related reduction in plasma cholesterol levels in repeat-dose dog and monkey studies; however, there was no correlation between plasma cholesterol and the presence of cataracts in individual dogs. The appearance of delta-8-cholestanol in plasma is consistent with inhibition of a late stage in cholesterol biosynthesis in these species. There also was a 25% reduction in cholesterol content of the outer cortex of the lens observed in a special study in quetiapine treated female dogs. Drug-related cataracts have not been seen in any other species; however, in a 1-year study in monkeys, a striated appearance of the anterior lens surface was detected in 2/7 females at a dose of 225 mg/kg or 5.5 times the maximum recommended human dose on a mg/m2 basis.
The efficacy of SEROQUEL in the treatment of schizophrenia was established in 3 short-term (6-week) controlled trials of inpatients with schizophrenia who met DSM III-R criteria for schizophrenia. Although a single fixed dose haloperidol arm was included as a comparative treatment in one of the three trials, this single haloperidol dose group was inadequate to provide a reliable and valid comparison of SEROQUEL and haloperidol.
Several instruments were used for assessing psychiatric signs and symptoms in these studies, among them the Brief Psychiatric Rating Scale (BPRS), a multi-item inventory of general psychopathology traditionally used to evaluate the effects of drug treatment in schizophrenia. The BPRS psychosis cluster (conceptual disorganization, hallucinatory behavior, suspiciousness, and unusual thought content) is considered a particularly useful subset for assessing actively psychotic schizophrenic patients. A second traditional assessment, the Clinical Global Impression (CGI), reflects the impression of a skilled observer, fully familiar with the manifestations of schizophrenia, about the overall clinical state of the patient.
The results of the trials follow:
Examination of population subsets (race, gender, and age) did not reveal any differential responsiveness on the basis of race or gender, with an apparently greater effect in patients under the age of 40 years compared to those older than 40. The clinical significance of this finding is unknown.
The efficacy of SEROQUEL in the treatment of schizophrenia in adolescents (13–17 years of age) was demonstrated in a six week, double-blind, placebo-controlled trial. Patients who met DSM-IV diagnostic criteria for schizophrenia were randomized into one of three treatment groups: SEROQUEL 400 mg/day (n = 73), SEROQUEL 800 mg/day (n = 74), or placebo (n = 75). Study medication was initiated at 50 mg/day and on day 2 increased to 100 mg/per day (divided and given two or three times per day). Subsequently, the dose was titrated to the target dose of 400 mg/day or 800 mg/day using increments of 100 mg/day, divided and given two or three times daily. The primary efficacy variable was the mean change from baseline in total Positive and Negative Syndrome Scale (PANSS).
SEROQUEL at 400 mg/day and 800 mg/day was superior to placebo in the reduction of PANSS total score.
The efficacy of SEROQUEL in the acute treatment of manic episodes was established in 3 placebo-controlled trials in patients who met DSM-IV criteria for bipolar I disorder with manic episodes. These trials included patients with or without psychotic features and excluded patients with rapid cycling and mixed episodes. Of these trials, 2 were monotherapy (12 weeks) and 1 was adjunct therapy (3 weeks) to either lithium or divalproex. Key outcomes in these trials were change from baseline in the Young Mania Rating Scale (YMRS) score at 3 and 12 weeks for monotherapy and at 3 weeks for adjunct therapy. Adjunct therapy is defined as the simultaneous initiation or subsequent administration of SEROQUEL with lithium or divalproex.
The primary rating instrument used for assessing manic symptoms in these trials was YMRS, an 11-item clinician-rated scale traditionally used to assess the degree of manic symptomatology (irritability, disruptive/aggressive behavior, sleep, elevated mood, speech, increased activity, sexual interest, language/thought disorder, thought content, appearance, and insight) in a range from 0 (no manic features) to 60 (maximum score).
