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Phenothiazine antipsychotic / antiemetic Pregnancy: §4.6, verbatim. Pregnancy: 'Safety in pregnancy has not been established. Neonates exposed to antipsychotics (including Nozinan) during the third trimester of pregnancy are at risk of adverse reactions including extrapyramidal and/or withdrawal symptoms that may vary in severity and duration following delivery. There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, or feeding disorder. The clinical data with levomepromazine are reassuring but still limited, and animal studies are insufficient for a conclusion to be reached regarding reproductive toxicity. In humans, the teratogenic risk of levomepromazine has not been evaluated. Different prospective epidemiological studies conducted with other phenothiazines have yielded contradictory results regarding teratogenic risk. Given these data, it is preferable to avoid using Nozinan during pregnancy as a precautionary measure and neonates must be closely monitored in the event of treatment at the end of pregnancy.' Breast-feeding: 'Levomepromazine is excreted in breast milk in low amounts in human milk. A risk to the breast-fed infant cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Nozinan therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.' Fertility: 'There are no fertility data in animals. In humans, because of the interaction with dopamine receptors, levomepromazine may cause hyperprolactinaemia which can be associated with impaired fertility in women. Some data suggest that levomepromazine treatment is associated with impaired fertility in men.'

Levomepromazine

Brand names: Nozinan

Levomepromazine is a phenothiazine antipsychotic used in palliative care for distressing symptoms such as nausea, vomiting and agitation, and also in the management of psychosis.

Adult dose

Dose: Terminal illness: 12.5–50 mg every 4–8 hours. Psychiatric conditions (adults): ambulant patients — initial total daily oral dose 25–50 mg, usually in 3 divided doses; bed patients — initial total daily oral dose 100–200 mg, usually in 3 divided doses, then titrated.
Route: Oral — the fetched SPC is for Nozinan 25 mg Tablets, and §4.2 frames the terminal-illness regimen as an oral substitution, verbatim: 'Nozinan tablets 25 mg may be substituted for the injection if oral therapy is more convenient, the dosage being 12.5 – 50 mg every 4 – 8 hours.' SCOPE: the page lists PO/SC/IM and a CSCI regimen; this bundle contains NO subcutaneous, CSCI or intramuscular posology, so none of the page's parenteral figures are sourced here.
Frequency: Terminal illness: every 4–8 hours. Psychiatric conditions: the total daily dose is 'usually divided into 3 doses', and §4.2 adds, verbatim: 'a larger portion of the dosage may be taken at bedtime to minimise diurnal sedation.'
SCOPE: oral levomepromazine only, covering both of this page's indications as the SPC itself labels them — 'Terminal illness' and 'Psychiatric conditions'. || TERMINAL ILLNESS, §4.2 verbatim and complete: 'Nozinan tablets 25 mg may be substituted for the injection if oral therapy is more convenient, the dosage being 12.5 – 50 mg every 4 – 8 hours.' ⚠️ THIS IS NOT LABELLED AS AN ANTIEMETIC DOSE. The SPC gives no separate antiemetic regimen at all and the 12.5–50 mg every 4–8 hours figure above must not be relabelled as an antiemetic dose. || PSYCHIATRIC CONDITIONS, §4.2 verbatim: 'Ambulant patients: initially the total daily oral dose should not exceed 25 – 50 mg usually divided into 3 doses; a larger portion of the dosage may be taken at bedtime to minimise diurnal sedation. The dosage is then gradually increased to the most effective level compatible with sedation and other side effects.' And: 'Bed patients: initially the total daily oral dosage may be 100 – 200 mg, usually divided into 3 doses, gradually increased to 1 g daily if necessary. When the patient is stable attempts should be made to reduce the dosage to an adequate maintenance level.' || WHY maxDose IS EMPTY: the SPC states no absolute adult ceiling. Its two ceiling-shaped statements are both narrower than the dose field above — 'the total daily oral dose should not exceed 25 – 50 mg' applies only to the INITIAL ambulant psychiatric dose and is explicitly escalated in the very next sentence, and 'gradually increased to 1 g daily if necessary' is the bed-patient psychiatric titration end-point, not a stated maximum and not applicable to the terminal-illness regimen. Neither can be shown as a single ceiling for a dose field carrying two indications. || GENERAL, §4.2 verbatim: 'Dosage varies with the condition under treatment and the individual response of the patient.' || ELDERLY: for terminal illness, §4.2 states 'No specific dosage recommendations.' For psychiatric use, verbatim: 'It is not advised to give levomepromazine to ambulant patients over 50 years of age unless the risk of a hypotensive reaction has been assessed.' || STRENGTH: every figure above is stated in milligrams in the SPC; the 25 mg tablet strength is pinned by the product name (Nozinan 25 mg Tablets).

