What medication is recommended for acute agitation?

Medication Management for Acute Agitation

For acute agitation, benzodiazepines and antipsychotics are the first-line treatments, with medication selection based on the suspected etiology of agitation: benzodiazepines for medical/intoxication causes, antipsychotics for psychiatric causes, and either option for unknown etiology. 1

Medication Selection Algorithm Based on Etiology

1. Medical/Intoxication-Related Agitation

• First choice: Benzodiazepines (lorazepam 2mg IM/IV/PO) 1
• For severe agitation: Add first-generation antipsychotic after benzodiazepine if needed 1

2. Psychiatric-Related Agitation

• Mild/Moderate: Either benzodiazepine or antipsychotic 1
• Severe: Antipsychotic (haloperidol 5mg IM or olanzapine 10mg IM) 1, 2
• Combination therapy: Haloperidol plus lorazepam can produce faster sedation than either agent alone 1

3. Unknown Etiology

• Start with either benzodiazepine or antipsychotic
• Consider adding the other medication class if first dose is ineffective 1

Specific Medication Options

Benzodiazepines

• Lorazepam: 2mg IM/IV/PO (adult dose), can repeat every 30-60 minutes 1
  • Pediatric dose: 0.05-0.1 mg/kg IM/IV/PO 1
  • Advantages: Preferred for intoxication and withdrawal states; no extrapyramidal symptoms (EPS) 1
  • Onset: 15-30 minutes (IM/PO); 5-10 minutes (IV) 1

First-Generation Antipsychotics

• Haloperidol: 5-10mg IM (adult dose) 1
  • Can repeat every 20-30 minutes for tranquilization 1
  • Caution: Higher risk of EPS compared to atypical antipsychotics 1, 3

Second-Generation (Atypical) Antipsychotics

• Olanzapine: 10mg IM (recommended dose) 2, 4

  • Lower doses (5-7.5mg) may be considered when clinically warranted 2
  • Advantages: Faster onset of action, fewer EPS than haloperidol 3, 5
  • Recent evidence shows olanzapine 10mg IM effectively sedates 78.9% of patients with undifferentiated agitation within 20 minutes 6
  • Particularly effective for agitation due to psychiatric conditions (90% sedation rate) and organic medical conditions (79.1% sedation rate) 6

• Ziprasidone: 10-20mg IM 1

  • 20mg dose shows greater efficacy than 10mg 1
  • Caution with QTc interval-associated conditions 7

Special Populations

Elderly Patients

• Reduce doses: For olanzapine, consider 5mg/injection instead of 10mg 2
• Caution: Antipsychotics carry black box warning for increased mortality in elderly patients with dementia 2

Debilitated Patients

• Consider lower doses (e.g., olanzapine 2.5mg) for patients who might be:
  • Debilitated
  • Predisposed to hypotensive reactions
  • More pharmacodynamically sensitive 2

Comparative Efficacy

Recent research shows that intramuscular midazolam achieves more effective sedation at 15 minutes compared to haloperidol, ziprasidone, and possibly olanzapine. Among antipsychotics, olanzapine provides more effective sedation than haloperidol 4.

Safety Considerations

• Orthostatic hypotension: Assess for orthostatic changes before administering subsequent doses, particularly with olanzapine 2
• QTc prolongation: Monitor with ziprasidone and other antipsychotics 7
• EPS: More common with haloperidol (16.7%) than olanzapine (0%) 3
• Respiratory depression: Monitor closely, especially when combining medications 1

Key Pitfalls to Avoid

1. Avoid excessive sedation: Start with appropriate doses based on patient characteristics
2. Don't ignore medical causes: Rule out medical causes of agitation before attributing to psychiatric causes
3. Avoid drug interactions: Be cautious when combining CNS depressants
4. Don't neglect monitoring: Watch for hypotension, respiratory depression, and EPS
5. Avoid maximal dosing without assessment: Evaluate patient response before administering subsequent doses

Remember that verbal de-escalation techniques should be attempted before pharmacological intervention whenever possible 1. The goal is to control agitation quickly while minimizing adverse effects and allowing for treatment of the underlying condition.