Table 17

Levomepromazine buccal or sublingual

Levomepromazine buccal or sublingual
What is it?Anti-psychotic
Mechanism of actionCentral nervous system (CNS); receptors include adrenergic, dopamine, histamine, cholinergic and serotonin receptors
Starting dose3 mg–25 mg once daily (or 6.25–12.5 mg as required maximum three times in 24 hours)
Time to onset of effectNot known (30 min via oral route)17
FormulationOral tablet crushed, with water 6.25–25 mg;
6 mg tablets (Levinan) 3 mg (1/2 tablet) 4–6 hourly PRN (can be crush);
OR injection 0.25–1 mL sublingual
IndicationSecond line for nausea and vomiting or delirium and agitation
Common adverse effectsPostural hypotension; falls; ‘asthenia; heat stroke’16
Contraindications‘CNS depression; comatose states; phaeochromocytoma’16
CautionDementia, cardiac, prolonged QT, Parkinsonism, hypothyroidism, seizure, postural hyotension, myasthenia, renal and liver impairment16
LicencingOral tablet licensed; Levinan is an unlicensed preparation available on a named patient basis; off licence route for injectable levoempromazine
BenefitsBuccal administration of broad spectrum, long acting anti-psychotic*
RisksInjection concentration is 25 mg/mL so challenging to administer 0.25 mL, risk of injury from glass ampoule to lay carer
Cost£20.26 for 84×25 mg tablets
£20.13 for 10×25 mg/mL ampoules for injection;
6 mg tablets—special price of application
  • *Level of evidence supporting its use (CBEM): level 5; authors EH and ICKCW have clinical experience of its use.