From the Guidelines
For managing acute agitation on an as-needed basis, benzodiazepines and antipsychotics are the primary medication options, with lorazepam (Ativan) 0.5-2mg orally or intramuscularly every 4-6 hours as needed being a common first-line choice due to its rapid onset and relatively short half-life 1. When considering the management of agitation, it's crucial to weigh the benefits and risks of each medication option.
- Benzodiazepines, such as lorazepam, diazepam, or midazolam, are often preferred for their rapid onset of action and efficacy in reducing agitation, especially in cases of substance withdrawal 1.
- Antipsychotics, including haloperidol, olanzapine, or risperidone, are effective for managing agitation associated with psychosis and can be used as monotherapy or in combination with benzodiazepines 1. Key factors influencing the choice between benzodiazepines and antipsychotics include the underlying cause of agitation, the presence of psychosis, and the patient's medical history and current condition 1. It's also important to consider the potential side effects and risks associated with each medication, such as the risk of QTc interval prolongation with certain antipsychotics 1. The choice of medication should be tailored to the individual patient's needs, with a focus on minimizing risks and optimizing outcomes in terms of morbidity, mortality, and quality of life 1.
From the FDA Drug Label
1.4 ZYPREXA IntraMuscular: Agitation Associated with Schizophrenia and Bipolar I Mania 2.4 ZYPREXA IntraMuscular: Agitation Associated with Schizophrenia and Bipolar I Mania
The recommended medication for managing agitation on an as-needed (prn) basis is olanzapine, specifically the intramuscular (IM) formulation, ZYPREXA IntraMuscular. This is indicated for agitation associated with schizophrenia and bipolar I mania 2.
- Key points:
- Olanzapine IM is used for agitation associated with schizophrenia and bipolar I mania.
- The medication is administered intramuscularly.
From the Research
Agitation PRN Medications
The management of agitation on an as-needed (prn) basis is crucial in various medical and psychiatric settings. Several medications have been studied for their efficacy and safety in this context.
Recommended Medications
- Haloperidol: a typical antipsychotic that has been widely used for acute agitation, although it can cause significant extrapyramidal symptoms and has rarely been associated with cardiac arrhythmia and sudden death 3.
- Olanzapine: an atypical antipsychotic that has shown faster onset of action, greater efficacy, and fewer adverse effects than haloperidol or lorazepam in the treatment of acute agitation 3.
- Midazolam: a benzodiazepine that has been shown to achieve more effective sedation in agitated patients than haloperidol, ziprasidone, and perhaps olanzapine 4.
- Ziprasidone: an atypical antipsychotic that has been developed for the treatment of acute agitation and has shown significant calming effects emerging 30 minutes after administration 3.
Comparison of Medications
- A study comparing intramuscular midazolam, olanzapine, ziprasidone, and haloperidol found that midazolam resulted in a greater proportion of patients adequately sedated at 15 minutes compared to the other medications 4.
- Another study found that olanzapine and haloperidol reduced agitation by less than 10 points, and only olanzapine reduced aggression by less than four points in the first hour 5.
- A review of 41 studies found that haloperidol alone was effective in controlling agitation and aggression, but its use was associated with a higher risk of dystonia and other adverse effects 6.
Safety and Efficacy
- The use of haloperidol, especially in high doses, has been associated with a higher risk of complications, including extrapyramidal symptoms and cardiac arrhythmia 7.
- Olanzapine and ziprasidone have been shown to have a faster onset of action and fewer adverse effects than haloperidol, but their use should be carefully monitored due to the risk of adverse events 3.
- Midazolam has been shown to be effective in achieving sedation, but its use should be carefully monitored due to the risk of respiratory depression and other adverse effects 4.