Zuclopenthixol (Clopixol-Depot, Clopixol-Acuphase)

Primer

Zuclopenthixol (Tradename: Clopixol) is a typical antipsychotic that comes in two formulations. Zuclopenthixol decanoate (Cloxpiol Depot) is for long-term treatment of schizophrenia, while zuclopenthixol acetate (Clopixol-Acuphase) is used in management of severe aggression that is not responsive to other medications.

Formulations

Zuclopenthixol Formulations

Formulation Tradename Indications
Zuclopenthixol decanoate Clopixol Depot This is a long-acting intramuscular (depot), injection used for the long-term management of schizophrenia.
Zuclopenthixol acetate Clopixol- Acuphase This is a short-acting intramusclar formulation, is used for the treatment of acute, difficult to control agitation/aggression, with a peak effect at 48-72 hours. It does not work to immediately stop acute agitation/aggression.

Clopixol Depot

Zuclopenthixol decanoate (Tradename: Clopixol Depot) is an intramuscular injection antipsychotic given every 2-4 weeks.

Dosing

  • The dose range for Clopixol Depot is 100-600 mg every 2-4 weeks
  • The most common dosage range is 200-400 mg every 4 weeks

Clopixol-Acuphase

Dosing

Dose ranges from 50 to 150mg, in 50mg increments, up to a maximum of 400mg in a 2-week period. This generally provides enough time for more long-term management. Injections should be given at least 24 hours apart. The evidence is unclear if there are harmful effects from more prolonged administration. Patients should be reassessed for why they need zuclopenthixol each time they receive the injection.

Pharmacodynamics

Clopixol-Acuphase's sedative effects begins about 2 hours after injection and peaks at 12 hours. The effects can last for up to 72 hours. Zuclopenthixol should never be used in rapid tranquilization because its action not rapid.

Indications

Clopixol-Acuphase should never be considered as a first-line drug for rapid tranquillization as its onset of action will not act rapidily enough in acute agitation. Additionally, it is an oil-based injection, which carries a high risk of oil embolus (via intravasation) in a highly agitated patient.[1]

Pearls

Clopixol-Acuphase is widely misused, and in reality, can be a potentially toxic medication with poor evidence to support its use. However, it should be considered as a last line of effective short-term chemical restraint. It is best reserved for patients with ongoing aggression/violence risk to others, and in the few patients who have previously had a good response to it.

Never Use Clopixol-Acuphase For These Reasons

Clopixol-Acuphase should never be administered:
  • In an attempt to hasten the effect of another antipsychotic
  • For rapid tranquilization (it won't work!)
  • At the same time with other parenteral (IV) antipsychotics or benzodiazepines, due to risk of over-sedation, which can be difficult to reverse and cause respiratory compromise
  • To a patient who is physically resistant, due to risk of intravasation and oil embolus

Contraindications

Clopixol-Acuphase should never be used for patients:
  • Who will accept oral antipsychotic medication
  • Who are antipsychotic-naïve
  • Who are known to be sensitive to extrapyramidal side effects
  • Who are unconscious
  • Who are pregnant or are breast-feeding
  • Who are known to have cardiac disease, renal, or hepatic impairment
  • Outside of an inpatient setting (as the patient will require close monitoring over a full 24-hour period)

References

1) NHS Guidelines for the use of zuclopenthixol acetate (Clopixol Acuphase®) injection