Levomepromazine buccal or sublingual
| Levomepromazine buccal or sublingual | |
| What is it? | Anti-psychotic |
| Mechanism of action | Central nervous system (CNS); receptors include adrenergic, dopamine, histamine, cholinergic and serotonin receptors |
| Starting dose | 3 mg–25 mg once daily (or 6.25–12.5 mg as required maximum three times in 24 hours) |
| Time to onset of effect | Not known (30 min via oral route)17 |
| Formulation | Oral tablet crushed, with water 6.25–25 mg; OR 6 mg tablets (Levinan) 3 mg (1/2 tablet) 4–6 hourly PRN (can be crush); OR injection 0.25–1 mL sublingual |
| Indication | Second line for nausea and vomiting or delirium and agitation |
| Common adverse effects | Postural hypotension; falls; ‘asthenia; heat stroke’16 |
| Contraindications | ‘CNS depression; comatose states; phaeochromocytoma’16 |
| Caution | Dementia, cardiac, prolonged QT, Parkinsonism, hypothyroidism, seizure, postural hyotension, myasthenia, renal and liver impairment16 |
| Licencing | Oral tablet licensed; Levinan is an unlicensed preparation available on a named patient basis; off licence route for injectable levoempromazine |
| Benefits | Buccal administration of broad spectrum, long acting anti-psychotic* |
| Risks | Injection 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.