Article

Pharmacological Management of Acute Agitation

Department of Psychiatry and Behavioural Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
Drugs (Impact Factor: 4.34). 02/2005; 65(9):1207-22. DOI: 10.2165/00003495-200565090-00003
Source: PubMed

ABSTRACT

Acute agitation occurs in a variety of medical and psychiatric conditions, and when severe can result in behavioural dyscontrol. Rapid tranquillisation is the assertive use of medication to calm severely agitated patients quickly, decrease dangerous behaviour and allow treatment of the underlying condition. Intramuscular injections of typical antipsychotics and benzodiazepines, given alone or in combination, have been the treatment of choice over the past few decades. Haloperidol and lorazepam are the most widely used agents for acute agitation, are effective in a wide diagnostic arena and can be used in medically compromised patients. Haloperidol can cause significant extrapyramidal symptoms, and has rarely been associated with cardiac arrhythmia and sudden death. Lorazepam can cause ataxia, sedation and has additive effects with other CNS depressant drugs.Recently, two fast-acting preparations of atypical antipsychotics, intramuscular ziprasidone and intramuscular olanzapine, have been developed for treatment of acute agitation. Intramuscular ziprasidone has shown significant calming effects emerging 30 minutes after administration for acutely agitated patients with schizophrenia and other nonspecific psychotic conditions. Intramuscular ziprasidone is well tolerated and has gained widespread use in psychiatric emergency services since its introduction in 2002. In comparison with other atypical antipsychotics, ziprasidone has a relatively greater propensity to increase the corrected QT (QTc) interval and, therefore, should not be used in patients with known QTc interval-associated conditions. Intramuscular olanzapine has shown faster onset of action, greater efficacy and fewer adverse effects than haloperidol or lorazepam in the treatment of acute agitation associated with schizophrenia, schizoaffective disorder, bipolar mania and dementia. Intramuscular olanzapine has been shown to have distinct calming versus nonspecific sedative effects. The recent reports of adverse events (including eight fatalities) associated with intramuscular olanzapine underscores the need to follow strict prescribing guidelines and avoid simultaneous use with other CNS depressants. Both intramuscular ziprasidone and intramuscular olanzapine have shown ease of transition to same-agent oral therapy once the episode of acute agitation has diminished. No randomised, controlled studies have examined either agent in patients with severe agitation, drug-induced states or significant medical comorbidity. Current clinical experience and one naturalistic study with intramuscular ziprasidone suggest that it is efficacious and can be safely used in such populations. These intramuscular atypical antipsychotics may represent a historical advance in the treatment of acute agitation.

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    • "Cette étude indique que jusqu'aux années 1990, l'association lorazépam et halopéridol représentait la combinaison la plus utilisée [17]. Une revue plus récente a confirmé l'utilisation fréquente de l'halopéridol et du lorazépam [24]. La controverse qui persiste dans le traitement des états d'agitation aux urgences porte sur l'alternative entre l'utilisation exclusive de BZD, celle d'AP ou l'association BZD/APT. "
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    ABSTRACT: Management of agitation is a frequent problematic of emergency departments that often leads to feelings of insecurity among clinicians. There are various practices regarding the drugs to be used in the management of agitations. Guidelines have been proposed by different groups of experts concerning the antipsychotic drugs that should be used for agitations in psychiatric conditions. Nevertheless, there is no clear-cut procedure referring to the utilization of intramuscular drugs in this situation. Moreover, there is no comparison available between the commonly used medications and other drugs, both in terms of superiority of efficacy and tolerance. In order to accurately assess these practices, evaluation protocols must minimize the interference with the service organization and the routine care. Further studies are required in order to develop guidelines about medications that have to be used to handle agitations, which must be based on robust evidence and applicable to emergency services.
    Full-text · Article · Oct 2014 · La Presse Médicale
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    • "Cette étude indique que jusqu'aux années 1990, l'association lorazépam et halopéridol représentait la combinaison la plus utilisée [17]. Une revue plus récente a confirmé l'utilisation fréquente de l'halopéridol et du lorazépam [24]. La controverse qui persiste dans le traitement des états d'agitation aux urgences porte sur l'alternative entre l'utilisation exclusive de BZD, celle d'AP ou l'association BZD/APT. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Management of agitation is a frequent problematic of emergency departments that often leads to feelings of insecurity among clinicians. There are various practices regarding the drugs to be used in the management of agitations. Guidelines have been proposed by different groups of experts concerning the antipsychotic drugs that should be used for agitations in psychiatric conditions. Nevertheless, there is no clear-cut procedure referring to the utilization of intramuscular drugs in this situation. Moreover, there is no comparison available between the commonly used medications and other drugs, both in terms of superiority of efficacy and tolerance. In order to accurately assess these practices, evaluation protocols must minimize the interference with the service organization and the routine care. Further studies are required in order to develop guidelines about medications that have to be used to handle agitations, which must be based on robust evidence and applicable to emergency services.
    Full-text · Article · Oct 2014 · La Presse Médicale
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    • "Each of these medications offers a unique pharmacological profile that must be considered when treating agitated patients, who may be unwilling or unable to adequately communicate their medical status and concomitant medications (Zimbroff, 2008). Intramuscular injections of FGA and BDZ, given alone or in combination, have been the treatment of choice over the past few decades, with haloperidol and lorazepam being among the most widely used agents for agitation (Battaglia, 2005). "
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    ABSTRACT: Agitated behavior constitutes up to 10% of emergency psychiatric interventions. Pharmacological tranquilization is often used as a valid treatment for agitation but a strong evidence base does not underpin it. Available literature shows different recommendations, supported by research data, theoretical considerations, or clinical experience. Rapid tranquilization (RT) is mainly based on parenteral drug treatment and the few existing guidelines on this topic, when suggesting the use of first generation antipsychotics and benzodiazepines, include drugs with questionable tolerability profile such as chlorpromazine, haloperidol, midazolam, and lorazepam. In order to systematically evaluate safety concerns related to the adoption of such guidelines, we reviewed them independently from principal diagnosis while examining tolerability data for suggested treatments. There is a growing evidence about safety profile of second generation antipsychotics for RT but further controlled studies providing definitive data in this area are urgently needed.
    Full-text · Article · May 2013 · Frontiers in Psychiatry
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