The results of the trials follow:
The efficacy of SEROQUEL in the acute treatment of bipolar mania was established in 2 placebo-controlled trials. In two 12-week trials (n=300, n=299) comparing SEROQUEL to placebo, SEROQUEL was superior to placebo in the reduction of the YMRS total score at weeks 3 and 12. The majority of patients in these trials taking SEROQUEL were dosed in a range between 400 mg/day and 800 mg per day.
In this 3-week placebo-controlled trial, 170 patients with bipolar mania (YMRS ≥ 20) were randomized to receive SEROQUEL or placebo as adjunct treatment to lithium or divalproex. Patients may or may not have received an adequate treatment course of lithium or divalproex prior to randomization. SEROQUEL was superior to placebo when added to lithium or divalproex alone in the reduction of YMRS total score.
The majority of patients in this trial taking SEROQUEL were dosed in a range between 400 mg/day and 800 mg per day. In a similarly designed trial (n=200), SEROQUEL was associated with an improvement in YMRS scores but did not demonstrate superiority to placebo, possibly due to a higher placebo effect.
The efficacy of SEROQUEL in the acute treatment of manic episodes associated with bipolar I disorder in children and adolescents (10 to 17 years of age) was demonstrated in a 3-week, double-blind, placebo controlled, multicenter trial. Patients who met DSM-IV diagnostic criteria for a manic episode were randomized into one of three treatment groups: SEROQUEL 400 mg/day (n = 95), SEROQUEL 600 mg/day (n = 98), or placebo (n = 91). Study medication was initiated at 50 mg/day and on day 2 increased to 100 mg/day (divided doses given two or three times daily). Subsequently, the dose was titrated to a target dose of 400 mg/day or 600 mg/day using increments of 100 mg/day, given in divided doses two or three times daily. The primary efficacy variable was the mean change from baseline in total YMRS score.
SEROQUEL 400 mg/day and 600 mg/day were superior to placebo in the reduction of YMRS total score.
The efficacy of SEROQUEL for the acute treatment of depressive episodes associated with bipolar disorder was established in 2 identically designed 8-week, randomized, double-blind, placebo-controlled studies (N=1045). These studies included patients with either bipolar I or II disorder and those with or without a rapid cycling course. Patients randomized to SEROQUEL were administered fixed doses of either 300 mg or 600 mg once daily.
The primary rating instrument used to assess depressive symptoms in these studies was the Montgomery-Asberg Depression Rating Scale (MADRS), a 10-item clinician-rated scale with scores ranging from 0 to 60. The primary endpoint in both studies was the change from baseline in MADRS score at week 8. In both studies, SEROQUEL was superior to placebo in reduction of MADRS score. Improvement in symptoms, as measured by change in MADRS score relative to placebo, was seen in both studies at Day 8 (week 1) and onwards. In these studies, no additional benefit was seen with the 600 mg dose. For the 300 mg dose group, statistically significant improvements over placebo were seen in overall quality of life and satisfaction related to various areas of functioning, as measured using the Q-LES-Q(SF).
The efficacy of SEROQUEL in the maintenance treatment of bipolar I disorder was established in 2 placebo-controlled trials in patients (n=1326) who met DSM-IV criteria for bipolar I disorder. The trials included patients whose most recent episode was manic, depressed, or mixed, with or without psychotic features. In the open-label phase, patients were required to be stable on SEROQUEL plus lithium or divalproex for at least 12 weeks in order to be randomized. On average, patients were stabilized for 15 weeks. In the randomization phase, patients continued treatment with lithium or divalproex and were randomized to receive either SEROQUEL (administered twice daily totaling 400 mg/day to 800 mg/day) or placebo. Approximately 50% of the patients had discontinued from the SEROQUEL group by day 280 and 50% of the placebo group had discontinued by day 117 of double-blind treatment. The primary endpoint in these studies was time to recurrence of a mood event (manic, mixed or depressed episode). A mood event was defined as medication initiation or hospitalization for a mood episode; YMRS score ≥ 20 or MADRS score ≥ 20 at 2 consecutive assessments; or study discontinuation due to a mood event.
