Two Sudden and Unexpected Deaths of Patientswith Schizophrenia Associated with Intramuscular Injectionsof Antipsychotics and Practice Guidelines to Limit the Useof High Doses of Intramuscular Antipsychotics

Intravenous haloperidol has been associated with torsades de pointes (TdP). These two sudden deaths were probable adverse drugreactions (ADRs) following intramuscular (IM) antipsychotics. The autopsies described lack of heart pathology and were highlycompatible with the possibility of TdP in the absence of risk factors other than the accumulation of antipsychotics with a highserum peak after the last injection, leading to death within hours. The first case was a 27-year-old African-American male withschizophrenia but no medical issues. His death was probably caused by repeated IM haloperidol injections of 10 mg (totaling 35 mgin 2 days). The second case involves a 42-year-old African-American female with metabolic syndrome. Her probable cause of deathwas the last ziprasidone IM injection of 20 mg in addition to (1) three extra haloperidol doses (2 hours before the ziprasidoneinjection, 5 mg oral haloperidol; approximately 21 hours earlier, 5 mg oral haloperidol; and 2 days prior, one 10 mg IM haloperidolinjection), (2) 10 mg/day of scheduled oral haloperidol for 6 days before death, and (3) a long-acting paliperidone injection of156 mg 18 days before death. The study of haloperidol glucuronidation and its impairment in some African-Americans is urgentlyrecommended