From the Guidelines
Haloperidol is often considered the first-line antipsychotic for delirious psychotic patients, particularly in acute settings, due to its efficacy and rapid onset of action, as suggested by the ESMO clinical practice guidelines 1. When managing delirium in adult cancer patients, it is essential to consider the potential benefits and risks of antipsychotic medications. The guidelines recommend using the lowest effective dose for the shortest period possible, with careful monitoring for side effects such as extrapyramidal symptoms, QT prolongation, and sedation. Some key points to consider when using antipsychotics for delirium management include:
- Typical starting doses for haloperidol range from 0.5-2mg orally or intramuscularly, which can be repeated every 30-60 minutes as needed, with careful monitoring 1.
- Lower doses (0.25-0.5mg) are recommended for elderly patients, and the dose should be titrated gradually to minimize the risk of adverse effects 1.
- Second-generation antipsychotics like risperidone (0.5-1mg), olanzapine (2.5-5mg), or quetiapine (25-50mg) may be alternatives with potentially fewer extrapyramidal side effects, as noted in the guidelines 1.
- Treatment should be short-term, typically days to weeks until delirium resolves, with daily reassessment for continued need, and it is crucial to simultaneously identify and treat the underlying cause of delirium 1.
- Non-pharmacological approaches should always accompany medication, including reorientation strategies, maintaining day-night cycles, ensuring adequate hydration, and minimizing unnecessary medications, as emphasized in the guidelines 1.
From the Research
Antipsychotic Drugs for Delirious Psychotic Patients
- The choice of antipsychotic drug for delirious psychotic patients depends on various factors, including the patient's medical history, current condition, and potential side effects of the medication 2, 3, 4, 5.
- Quetiapine has been shown to be an effective and safe agent for the treatment of delirium in both general medicine and intensive care unit patients, with a lower incidence of extrapyramidal side effects compared to haloperidol 2.
- Other atypical antipsychotics, such as olanzapine and risperidone, have also been found to be effective in treating delirium, with a similar efficacy to haloperidol but a lower risk of extrapyramidal side effects 3, 5.
- The use of antipsychotics in the treatment of delirium is not without controversy, with some studies suggesting that they may not be effective in reducing the duration or severity of delirium, and may even be associated with harmful cardiac effects 4.
- The selection of an antipsychotic drug for delirious psychotic patients should be based on individual patient characteristics and needs, taking into account factors such as the patient's medical history, current condition, and potential side effects of the medication 6.
Comparison of Antipsychotic Drugs
- Quetiapine and olanzapine have been found to be effective in placebo-controlled trials, with a lower incidence of extrapyramidal side effects compared to haloperidol 2, 5.
- Risperidone has been found to be similarly effective to haloperidol, but with a lower risk of extrapyramidal side effects 3, 5.
- Ziprasidone has not been shown to be effective in the treatment of delirium 5.
- There is limited evidence available for other atypical antipsychotics, such as aripiprazole, paliperidone, and clozapine, and larger-scale randomized controlled trials are needed to fully evaluate their efficacy and tolerability in the treatment of delirium 5.