Are Thorazine (chlorpromazine) drips ever used?

Thorazine (Chlorpromazine) Drips: Current Clinical Use

Thorazine (chlorpromazine) drips are rarely used in modern clinical practice due to safety concerns, particularly regarding cardiac complications and the availability of safer alternatives. 1

Historical Context and Current Status

Chlorpromazine was one of the first antipsychotic medications developed, but intravenous administration has fallen out of favor due to:

• Risk of QT prolongation and cardiac arrhythmias 1
• Potential for severe hypotension 2
• Availability of safer alternatives with fewer side effects 1

The FDA label for chlorpromazine does not specifically recommend continuous IV infusion (drip) administration, though it does mention intravenous administration is possible 2. Guidelines from major psychiatric and emergency medicine organizations now recommend intramuscular administration as the preferred parenteral route for antipsychotics in emergency settings 1.

Limited Scenarios Where IV Chlorpromazine May Be Used

In extremely limited circumstances, IV chlorpromazine might still be considered:

1. Severe nausea management: In some palliative care settings, chlorpromazine may be used for intractable nausea, though guidelines now prefer alternatives like ondansetron 1, 3

2. Chemical restraint in specific emergency situations: When other options have failed, though guidelines strongly favor newer agents and different routes of administration 1

Safety Concerns with IV Chlorpromazine

Cardiac Risks

• QT interval prolongation (5-22ms) 1
• Risk of torsades de pointes and sudden cardiac death 1, 4
• Particular risk when combined with other QT-prolonging medications 1

Neurological Risks

• Extrapyramidal symptoms (EPS) including acute dystonia, akathisia, and parkinsonism 2, 5
• Risk of neuroleptic malignant syndrome 2

Other Concerns

• Hypotension, particularly orthostatic 2
• Sedation and respiratory depression 2
• Local irritation at IV site 1

Preferred Alternatives in Modern Practice

Current guidelines recommend:

1. Intramuscular administration rather than IV for parenteral antipsychotics 1

2. Newer antipsychotics with better safety profiles:

   • Haloperidol (lower QT prolongation of ~7ms vs. chlorpromazine) 1
   • Olanzapine (QT prolongation of only ~2ms) 1
   • Risperidone (QT prolongation of 0-5ms) 1

3. Benzodiazepines like lorazepam or midazolam for acute agitation 1

Monitoring Requirements If IV Chlorpromazine Is Used

If IV chlorpromazine must be used in an exceptional circumstance:

• Continuous cardiac monitoring
• Regular ECG monitoring for QT prolongation
• Blood pressure monitoring
• Close observation for extrapyramidal symptoms
• Monitoring for respiratory depression
• Electrolyte monitoring (particularly potassium and magnesium) 1

Conclusion

While historically Thorazine (chlorpromazine) drips were used, they have been largely abandoned in contemporary practice due to significant safety concerns and the availability of safer alternatives. Current guidelines strongly favor other medications and routes of administration for managing conditions where chlorpromazine was once used intravenously.