When is ABH Gel (Ativan (Lorazepam), Benadryl (Diphenhydramine), Haldol (Haloperidol)) administered?

When to Administer ABH Gel (Ativan, Benadryl, Haldol)

ABH gel should NOT be administered as it has been shown to have insufficient absorption through the skin to be effective for symptom management. 1

Evidence Against ABH Gel Use

• A study of 10 healthy volunteers demonstrated that lorazepam and haloperidol were not detected in plasma after topical application of ABH gel, while diphenhydramine was only erratically absorbed at subtherapeutic levels 1
• No subject in the study experienced any therapeutic effects or side effects, confirming the lack of systemic absorption 1
• The study concluded that "none of the lorazepam, haloperidol, or diphenhydramine in ABH gel is absorbed in sufficient quantities to be effective in the treatment of nausea and vomiting" 1

Alternative Approaches for Symptom Management

For Delirium Management

Instead of ABH gel, consider these evidence-based approaches for managing delirium:

First-line Antipsychotics:

• Haloperidol: 0.5-1 mg PO or SC stat, with PRN dosing of 0.5-1 mg every 1 hour as needed 2
  • Use lower doses (0.25-0.5 mg) in older or frail patients 2
  • May cause extrapyramidal symptoms (EPS) and QTc prolongation 2

Second-line Antipsychotics:

• Olanzapine: 2.5-5 mg PO or SC stat 2
• Quetiapine: 25 mg (immediate release) PO stat 2
• Risperidone: 0.5 mg PO stat 2

For Severe Agitation:

• Lorazepam: 1 mg SC or IV stat (up to 2 mg maximum) 2
  • Use lower doses (0.25-0.5 mg) in older or frail patients or those with COPD 2
  • May be combined with haloperidol for refractory agitation 2

For Nausea and Vomiting

For patients requiring nausea and vomiting management in palliative care:

• Consider appropriate routes of administration: rectal, transdermal, subcutaneous, or intravenous 2
• Antiemetics should be selected based on the underlying cause 2
• For bowel obstruction: avoid metoclopramide in complete obstruction, but it may be beneficial in incomplete obstruction 2
• Consider octreotide early due to high efficacy and tolerability (starting at 150 mcg SC twice daily) 2

Important Considerations for Parenteral Administration

When administering these medications parenterally:

• Visual compatibility studies have shown that lorazepam and haloperidol can be physically compatible when combined with either benztropine or diphenhydramine in the same syringe 3
• Benzodiazepines should be used with caution in patients with severe pulmonary insufficiency, severe liver disease, or myasthenia gravis 2
• Fatalities have been reported with concurrent use of benzodiazepines with high-dose olanzapine 2

Patient-Specific Considerations

• For patients with alcohol or benzodiazepine withdrawal, benzodiazepines are the treatment of choice as monotherapy 2
• In patients with Parkinson's disease or Lewy body dementia, avoid haloperidol due to risk of extrapyramidal symptoms 2
• For older patients, use lower doses of all medications and titrate gradually 2

Summary

ABH gel should not be used as evidence shows it is not effectively absorbed through the skin 1. Instead, use appropriate systemic medications via effective routes of administration (oral, sublingual, subcutaneous, intramuscular, or intravenous) based on the specific symptoms being targeted and patient characteristics.