From the Guidelines
I strongly recommend contacting the physician for additional medication orders to manage the patient's agitation, as the patient has already received Xanax and has no other PRN medications ordered. Since the patient has already received Xanax and has no other PRN (as-needed) medications ordered, you cannot administer additional medications without a new order. While waiting for the physician's response, implement non-pharmacological interventions such as reorientation, maintaining a calm environment with appropriate lighting, having a family member present if possible, and using clear, simple communication. Consider checking vital signs and assessing for pain, full bladder, or other physical discomfort that might be contributing to the agitation. The physician may consider ordering a different class of medication such as an antipsychotic (like haloperidol, with a dose of 0.5-1 mg orally at night and every 2 hours when required, as suggested by 1) or additional benzodiazepines at an appropriate dose. Agitation can have multiple causes including delirium, pain, medication effects, or underlying psychiatric conditions, so addressing the root cause is important for effective management, as supported by the Level B recommendations in 1. In particular, the use of a benzodiazepine (such as lorazepam or midazolam) or a conventional antipsychotic (such as haloperidol) as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient, as recommended in 1, may be considered. Additionally, the use of a combination of an oral benzodiazepine (such as lorazepam) and an oral antipsychotic (such as risperidone) for agitated but cooperative patients, as suggested in 1, may also be an option. However, the most recent and highest quality study, 1, suggests that haloperidol may be a suitable option, with a recommended dose of 0.5-1 mg orally at night and every 2 hours when required. It is essential to follow the physician's orders and to prioritize the patient's safety and well-being. Some key points to consider when managing the patient's agitation include:
- Implementing non-pharmacological interventions to calm the patient
- Assessing for underlying causes of agitation, such as pain or physical discomfort
- Considering the use of antipsychotics, such as haloperidol, as recommended in 1
- Prioritizing the patient's safety and well-being above all else.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Alternative Medications for Agitation
Given that the patient is still agitated after receiving Xanax, alternative medications may be considered. The following options have been studied for their effectiveness in managing agitation:
- Haloperidol plus promethazine, which has been shown to be effective in reducing agitation and aggression, although it may have a higher risk of extrapyramidal symptoms 2, 3, 4
- Olanzapine, which has been found to be effective in controlling agitation and aggression, with a relatively low risk of side effects 2, 3, 5
- Ziprasidone, which has been shown to be effective in reducing agitation, with a faster onset of action when administered intramuscularly 3, 4
- Lorazepam, which has been found to be effective in reducing agitation, with fewer side effects than antipsychotics, and enhanced efficacy when combined with them 6
- Midazolam, which provides rapid sedation, but poses risks of severe side effects, especially in older adults 3, 6
- Droperidol, which has been found to be as effective as olanzapine, with faster sedation 6
- Aripiprazole, which has been shown to be effective in reducing agitation, with less sedation compared to olanzapine 6
- Loxapine, which has been found to be effective in reducing agitation, with inhaled formulations providing rapid relief in patients with acute psychosis 6
Combination Therapy
Combination therapy, such as haloperidol with promethazine, may also be effective in reducing aggression with a lower incidence of adverse effects 4, 6.
Considerations
When selecting an alternative medication, it is essential to consider the patient's individual needs, medical history, and potential side effects. The choice of medication should be tailored to the patient's specific condition and response to treatment.