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 quetiapine as the preferred antipsychotic for agitation management, as supported by the most recent guidelines from 2018 1.

Key Considerations

• The patient's cardiac history and substance use disorders necessitate careful selection of an antipsychotic to minimize cardiovascular risk.
• Quetiapine is preferred due to its lower risk of QT prolongation compared to other antipsychotics like ziprasidone and thioridazine, as noted in earlier studies 1.
• The dosage should start at 25mg orally, which can be repeated every 4-6 hours as needed, with careful titration, as suggested by the guidelines for delirium management in adult cancer patients 1.

Administration and Monitoring

• If IV/IM administration is necessary due to severe agitation, low-dose haloperidol (0.5-1mg) would be appropriate, though with caution regarding QT prolongation, as indicated by the clinical policy for managing adult psychiatric patients in the emergency department 1.
• Continuous cardiac monitoring is essential during treatment to mitigate the risk of QT prolongation and other cardiac complications.
• The underlying alcohol withdrawal should remain the primary treatment focus, with the use of antipsychotics aimed at managing agitation while minimizing cardiovascular risk.

Alternatives and Precautions

• Other antipsychotics like olanzapine and aripiprazole may also be considered for delirium management, as they appear less likely to be associated with extrapyramidal symptoms (EPSEs) than first-generation antipsychotics, as noted in the guidelines 1.
• However, the choice of antipsychotic should be tailored to the individual patient's needs and medical history, with careful consideration of potential side effects and interactions.
• Benzodiazepines, such as midazolam or lorazepam, may be used for sedation in severe cases but should be used cautiously due to their potential to exacerbate delirium and increase the risk of falls, as advised in the clinical practice guidelines for delirium management 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 recommended dose is 10 mg to 20 mg administered as required up to a maximum dose of 40 mg per day.
  • Olanzapine (IM): 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. However, ziprasidone (IM) should not be administered intravenously. Given the patient's complex medical history, it is crucial to carefully evaluate the potential risks and benefits of each option and consider consulting with a specialist or the patient's primary care physician before making a decision 2 3.

From the Research

Suitable Antipsychotic for Agitated Delirium

Given the patient's 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, the following points should be considered:

• The patient's age (75 years) and medical history suggest the need for careful consideration of potential side effects and interactions with other medications.
• According to 4, IM olanzapine 10 mg is effective for rapid sedation in acute undifferentiated agitation, and it is superior to haloperidol in agitation secondary to organic medical conditions.
• However, in agitation due to alcohol intoxication, haloperidol 5 mg is slightly better, although not statistically significant 4.
• Dexmedetomidine is recommended for patients with severe agitation, especially those weaning from invasive mechanical ventilation 5.
• Benzodiazepines are the mainstay of treatment for alcohol withdrawal, but alternative pharmacotherapies, including antipsychotics, can be used in certain cases 6.
• IV olanzapine has been used off-label for the management of agitation, with doses ranging from 2.5 to 10 mg given as an IV bolus, and has shown efficacy similar to droperidol in achieving adequate sedation within 10 minutes 7.
• Atypical antipsychotics, such as olanzapine, are preferred over first-generation antipsychotics due to their lower incidence of extrapyramidal adverse effects, but they can still occur, as seen in a case report of olanzapine-induced akathisia 8.

Key Considerations

• The choice of antipsychotic should be based on the patient's specific medical history, current condition, and potential side effects.
• Close monitoring of the patient's response to treatment and potential side effects is crucial.
• A comprehensive assessment of the patient's condition, including the use of validated scales, should be performed to guide treatment decisions 5.