From the Guidelines
Benzodiazepines, such as lorazepam or midazolam, and conventional antipsychotics, like droperidol or haloperidol, are recommended as effective monotherapy for the initial drug treatment of acute behavioral disturbances. When considering the management of acute behavioral disturbances, the primary goal is to prioritize the patient's safety and well-being, while also reducing morbidity, mortality, and improving quality of life. According to the Annals of Emergency Medicine 1, the use of benzodiazepines or conventional antipsychotics is supported by Level B recommendations, indicating a moderate level of evidence. Some key points to consider when managing acute behavioral disturbances include:
- Using a benzodiazepine, such as lorazepam, for rapid sedation, particularly when the cause is unknown or related to substance withdrawal
- Considering droperidol instead of haloperidol if rapid sedation is required
- Using an antipsychotic, such as risperidone, for management of agitation and initial drug therapy in patients with known psychiatric illness
- Combining an oral benzodiazepine, like lorazepam, with an oral antipsychotic, like risperidone, for agitated but cooperative patients. It is essential to administer medication in the least restrictive manner possible, preferably orally when the patient can cooperate, and to monitor vital signs and sedation levels closely after administration, particularly with parenteral medications. The choice between medications depends on the suspected cause of agitation, patient's medical history, and previous medication responses, as well as the need for rapid sedation or the presence of psychosis-related agitation.
From the FDA Drug Label
Haloperidol tablets are effective for the treatment of severe behavior problems in children of combative, explosive hyperexcitability Haloperidol tablets are indicated for the management of manifestations of psychotic disorders
The recommended medication for acute behavioral disturbances is haloperidol (PO), as it is indicated for the treatment of severe behavior problems and management of manifestations of psychotic disorders 2.
- Key indications include:
- Severe behavior problems in children
- Management of psychotic disorders
- Haloperidol should be used with caution and reserved for cases where other treatments have failed.
From the Research
Recommended Medications for Acute Behavioral Disturbances
The following medications are recommended for acute behavioral disturbances:
- Haloperidol, alone or in combination with antihistaminergic and anticholinergic drugs such as promethazine 3
- Benzodiazepines, such as lorazepam, diazepam, and midazolam 3, 4
- Atypical antipsychotics, such as aripiprazole, ziprasidone, and olanzapine 3, 5
- Combination therapy, such as haloperidol with promethazine, which effectively reduces aggression with a lower incidence of adverse effects 3, 5
Comparison of Medications
Studies have compared the efficacy and safety of different medications for acute behavioral disturbances:
- Benzodiazepines versus antipsychotics: no clear difference in sedation or improvement in symptoms 4
- Benzodiazepines versus combined antipsychotics/antihistamines: benzodiazepines may have a higher risk of no improvement in symptoms 4
- Haloperidol versus olanzapine: haloperidol may be less effective at 60 minutes, but requires fewer additional doses 5
- Aripiprazole versus olanzapine: aripiprazole is effective and causes less sedation compared to olanzapine 5
- Lorazepam versus midazolam: lorazepam is effective with fewer side effects, while midazolam provides rapid sedation but poses risks of severe side effects 5
Combination Therapy
Combination therapy, such as haloperidol with lorazepam and diphenhydramine, has been studied:
- No difference in administration frequency of additional agitation medication(s) between combination haloperidol, lorazepam, and diphenhydramine and combination haloperidol and lorazepam 6
- Patients who received combination haloperidol and lorazepam were more likely to require an antimuscarinic medication within 2 days 6
- Combination haloperidol and lorazepam had a shorter length of stay, lower incidence of hypotension, and fewer physical restraints compared to combination haloperidol, lorazepam, and diphenhydramine 6