What PRN (as needed medication) can be given to an inpatient on lithium to Depakote (valproate) titration who is becoming agitated?

PRN Medication for Agitation During Lithium to Depakote Titration

For a patient becoming agitated during inpatient lithium to Depakote titration, lorazepam 1 mg PRN is the most appropriate medication choice due to its rapid onset, efficacy in controlling agitation, and favorable safety profile. 1

First-Line PRN Options

• Lorazepam 1 mg PRN (oral, sublingual, IV, or IM depending on patient cooperation) is recommended as the first-line PRN medication for acute agitation in this clinical scenario 2, 1
• For oral administration, can be given every 4-6 hours as needed; for parenteral administration, can be given every 1 hour PRN up to 2 mg maximum 2
• Lower doses (0.25-0.5 mg) should be used if the patient is elderly, frail, or has respiratory conditions 2, 1

Rationale for Benzodiazepine Selection

• Benzodiazepines are particularly appropriate during medication transitions as they:
  • Provide rapid control of agitation without interfering with the ongoing medication titration 2
  • Have less potential for drug interactions with lithium and valproate compared to some antipsychotics 1
  • Can be administered through multiple routes (oral, sublingual, IV, IM) depending on patient cooperation 2, 3

Alternative Options if Lorazepam is Contraindicated or Ineffective

• Haloperidol 0.5-1 mg PRN can be considered as an alternative, but carries higher risk of extrapyramidal side effects 2, 4
• Olanzapine 2.5-5 mg PRN (oral or IM) is another option with less risk of extrapyramidal symptoms 2
• Quetiapine 25 mg (immediate release) PRN is suitable if an oral-only option is preferred 2

Combination Therapy for Severe Agitation

• For severe agitation unresponsive to monotherapy, consider the combination of lorazepam 1 mg plus haloperidol 5 mg, which has shown superior efficacy in rapid tranquilization 2, 5
• This combination provides more rapid sedation than either agent alone while reducing the risk of extrapyramidal side effects 5

Monitoring and Precautions

• Monitor for excessive sedation, especially given the concurrent titration of mood stabilizers 3
• Be aware of the risk of paradoxical agitation, which occurs in approximately 10% of patients treated with benzodiazepines 2, 1
• Ensure resuscitative equipment is readily available when administering parenteral benzodiazepines 3
• Avoid long-term regular use of benzodiazepines as this can lead to tolerance and dependence 3

Implementation Strategy

1. Start with lorazepam 1 mg PO/SL if the patient is cooperative; use parenteral route if uncooperative 2, 1
2. Reassess agitation level 30-60 minutes after administration 6
3. If inadequate response, can repeat dose after appropriate interval (1 hour for parenteral, 4-6 hours for oral) 2
4. For persistent severe agitation despite lorazepam, consider adding haloperidol or switching to combination therapy 2, 5
5. Continue PRN medications only as needed while optimizing the standing Depakote regimen 1