Paediatric dose

Route: Oral (Nozinan 25 mg Tablets).
Frequency: Not stated. The SPC expresses the paediatric dose only as a TOTAL DAILY INTAKE and gives no dosing interval or number of divided doses for children.
Max: Maximum total daily oral dose 1½ tablets = 37.5 mg. §4.2 Paediatric population, verbatim: 'It is advised that a total daily oral dosage of 1½ tablets should not be exceeded.' The tablet strength is pinned by the product name (Nozinan 25 mg Tablets).
WEIGHT CALCULATOR DELIBERATELY LEFT UNSET (dosePerKg null): the SPC gives no per-kg figure for children — the paediatric rule is expressed as a tablet count for one stated age, so nothing here can drive a per-dose weight calculation. || §4.2 Paediatric population, verbatim and complete: 'Children are very susceptible to the hypotensive and soporific effects of levomepromazine. It is advised that a total daily oral dosage of 1½ tablets should not be exceeded. The average effective daily intake for a ten year old is ½ to 1 tablet.' At the 25 mg tablet strength pinned by the product name, that is a ceiling of 37.5 mg daily, with an average effective daily intake for a ten-year-old of 12.5–25 mg. || AGE SCOPE: the ½–1 tablet figure is stated for a TEN YEAR OLD only. The SPC gives no figure for any other age, no lower age limit and no neonatal or infant dosing. || Verify the paediatric dose against a children's formulary before prescribing. || §4.8 states no separate paediatric adverse-reaction profile, and §4.4's warnings on hypotension, QT prolongation and neuroleptic malignant syndrome are not age-limited.

Dose adjustments

Renal

Not stated. No renal-impairment dosing statement appears in any fetched section (§4.2, §4.3, §4.4, §4.6, §4.8) of the Nozinan 25 mg Tablets SPC. Nothing here should be read as 'no adjustment needed' — the SPC simply does not address it, and §4.4 is truncated at the source-fetch limit, so a statement may exist beyond the fetched text. §4.8 does list acute renal failure as part of the neuroleptic malignant syndrome picture (myoglobinuria/rhabdomyolysis), which is an adverse effect and not a dosing rule.

Hepatic

Not stated. No hepatic-impairment dosing statement appears in any fetched section of this SPC. §4.8 lists jaundice (rare) and 'Hepatocellular, cholestatic and mixed liver injury' (frequency not known) as adverse reactions, but no dose adjustment is given. Some sections of the product information we used were incomplete — check the full SPC.

Dose independently re-sourced from UK Summary of Product Characteristics (SPC) via the eMC — clinician-reviewed. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

  • §4.3, verbatim: 'Hypersensitivity to levomepromazine or any of the other ingredients.'
  • §4.3, verbatim — contraindicated in combination with: 'citalopram, escitalopram'
  • §4.3, verbatim — contraindicated in combination with: 'hydroxyzine'
  • §4.3, verbatim — contraindicated in combination with: 'piperaquine'
  • §4.3, verbatim — contraindicated in combination with: 'domperidone'
  • §4.3 qualifier, verbatim and important for the palliative use on this page: 'There are no absolute contraindications to the use of Nozinan in terminal care.'
  • Not a contraindication but a §4.2 age/population restriction: 'It is not advised to give levomepromazine to ambulant patients over 50 years of age unless the risk of a hypotensive reaction has been assessed.'
  • Not a contraindication but a §4.4 caution: 'The hypotensive effects of Nozinan should be taken into account when it is administered to patients with cardiac disease and the elderly or debilitated.'
  • Not a contraindication but a §4.4 pre-treatment check — ensure the absence of these QT risk factors before administration if the clinical situation allows: 'Bradycardia (<55 beats per minute) or 2nd or 3rd degree heart block'; 'Metabolic abnormalities such as hypokalaemia, hypocalcaemia or hypomagnesaemia'; 'Starvation or alcohol abuse'; 'A personal or family history of QT interval prolongation, ventricular arrhythmias or torsades de pointes'; 'Ongoing treatment with other medicinal product(s) liable to induce significant bradycardia (<55 beats per minute), electrolyte imbalance (including hypokalaemia), slowed intracardiac conduction or QT interval prolongation'
  • Not a contraindication but a §4.4 instruction to patients: 'Patients are strongly advised not to consume alcoholic beverages or to take medicines containing alcohol during treatment.'

