What are the best initial chemical restraints (medications) to initiate for acute agitation?

From the Guidelines

For acute agitation, the best initial chemical restraints to initiate are benzodiazepines, such as lorazepam or midazolam, or conventional antipsychotics, like droperidol or haloperidol, as effective monotherapy. When considering the management of acute agitation, it's crucial to prioritize the patient's safety and the safety of others. The choice between benzodiazepines and antipsychotics may depend on the underlying cause of agitation and the patient's medical history 1.

Key Considerations

• Benzodiazepines, specifically lorazepam or midazolam, are recommended for their effectiveness in rapidly sedating agitated patients 1.
• Conventional antipsychotics, such as droperidol or haloperidol, are also effective for initial treatment, with droperidol considered for rapid sedation needs 1.
• The use of antipsychotics, either typical or atypical, is indicated for patients with known psychiatric illness where antipsychotics are appropriate 1.
• Combination therapy, such as an oral benzodiazepine (lorazepam) and an oral antipsychotic (risperidone), can be used for agitated but cooperative patients 1.

Administration and Monitoring

• Medications should be administered in a controlled environment with monitoring of vital signs, particularly for potential side effects like respiratory depression with benzodiazepines and QT prolongation with antipsychotics.
• The route of administration (oral, intramuscular, or intravenous) depends on the patient's cooperation and the urgency of the situation, with intravenous administration providing the fastest onset but requiring established IV access.

From the FDA Drug Label

ZYPREXA IntraMuscular is indicated for the treatment of acute agitation associated with schizophrenia and bipolar I mania Efficacy was demonstrated in 3 short-term (24 hours of IM treatment) placebo-controlled trials in agitated adult inpatients with: schizophrenia or bipolar I disorder (manic or mixed episodes) Parenteral medication, administered intramuscularly in doses of 2 to 5 mg, is utilized for prompt control of the acutely agitated schizophrenic patient with moderately severe to very severe symptoms

The best initial chemical restraints to initiate for acute agitation are:

• Olanzapine (IM), as indicated for the treatment of acute agitation associated with schizophrenia and bipolar I mania 2
• Haloperidol (IM), in doses of 2 to 5 mg, for prompt control of the acutely agitated schizophrenic patient with moderately severe to very severe symptoms 3 Key considerations include:
• Dose and administration: Olanzapine (IM) and haloperidol (IM) have different dosing recommendations, and the choice of medication and dose should be individualized based on the patient's needs and response.
• Monitoring: Careful monitoring of clinical signs and symptoms, including clinical efficacy, sedation, and adverse effects, is recommended after initiating treatment with either medication.

From the Research

Initial Chemical Restraints for Acute Agitation

The choice of initial chemical restraints for acute agitation can depend on various factors, including the patient's diagnosis, medical history, and the severity of agitation. Based on the available evidence, the following options are considered:

• Intramuscular Midazolam: A study published in 2018 found that intramuscular midazolam resulted in a greater proportion of patients adequately sedated at 15 minutes compared to ziprasidone, haloperidol, and olanzapine 4.
• Olanzapine: The same study found that olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared to haloperidol and ziprasidone 4.
• Benzodiazepines: A study published in 2005 found that benzodiazepines are recommended when no data are available, when there is no specific treatment, or when they may have specific benefits (e.g., intoxication) 5.
• Second-generation Antipsychotics: The 2005 study also found that different second-generation antipsychotics are preferred in various circumstances, and that no single antipsychotic emerges as a nonspecific replacement for haloperidol 5.

Key Considerations

When choosing an initial chemical restraint, the following factors should be considered:

• Diagnosis: The patient's diagnosis and medical history should be taken into account when selecting a chemical restraint.
• Severity of Agitation: The severity of agitation should be assessed and the chosen chemical restraint should be effective in managing the patient's symptoms.
• Safety Profile: The safety profile of the chosen chemical restraint should be considered, including the risk of adverse events and interactions with other medications.
• Patient Preferences: Patient preferences and values should be taken into account when selecting a chemical restraint, whenever possible.

Available Options

The following chemical restraints are available for the management of acute agitation:

• Lorazepam: A benzodiazepine that can be used for the management of acute agitation, although it may require repeat dosing 6.
• Droperidol: A butyrophenone that can be used for the management of acute agitation, although it may have a higher risk of adverse events 6.
• Haloperidol: A typical antipsychotic that can be used for the management of acute agitation, although it may have a higher risk of extrapyramidal side effects 4, 5.
• Ziprasidone: An atypical antipsychotic that can be used for the management of acute agitation, although it may have a lower efficacy compared to other options 4.