In both studies, SEROQUEL was superior to placebo in increasing the time to recurrence of any mood event. The treatment effect was present for increasing time to recurrence of both manic and depressed episodes. The effect of SEROQUEL was independent of any specific subgroup (assigned mood stabilizer, sex, age, race, most recent bipolar episode, or rapid cycling course).
Last updated on RxList: 12/29/2009
Medication Guide
SEROQUEL
(SER-oh-kwell)
( quetiapine fumarate) Tablets
Read this Medication Guide before you start taking SEROQUEL and each time you get a refill. There may be new information. This Medication Guide does not take the place of talking to your healthcare provider about your medical condition or treatment.
What is the most important information I should know about SEROQUEL?
Serious side effects may happen when you take SEROQUEL, including:
Call a healthcare provider right away if you or your family member has any of the following symptoms, especially if they are new, worse, or worry you:
What else do I need to know about antidepressant medicines?
What is SEROQUEL?
SEROQUEL has not been studied in patients younger than 10 years of age.
What should I tell my healthcare provider before taking SEROQUEL?
Before taking SEROQUEL, tell your healthcare provider if you have or have had:
Tell the healthcare provider about all the medicines that you take or recently have taken including prescription medicines, non-prescription medicines, herbal supplements and vitamins.
SEROQUEL and other medicines may affect each other causing serious side effects. SEROQUEL may affect the way other medicines work, and other medicines may affect how SEROQUEL works.
Especially tell your healthcare provider if you take or plan to take medicines for:
Also tell your healthcare provider if you take or plan to take any of these medicines:
This is not a complete list of medicines that can affect or be affected by SEROQUEL. Your doctor can tell you if it is safe to take SEROQUEL with your other medicines. Do not start or stop any medicines while taking SEROQUEL without talking to your healthcare provider first. Know the medicines you take. Keep a list of your medicines to show your healthcare provider and pharmacist when you get a new medicine.
How should I take SEROQUEL?
If you suddenly stop taking SEROQUEL, you may experience side effects such as trouble sleeping or trouble staying asleep (insomnia), nausea, and vomiting.
What should I avoid while taking SEROQUEL?
Do not drive, operate machinery, or do other dangerous activities until you know how SEROQUEL affects you. SEROQUEL may make you drowsy.
What are possible side effects of SEROQUEL?
Serious side effects have been reported with SEROQUEL including:
Also, see “What is the most important information I should know about SEROQUEL?” at the beginning of this Medication Guide
Call your healthcare provider if you have any of these symptoms of high blood sugar while taking SEROQUEL:
Common possible side effects with SEROQUEL include:
Adults
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Children and Adolescents
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These are not all the possible side effects of SEROQUEL. For more information, ask your healthcare provider or pharmacist.
Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
How should I store SEROQUEL?
General information about SEROQUEL
Do not take SEROQUEL unless your healthcare provider has prescribed it for you for your condition. Do not share SEROQUEL with other people, even if they have the same condition. It may harm them.
This Medication Guide provides a summary of important information about SEROQUEL. For more information about SEROQUEL, talk with your healthcare provider or pharmacist or call 1-800-236-9933. You can ask your healthcare provider for information about SEROQUEL that is written for health professionals.
What are the ingredients in SEROQUEL?
Active ingredient: quetiapine fumarate
Inactive ingredients: povidone, dibasic dicalcium phosphate dihydrate, microcrystalline cellulose, sodium starch glycolate, lactose monohydrate, magnesium stearate, hypromellose, polyethylene glycol, and titanium dioxide. The 25 mg tablets contain red and yellow ferric oxide. The 100 mg and 400 mg tablets contain only yellow ferric oxide
The symptoms of Schizophrenia include:
The symptoms of Bipolar Disorder include:
This Medication Guide has been approved by the U.S. Food and Drug Administration.
Last updated on RxList: 12/29/2009
IMPORTANT NOTE: This is a summary and does not contain all possible information about this product. For complete information about this product or your specific health needs, ask your health care professional. Always seek the advice of your health care professional if you have any questions about this product or your medical condition. This information is not intended as individual medical advice and does not substitute for the knowledge and judgment of your health care professional. This information does not contain any assurances that this product is safe, effective, or appropriate for you.