Side effects

  • Very common (≥1/10): 'Sedation or somnolence, more pronounced early on in the treatment'; dry mouth
  • Common (≥1/100 to <1/10): postural hypotension ('especially in elderly patients'); asthenia; heat stroke ('in hot and humid' conditions — the §4.8 sentence is cut at the source-fetch limit)
  • Uncommon (≥1/1,000 to <1/100): agranulocytosis; constipation; parkinsonism ('with prolonged high dosage'); convulsions
  • Rare (≥1/10,000 to <1/1,000): 'Torsade de pointes, ECG changes include QT interval prolongation (as with other neuroleptics), ST depression, U-Wave and T-Wave changes'; jaundice
  • Frequency not known — cardiac/vascular: 'Cardiac arrhythmias, including ventricular arrhythmias and atrial arrhythmias, A-V block, ventricular tachycardia, which may result in ventricular fibrillation or cardiac arrest have been reported during neuroleptic phenothiazine therapy, possibly related to dosage'; venous thromboembolism, deep vein thrombosis, pulmonary embolism ('sometimes fatal')
  • Frequency not known — neurological: early dyskinesia (spasmodic torticollis, oculogyric crisis, trismus); extrapyramidal syndrome (akinetic with or without hypertonia; hyperkinetic-hypertonic movements; akathisia); tardive dyskinesia ('anticholinergic antiparkinsonian agents have no effect or may cause the condition to worsen'); neuroleptic malignant syndrome
  • Frequency not known — endocrine/metabolic: thermal dysregulation; hyperprolactinaemia (including galactorrhoea, gynaecomastia, amenorrhoea, impotence); impaired glucose tolerance, hyperglycaemia; hyponatraemia; SIADH
  • Frequency not known — gastrointestinal: paralytic ileus; 'necrotising enterocolitis (which can be fatal)'
  • Frequency not known — psychiatric: confusional states, delirium, indifference, anxiety, mood swings
  • Frequency not known — other: leukopenia; brownish deposits in the anterior segment of the eye 'due to the accumulation of the product, generally with no impact on vision'; accommodation disorders; photosensitivity reaction; allergic dermatitis; priapism; neonatal drug withdrawal syndrome; weight gain; antinuclear antibody positivity without clinical lupus erythematosus
  • §4.4 neuroleptic malignant syndrome, verbatim: 'a rare idiosyncratic response characterised by hypothermia, generalised muscle rigidity, autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardia dysrhythmia), altered consciousness and increased serum creatine phosphokinase levels. Hyperthermia is often an early sign of this syndrome... Antipsychotic treatment must be withdrawn immediately and appropriate supportive therapy and careful monitoring instituted.'
  • §4.4 on QT, verbatim: 'cases of QT interval prolongation have been very rarely reported with levomepromazine, in a dose-dependent manner. This effect, which is known to potentiate the risk of onset of severe ventricular rhythm disorders, particularly torsades de pointes, is increased by the existence of bradycardia, hypokalaemia or a congenital or acquired long QT.'

Monitoring

  • §4.4 blood disorders, verbatim: 'In case of a persistent fever, sore throat or infection under levomepromazine use a complete blood count is advised. Treatment should be stopped in case of leucytosis, or leucopenia.'
  • §4.4 baseline cardiac work-up, verbatim: 'Except for in emergency situations, it is recommended that an ECG with measurement of serum calcium, magnesium and potassium levels is performed during the initial assessment of patients who require treatment with a neuroleptic.'
  • §4.4 ongoing electrolytes, verbatim: 'Periodic serum electrolyte levels should be monitored and corrected, if necessary, especially during long-term chronic usage.'
  • §4.4 ECG on titration, verbatim: 'An ECG may be appropriate to assess the QT interval whenever dose escalation is proposed and when the maximum therapeutic dose is reached.'
  • §4.4 neuroleptic malignant syndrome: withdraw immediately and institute 'appropriate supportive therapy and careful monitoring' — hyperthermia is often the early sign, with elevated creatine phosphokinase, myoglobinuria (rhabdomyolysis) and acute renal failure as additional signs.
  • §4.4 blood pressure: the hypotensive effect must be taken into account in cardiac disease and in the elderly or debilitated; §4.2 requires the risk of a hypotensive reaction to be assessed before giving levomepromazine to ambulant patients over 50 years of age.
  • §4.6 (neonatal): 'neonates must be closely monitored in the event of treatment at the end of pregnancy.'

Clinical monograph

How it works

It antagonises dopamine D2 receptors and has additional antagonist activity at histamine, muscarinic, serotonergic and alpha-adrenergic receptors, contributing to its sedative and antiemetic effects.

Prescribing in practice

  • It commonly causes pronounced sedation and postural hypotension, so use cautiously and monitor blood pressure, particularly in frail or palliative patients.
  • Like other antipsychotics it can cause extrapyramidal effects and QT-interval prolongation.
  • In the elderly with dementia, antipsychotics increase the risk of stroke and death.

Monitoring

Monitor blood pressure for postural hypotension and observe for sedation, extrapyramidal symptoms and QT prolongation.

Counselling the patient

  • Warn that drowsiness is expected and may be marked.
  • Rise slowly from sitting or lying to reduce dizziness.
  • Report any abnormal movements or fainting.

Evidence & guidelines

Levomepromazine is widely used in UK palliative care for nausea and agitation, supported by established practice and palliative care guidance.

Reference: Palliative care formulary; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Related

Curated clinical cross-links plus same-class fallbacks.

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