The Hospice Clinician Blog

There are several choices available among the antipsychotic (neuroleptic) drug class for managing psychotic symptoms and end-of-life delirium in hospice patients.   The range in cost from the least expensive to some of the most expensive antipsychotics is very broad.   Equivalent dose costs can range from as low as $20 per month (Haloperidol 1mg twice a day) to more than $600 per month (Abilify 5mg daily).    Efficacy of the various antipsychotic drugs for managing these symptoms in hospice patients is comparable, so the higher cost agents may not be justified when based solely on any clinical evidence of ability to control symptoms. (1, 2)     The newer atypical antipsychotics which are significantly higher in cost may have the advantage of lower potential for side-effects, specifically involuntary movement disorders, in certain select groups of patients.    This would include patients with a history of drug induced extrapyramidal symptoms (EPS) or a diagnosis of Parkinson’s disease.   An atypical antipsychotic may be justified in one of these types of patients.   Risperidone should be the primary drug considered in this situation since it is the most cost-effective of the atypical group.   

A table of antipsychotic dose equivalents and corresponding estimated costs to the hospice is provided below.   The dose equivalents were taken from an article that appeared in the Journal of Clinical Psychiatry in 2003.(3)   The dose equivalents were determined by the researcher after an exhaustive review of published studies of fixed dose antipsychotics up until June of 2002.  The search included; Medline, the bibliographies of identified reports, published meta-analyses and reviews,  Cochrane reviews, Freedom of Information Act material from the FDA, and abstracts from several scientific meetings from 1997 – 2002.   The dosage equivalence for the various antipsychotics was reported as “minimal effective dose” equivalents.    Most of the reports reviewed to come up with this data were probably not studies that included hospice or terminally ill patients, so keep in mind that “minimal effective” doses in the terminally ill may be lower than that in other populations.   The dosage ratios between the drugs, however, would probably still hold true when considering converting from one drug to another. 
 
The table below may be useful in estimating comparative antipsychotic drug costs for a hospice patient, as well as providing an equivalency guide for conversion from one antipsychotic drug to another more cost-effective agent. 

*All prices are for the generic version of the drug, except Abilify because there is no generic available at this time.
 

References:
1) Boustani, M.  J. General Internal Med. 2009; 24: 848-853
2) Cochrane Database Syst. Rev. 2007 April 18 (2): CD005594
3) Woods SW.   J. Clin. Psychiatry.  2003 Jun;64(6):663-7.