QUETIAPINE - ORAL
(kweh-TIE-ah-peen)
COMMON BRAND NAME(S): Seroquel
WARNING: There may be a slightly increased risk of serious, possibly fatal side effects (e.g., stroke, heart failure) when this medication is used in elderly patients with dementia. This medication is not approved for the treatment of dementia-related behavior problems. Discuss the risks and benefits of this medication, as well as other effective and possibly safer treatments for dementia-related behavior problems, with the doctor.
USES: This medication is used with or without other medications to treat certain mental/mood conditions (e.g., bipolar disorder, schizophrenia). Quetiapine is known as an anti-psychotic drug (atypical type). It works by helping to restore the balance of certain natural chemicals (neurotransmitters) in the brain.
This medication can decrease hallucinations and improve your concentration. It helps you to think more clearly and positively about yourself, feel less nervous, and take a more active part in everyday life. Quetiapine can help prevent severe mood swings or decrease how often mood swings occur.
HOW TO USE: Read the Medication Guide available from your pharmacist before you start using quetiapine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.
Take this medication by mouth with or without food, usually 2 or 3 times daily or as directed by your doctor. Dosage is based on your medical condition and response to therapy. Your doctor will start you at a low dose and gradually increase the dose to reduce the dizziness and lightheadedness that may occur when you first start to take this drug. It may take several weeks to notice the full benefit of this drug.
Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same times each day. If you stop taking quetiapine for more than one week, notify your doctor. If you restart the drug, you may need to start at a low dose and gradually increase the dose again.
Continue taking this medication exactly as prescribed, even if you are feeling better and thinking more clearly. Do not stop taking this medication without first consulting your doctor. Some conditions may become worse when the drug is suddenly stopped.
This medication may cause dependence, especially if it has been used regularly for an extended time or if it has been used in high doses. In such cases, withdrawal reactions (such as trouble sleeping, nausea, diarrhea, irritability) may occur if you suddenly stop this drug. To prevent withdrawal when stopping extended/regular treatment with this drug, gradually reduce the dosage as directed. Consult your doctor or pharmacist for more details, and report any withdrawal reactions immediately.
Limit the amount of grapefruit or grapefruit juice you may eat or drink while being treated with this medication unless your doctor directs you otherwise. Grapefruit may increase the amount of certain medications in your blood stream. Consult your doctor or pharmacist for more details.
Inform your doctor if your condition persists or worsens.
Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.
Tell your doctor immediately if any of these unlikely but serious side effects occur: fainting, unusually fast/irregular heartbeat, signs of infection (e.g., fever, persistent sore throat), mental/mood changes (e.g., increased anxiety, depression, suicidal thoughts), difficulty swallowing, weakness, swelling arms/legs/feet.
Tell your doctor immediately if any of these rare but very serious side effects occur: seizures, vision changes.
Quetiapine may rarely cause a condition known as tardive dyskinesia. In some cases, this condition may be permanent. Tell your doctor immediately if you develop any unusual/uncontrolled movements (especially of the face, lips, mouth, tongue, arms or legs).
For males, in the very unlikely event you have a painful or prolonged erection (lasting more than 4 hours), stop using this drug and seek immediate medical attention, or permanent problems could occur.
This drug may infrequently cause a serious (rarely fatal) nervous system disorder (neuroleptic malignant syndrome). Seek immediate medical attention if you notice any of the following rare but very serious side effects: muscle stiffness, high fever, increased sweating, fast heartbeat, mental/mood changes, change in the amount of urine.
A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include: rash, itching, swelling, severe dizziness, trouble breathing.
This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.
Contact your doctor for medical advice about side effects. The following numbers do not provide medical advice, but in the US you may report side effects to the Food and Drug Administration (FDA) at 1-800-FDA-1088. In Canada, you may call Health Canada at 1-866-234-2345.
