How should ABH Gel (Ativan (Lorazepam), Benadryl (Diphenhydramine), Haldol (Haloperidol)) be used?

ABH Gel (Ativan, Benadryl, Haldol) Should Not Be Used Due to Lack of Absorption and Efficacy

ABH gel (containing lorazepam/Ativan, diphenhydramine/Benadryl, and haloperidol/Haldol) should not be used as it has been proven ineffective due to insufficient absorption through the skin and lack of clinical benefit in randomized trials. 1, 2, 3

Evidence Against ABH Gel Use

• Pharmacokinetic studies demonstrate that lorazepam and haloperidol are not absorbed through the skin at all, while diphenhydramine is only erratically absorbed at subtherapeutic levels 1
• A randomized, double-blind, placebo-controlled trial found ABH gel was not superior to placebo for treating nausea in cancer patients 3
• ABH gel has been described as a "pricey placebo" that delays the implementation of effective treatments for end-of-life symptoms 2

Alternative Approaches for Specific Indications

For Delirium Management:

• Clinical practice guidelines recommend against routine use of haloperidol or atypical antipsychotics for treating delirium in critically ill adults 4
• Short-term use of haloperidol or atypical antipsychotics may be warranted only for patients experiencing significant distress from symptoms such as hallucinations, delusions, or agitation that poses physical harm 4
• For mechanically ventilated patients with agitation precluding ventilator weaning/extubation, dexmedetomidine may be considered 4
• Non-pharmacological multicomponent interventions (reorientation, cognitive stimulation, sleep optimization, early mobilization) are recommended as first-line approaches 4

For Acute Agitation:

• For acute agitation requiring medication, parenteral administration of individual medications is recommended rather than topical gel formulations 4
• In emergency settings, benzodiazepines (lorazepam) and antipsychotics (haloperidol) are commonly used individually or in combination for acute agitation 4
• When combination therapy is needed, haloperidol plus lorazepam has shown similar efficacy with fewer adverse effects compared to triple therapy with diphenhydramine added 5

For Nausea and Vomiting:

• For chemotherapy-induced nausea and vomiting, evidence-based guidelines recommend specific antiemetic regimens based on the emetogenic risk of chemotherapy agents 4
• Lorazepam and diphenhydramine are considered useful adjuncts to primary antiemetic drugs but are not recommended as single agents 4
• These medications should be administered via appropriate routes (oral, IV) rather than topical gel 4

Physical Compatibility of Components

• While some combinations of psychotropic medications can be physically compatible when mixed in syringes for intramuscular administration (including lorazepam and haloperidol with either benztropine or diphenhydramine), this does not support the use of topical gel formulations 6

Potential Harms and Concerns

• Use of ABH gel may delay implementation of effective treatments 2
• When the individual components are administered parenterally in combination (B52), increased rates of oxygen desaturation, hypotension, physical restraint use, and longer length of stay have been observed compared to dual therapy 5
• Antipsychotic medications like haloperidol carry risks of extrapyramidal symptoms, QT prolongation, and other adverse effects 4

Conclusion

Based on the available evidence, ABH gel should not be scheduled or used for any indication. The individual medications may be appropriate when administered through proper routes (oral, IV, IM) for specific indications, but the topical gel formulation lacks scientific support for clinical use.