What can be given intravenously (IV) for a patient with racing thoughts and anxiety?

From the Guidelines

For patients with racing thoughts and anxiety requiring IV medication, lorazepam 1 mg IV is the recommended initial treatment, given its efficacy and relatively favorable side effect profile, as suggested by the most recent and highest quality study 1. When considering IV medication for patients with racing thoughts and anxiety, it's essential to weigh the potential benefits and risks of each option.

• Benzodiazepines, such as lorazepam and midazolam, are commonly used for their anxiolytic and sedative effects.
• Lorazepam, in particular, has a well-established track record, with a suggested starting dose of 1 mg IV, as outlined in the guidelines 1.
• Midazolam is also an option, with a suggested starting dose of 2.5 mg IV, but it may have a faster onset and shorter duration of action compared to lorazepam 1. Key considerations when administering these medications include:
• Starting with the lowest effective dose and titrating as needed to minimize the risk of adverse effects, such as respiratory depression, especially in elderly patients or those with respiratory conditions.
• Monitoring vital signs closely during administration and having resuscitation equipment available.
• Being aware of the potential for benzodiazepines to cause paradoxical agitation, delirium, or other adverse effects, particularly in certain patient populations, such as those with chronic obstructive pulmonary disease (COPD) or the elderly 1. Overall, the goal is to provide effective symptom management while minimizing the risk of adverse effects and ensuring the patient's safety, as emphasized in the guidelines 1 and supported by earlier recommendations 1.

From the FDA Drug Label

5 mg should be given over a period of no less than 2 minutes. Wait an additional 2 or more minutes to fully evaluate the sedative effect. If additional titration is necessary, it should be given at a rate of no more than 1 mg over a period of 2 minutes, waiting an additional 2 or more minutes each time to fully evaluate the sedative effect. Total doses greater than 3. 5 mg are not usually necessary. For continuous infusion, midazolam 5 mg/mL formulation is recommended diluted to a concentration of 0.5 mg/mL with 0.9% sodium chloride or 5% dextrose in water. Usual Adult Dose: If a loading dose is necessary to rapidly initiate sedation, 0.01 to 0.05 mg/kg (approximately 0.5 to 4 mg for a typical adult) may be given slowly or infused over several minutes.

For a patient with racing thoughts and anxiety, midazolam (IV) can be given. The recommended dose is:

• 0.01 to 0.05 mg/kg (approximately 0.5 to 4 mg for a typical adult) as a loading dose, given slowly or infused over several minutes.
• The dose should be titrated to the desired effect, with increments of no more than 1 mg over a period of 2 minutes, waiting an additional 2 or more minutes each time to fully evaluate the sedative effect.
• Total doses greater than 3.5 mg are not usually necessary.
• The infusion rate should be titrated to the desired level of sedation, taking into account the patient’s age, clinical status, and current medications. 2 2

From the Research

Treatment Options for Acute Agitation

• For patients with racing thoughts and anxiety, several treatment options are available, including:
  • Haloperidol, a typical antipsychotic, which can be used alone or in combination with other medications such as promethazine or lorazepam 3
  • Benzodiazepines, such as lorazepam, diazepam, and midazolam, which have a more pronounced sedating activity 3
  • Atypical antipsychotics, such as olanzapine, ziprasidone, and aripiprazole, which are better tolerated and can be effective in reducing agitation 3, 4

Intravenous Dosing Strategies

• When administering sedatives and analgesics intravenously, it is essential to understand the clinical pharmacology of the medications and to titrate the dose to the desired clinical effect while minimizing the risk of excessive sedation and cardiopulmonary depression 5
• The use of a sedation scale can help standardize the level of sedation to be maintained and enable clinicians to communicate effectively with nursing staff 5

Effective Medications for Acute Agitation

• Studies have shown that low doses of haloperidol combined with midazolam can be as effective as olanzapine in reducing psychomotor agitation without increasing the risk of extrapyramidal effects 4
• Olanzapine, haloperidol plus promethazine, and droperidol are most effective and safe for use as rapid tranquilization, while midazolam sedates most quickly but may be restricted to use within an emergency department due to increased saturation problems 6
• Intramuscular midazolam has been shown to achieve more effective sedation in agitated patients at 15 minutes than haloperidol, ziprasidone, and perhaps olanzapine, with no differences in adverse events identified 7