Can we add Thorazine (chlorpromazine) 25 mg to a patient's regimen who remains aggressive while on Olanzapine (olanzapine) 10 mg?

Management of Acute Agitation in a Patient on Olanzapine

Yes, chlorpromazine (Thorazine) 25 mg can be added for a patient who remains aggressive and threatening despite being on olanzapine 10 mg. 1

Rationale for Adding Chlorpromazine

According to the NCCN Clinical Practice Guidelines in Palliative Care, when patients demonstrate severe agitation that is refractory to high doses of neuroleptics (such as olanzapine), additional interventions are warranted. The guidelines specifically mention chlorpromazine as an appropriate option for patients with severe agitation that has not responded adequately to initial antipsychotic therapy 1.

Dosing and Administration Considerations

• Start with chlorpromazine 25 mg as requested
• The low dose is appropriate to minimize side effects while assessing response
• Chlorpromazine can be administered via various routes (oral, IM, IV) depending on the urgency of the situation and patient cooperation

Monitoring After Administration

After administering chlorpromazine, monitor for:

• Vital signs, particularly blood pressure (risk of orthostatic hypotension)
• Level of sedation (may be more pronounced with combination therapy)
• Respiratory status (risk of respiratory depression, especially with combined CNS depressants)
• QT interval prolongation if ECG monitoring is available

Safety Considerations

• Additive Effects: Be aware that combining two antipsychotics will have additive sedative effects 2
• Cardiovascular Effects: Monitor for hypotension, which is more common with chlorpromazine than with olanzapine alone 3
• Respiratory Depression: The risk increases when combining multiple CNS depressants 2
• Extrapyramidal Symptoms: Watch for acute dystonia, akathisia, or parkinsonism, which may occur with chlorpromazine 1

Alternative Approaches if Ineffective

If the combination of olanzapine and chlorpromazine is ineffective:

1. Consider adding lorazepam 0.5-2 mg if agitation remains refractory to high doses of neuroleptics 1
2. Consider switching to a different antipsychotic such as haloperidol 1
3. Evaluate for underlying causes of persistent agitation (pain, delirium, substance withdrawal) 1, 4

Important Cautions

• Avoid this combination in elderly patients with dementia-related psychosis due to increased mortality risk 4
• Use with caution in patients with cardiovascular disease, seizure disorders, or hepatic impairment
• The combination may increase the risk of neuroleptic malignant syndrome, though this is rare

Long-term Considerations

If the acute agitation resolves with this combination:

• Develop a plan to taper one of the antipsychotics when clinically appropriate
• Consider transitioning to a single agent at an optimized dose
• Continue to monitor for metabolic effects if long-term therapy is required 4

This approach aligns with guidelines for managing severe agitation that is refractory to initial therapy, with the goal of achieving adequate symptom control while minimizing adverse effects.