From the Guidelines
I strongly recommend ordering additional PRN medications for agitation, specifically considering lorazepam (Ativan) 0.5-1mg IV/IM every 4-6 hours as needed for severe agitation, as it is a more effective and faster-acting option compared to oral Xanax, according to the most recent guidelines 1. Given the patient's severe agitation and restlessness despite receiving oral Xanax, it is crucial to consider alternative or additional medications to ensure the patient's safety and comfort. The patient's current state of agitation and attempts to get out of bed and yelling suggest a need for more potent and rapid-acting medications. Some key considerations for managing agitation include:
- Using a benzodiazepine, such as lorazepam, for its sedative and anxiolytic effects, as recommended by the Annals of Emergency Medicine 1
- Considering the use of antipsychotics, such as haloperidol, for agitation with psychotic features, as suggested by the BMJ guidelines 1
- Implementing non-pharmacological interventions, such as maintaining a calm environment, frequent reorientation, and having a family member present, to help reduce agitation and promote a sense of calm
- Monitoring vital signs closely and investigating the underlying cause of agitation, such as pain, hypoxia, or medication side effects, to address any potential underlying issues It is essential to document the patient's response to any interventions for ongoing assessment and to adjust the treatment plan as needed to ensure the best possible outcomes. In this case, considering the patient's severe agitation and the ineffectiveness of oral Xanax, adding lorazepam (Ativan) 0.5-1mg IV/IM every 4-6 hours as needed for severe agitation is a reasonable and evidence-based approach, as supported by the most recent guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Possible Medications to Order
Given the patient's continued agitation and restlessness after being administered Xanax, other medications may be considered to manage their symptoms. The following options are based on the provided studies:
- Haloperidol: According to 2, low-dose haloperidol (≤0.5 mg) may be effective in managing agitation in older patients, with similar efficacy to higher doses.
- Olanzapine: Studies 3, 4, and 5 suggest that olanzapine can be used to manage acute agitation, with 5 noting its effectiveness in reducing agitation within a short time frame.
- Lorazepam: 5 and 6 indicate that lorazepam can be effective in managing acute agitation, with fewer side effects compared to antipsychotics.
- Droperidol: 5 and 6 suggest that droperidol can be effective in managing acute disturbance, with rapid sedation and a favorable adverse event profile.
- Ziprasidone: 5 notes that ziprasidone, administered intramuscularly, offers a faster onset and is better tolerated than haloperidol.
Considerations for Medication Choice
When selecting a medication to order, consider the following factors:
- Patient age and medical history
- Severity of agitation and restlessness
- Potential side effects and interactions with other medications
- Route of administration (e.g., intravenous, intramuscular, oral)
- Availability of medications and hospital protocols
Additional Considerations
It is essential to consult with the patient's healthcare team and consider their individual needs and medical history when selecting a medication to manage their agitation. Additionally, de-escalation techniques and other non-pharmacological interventions should be considered in conjunction with medication therapy.