What antipsychotic is suitable for a 75-year-old patient with a history of heart failure, cardiomyopathy, alcohol use disorder, and cocaine use disorder, presenting with agitated delirium, possibly due to alcohol withdrawal, requiring intravenous (IV) or intramuscular (IM) administration?

From the Guidelines

For a 75-year-old patient with complicated cardiac history (heart failure, cardiomyopathy) and substance use disorders experiencing agitated delirium possibly due to alcohol withdrawal, I would recommend low-dose haloperidol as the preferred antipsychotic, given the most recent and highest quality evidence available 1.

Key Considerations

• The patient's cardiac history and substance use disorders increase the risk of QT prolongation and other cardiac complications, making it essential to choose an antipsychotic with a lower risk of QT prolongation.
• Haloperidol, although a typical antipsychotic, has a relatively lower risk of QT prolongation compared to other antipsychotics, with a mean QT prolongation of 7ms 1.
• The patient's age and cardiac comorbidities also increase the risk of extrapyramidal side effects, but haloperidol at low doses (0.5-1mg IV/IM) can be used cautiously to minimize this risk.

Administration and Monitoring

• Start with a low dose of haloperidol (0.5-1mg IV/IM) and titrate cautiously as needed, with close cardiac monitoring, including baseline and follow-up ECGs to monitor QTc interval.
• Consider adding a benzodiazepine such as lorazepam or midazolam if the patient remains agitated, as recommended by the NICE guidelines 1.
• Non-pharmacological approaches, including frequent reorientation, maintaining day-night cycles, and ensuring family presence when possible, should be implemented concurrently to reduce agitation and improve patient outcomes.

Alternative Options

• Quetiapine, although preferred in some cases due to its lower risk of QT prolongation and extrapyramidal side effects, is not the most suitable option in this case, given the patient's cardiac comorbidities and the need for IV/IM administration.
• Ziprasidone and droperidol, although effective in reducing agitation, carry a higher risk of QT prolongation and are not recommended as first-line options in this patient population 1.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION 2. 3 Acute Treatment of Agitation in Schizophrenia Intramuscular Dosing The recommended dose is 10 mg to 20 mg administered as required up to a maximum dose of 40 mg per day.

14 CLINICAL STUDIES 14. 3 Agitation Associated with Schizophrenia and Bipolar I Mania The efficacy of intramuscular olanzapine for injection for the treatment of agitation was established in 3 short-term (24 hours of IM treatment) placebo-controlled trials in agitated adult inpatients from 2 diagnostic groups: schizophrenia and bipolar I disorder (manic or mixed episodes)

The suitable antipsychotic for a 75-year-old patient with a history of heart failure, cardiomyopathy, alcohol use disorder, and cocaine use disorder, presenting with agitated delirium, possibly due to alcohol withdrawal, requiring intravenous (IV) or intramuscular (IM) administration is olanzapine (IM) or ziprasidone (IM).

• Key considerations:
  • Ziprasidone (IM): The patient's history of heart failure and cardiomyopathy may be a concern due to the potential for ziprasidone to prolong the QT interval 2.
  • Olanzapine (IM): May be a better option due to its efficacy in treating agitation and relatively safer cardiovascular profile compared to ziprasidone 3. However, it is crucial to weigh the benefits and risks of each medication and consider the patient's overall clinical presentation before making a decision.

From the Research

Suitable Antipsychotics for Agitated Delirium

Given the patient's history of heart failure, cardiomyopathy, alcohol use disorder, and cocaine use disorder, presenting with agitated delirium, the following antipsychotics may be considered:

• Dexmedetomidine is recommended for patients with severe agitation, especially those weaning from invasive mechanical ventilation 4.
• Benzodiazepines are the mainstay of treatment for alcohol withdrawal, but may not be suitable for patients with a history of substance use disorders due to the risk of dependence and withdrawal 5.
• Phenobarbital may be considered as an alternative treatment for resistant alcohol withdrawal syndrome, as it has been shown to be effective in controlling severe agitation in patients who are resistant to benzodiazepines 6.
• Atypical antipsychotics, such as risperidone and quetiapine, may be beneficial in treating ethanol withdrawal syndrome, but should be used with caution due to the risk of extrapyramidal symptoms 7, 8.
• Olanzapine may not be the best option due to its potential to precipitate abnormal posture and gait in patients with ethanol withdrawal syndrome 8.

Administration Route

For IV or IM administration, the following options may be considered:

• Dexmedetomidine can be administered intravenously for sedation and agitation 4.
• Benzodiazepines, such as lorazepam, can be administered intravenously or intramuscularly for alcohol withdrawal 5.
• Phenobarbital can be administered intravenously for resistant alcohol withdrawal syndrome 6.
• Atypical antipsychotics, such as risperidone and quetiapine, may be available in injectable forms, but their use should be carefully considered due to the risk of extrapyramidal symptoms 7, 8.