From the Guidelines
The first-line medications for treating psychotic agitation are benzodiazepines, such as lorazepam or midazolam, or conventional antipsychotics, like droperidol or haloperidol, as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED. According to the study by 1, these medications are recommended as Level B for the treatment of psychotic agitation. The study suggests that benzodiazepines or conventional antipsychotics can be used as monotherapy for the initial treatment of agitation in undifferentiated patients.
Some key points to consider when treating psychotic agitation include:
- Using a combination of an oral benzodiazepine, such as lorazepam, and an oral antipsychotic, like risperidone, for agitated but cooperative patients, as recommended by 1.
- Considering droperidol instead of haloperidol if rapid sedation is required, as suggested by 1 and supported by the study 1, which found that droperidol was more effective in producing sedation and required fewer repeat doses.
- Monitoring for side effects, including sedation, orthostatic hypotension, extrapyramidal symptoms, and QT prolongation, when administering these medications.
- Starting with the lowest effective dose and titrating as needed, while ensuring appropriate monitoring of vital signs and mental status.
It's also important to note that the choice between medications should consider the patient's medical history, previous medication response, and the clinical setting. Additionally, the study by 1 found that ziprasidone IM was effective in rapidly and substantially reducing the symptoms of acute agitation in patients with known psychotic disorders, and it was well tolerated. However, the most recent and highest quality study, 1, recommends benzodiazepines or conventional antipsychotics as the first-line treatment for psychotic agitation.
From the FDA Drug Label
1.4 Olanzapine for Injection: Agitation Associated with Schizophrenia and Bipolar I Mania 2.4 Olanzapine for Injection: Agitation Associated with Schizophrenia and Bipolar I Mania
- First-line medication: Olanzapine for Injection is indicated for the treatment of agitation associated with schizophrenia and bipolar I mania.
- Key points:
- Olanzapine is used to treat psychotic agitation.
- It is specifically indicated for agitation associated with schizophrenia and bipolar I mania. 2
From the Research
First-Line Medications for Treating Psychotic Agitation
The following medications are considered first-line treatments for psychotic agitation:
- Oral risperidone plus lorazepam 3
- Intramuscular (IM) formulations of atypical antipsychotics, such as ziprasidone, olanzapine, and aripiprazole 4
- IM haloperidol plus lorazepam 3
Efficacy of Medications
Studies have shown that:
- Oral risperidone plus lorazepam is as effective as IM haloperidol plus lorazepam for the rapid control of agitation and psychosis 3
- IM ziprasidone, IM olanzapine, and IM aripiprazole are at least as effective and better tolerated than IM haloperidol, with lower extrapyramidal side effects 4
- Olanzapine is superior to aripiprazole in calming patients at 2 hours after administration 5
Safety and Tolerability
- Both oral risperidone plus lorazepam and IM haloperidol plus lorazepam are well tolerated 3
- IM formulations of atypical antipsychotics have a lower risk of extrapyramidal side effects compared to IM haloperidol 4
- Haloperidol is associated with a higher risk of dystonia and other adverse effects, particularly when used alone 6
Treatment Recommendations
- IM formulations of atypical antipsychotics are recommended as first-line treatment for acute agitation, with subsequent transition to an oral formulation of the same agent for ongoing management 4
- Haloperidol may be considered for use in situations where no other alternative exists, but its use should be carefully weighed against the potential risks and benefits 6