PRECAUTIONS: Before taking quetiapine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Before using this medication, tell your doctor or pharmacist your medical history, especially of: Alzheimer's disease, low blood pressure, disease of the blood vessels in the brain (e.g., stroke), blood disorders (e.g., leukopenia, neutropenia), a severe loss of body water (dehydration), certain eye problems (cataracts), liver disease, seizures, trouble swallowing, thyroid problems.
Also tell your doctor or pharmacist if you or a family member has a history of the following: alcohol/drug abuse, diabetes, heart disease (e.g., ischemic heart disease, heart failure, heart rhythm problems), high blood cholesterol/triglyceride levels, high blood pressure, obesity.
Get up slowly when rising from a sitting or lying position to avoid dizziness and lightheadedness. This is more likely to occur in the first few days after starting/restarting the drug or after your dose increases.
This drug may make you dizzy or drowsy; use caution engaging in activities requiring alertness such as driving or using machinery. Avoid alcoholic beverages.
This drug may also cause significant weight gain and a rise in your blood cholesterol (or triglyceride) levels. These effects may increase your risk for developing heart disease, especially if you also have diabetes. Discuss the risks and benefits of treatment with your doctor. (See also Notes section.)
This drug may infrequently make your blood sugar level rise, causing or worsening diabetes. This high blood sugar can rarely cause serious conditions such as diabetic coma. Tell your doctor immediately if you develop symptoms of high blood sugar such as unusual increased thirst/urination or vision changes. If you already have diabetes, be sure to check your blood sugar level regularly.
This drug can make you more likely to get heat stroke. Avoid activities that may cause you to overheat (e.g., strenuous work, exercising in hot weather, using hot tubs). Drink plenty of fluids, dress lightly, and stay in cool/air-conditioned areas when the weather is hot.
Caution is advised when using this drug in the elderly because they may be more sensitive to its effects, especially dizziness.
This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor.
It is not known whether this drug passes into breast milk. Because of the possible risk to the infant, breast-feeding while using this drug is not recommended. Consult your doctor before breast-feeding.
This drug should not be used with the following medication because very serious interactions may occur: sibutramine.
If you are currently using this medication, tell your doctor or pharmacist before starting quetiapine.
Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: anticholinergics (e.g., belladonna alkaloids, benztropine, scopolamine), dopamine-like drugs (e.g., bromocriptine, cabergoline), levodopa, rifabutin, drugs for treating high blood pressure (e.g., alpha blockers such as prazosin, calcium channel blockers such as diltiazem, "water pills"/diuretics such as hydrochlorothiazide), drugs affecting liver enzymes that remove quetiapine from your body (e.g., azole antifungals such as fluconazole/ketoconazole/itraconazole, barbiturates such as phenobarbital, glucocorticoids such as dexamethasone, macrolide antibiotics such as erythromycin, rifampin, certain anti-seizure drugs such as carbamazepine/phenytoin, thioridazine), thyroid medicine (e.g., thyroxine).
Also report the use of drugs which might increase seizure risk (decrease seizure threshold) when combined with quetiapine such as: bupropion, isoniazid (INH), other antipsychotics (e.g., chlorpromazine), tramadol, theophylline, and tricyclic antidepressants (e.g., amitriptyline), among others. Consult your doctor or pharmacist for details.
Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as: certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., alprazolam, diazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., chlorpromazine, risperidone, amitriptyline, trazodone). Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain drowsiness-causing ingredients. Ask your pharmacist about the safe use of those products.
This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.
OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include drowsiness, rapid pulse, weakness, tiredness, and dizziness.
NOTES: Do not share this medication with others.
Laboratory and/or medical tests (e.g., fasting blood sugar, weight, blood pressure, blood cholesterol/triglyceride levels, eye exams) should be performed regularly to monitor your progress or check for side effects. Consult your doctor for more details.
MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.
STORAGE: Store at room temperature at 77 degrees F (25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Keep all medicines away from children and pets.
Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.
Information last revised July 2008 Copyright(c) 2008 First DataBank, Inc.
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