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Introduction

  • Antipsychotic medications are used for numerous acute states in the emergency department,

    • especially agitation.

  • IV access is often not available for patients with agitation and alternative routes must be

    • considered; the drug of choice may change depending on the route of administration.

  • This handout will focus on the pharmacotherapy of the most utilized antipsychotics in the

    • emergency department for acute agitation.

Clinical Detail

    Haloperidol

    (Haldol®)

    Droperidol

    (Inapsine®)

    Olanzapine

    (Zyprexa™)

    Ziprasidone

    (Geodon®)

    Dose

    • PO: 0.5-5 mg

    • IM/IV: 2-5 mg

    • IM: 5-10 mg

    • IV: 2.5-5 mg

    • PO: 5-10 mg

    • IM: 5-10 mg

    • PO: 20-40 mg

    • IM: 10-20 mg

    Onset

    • PO: 30-60 min

    • IM: 20-40 min

    • IV/IM: 5-15 min

    • PO (ODT): 15-20 min

    • IM: 5-10 min

    • PO: 45-60 min

    • IM: 15-60min

    Elimination

    Half-life

Evidence

    Author,

    year

    Design/

    sample size

    Intervention & Comparison

    Outcome

    Klein,

    2018

    Observational

    n=737

    • IM haloperidol 5 mg

    • IM ziprasidone 20 mg

    • IM olanzapine 10 mg

    • IM midazolam 5 mg

    • IM haloperidol 10 mg

    At 15 minutes, midazolam resulted in more patients

    adequately sedated compared with ziprasidone 20 mg,

    haloperidol 5 mg, haloperidol 10 mg, and olanzapine.

    At 15 minutes, olanzapine resulted in more patients

    adequately sedated compared with haloperidol 5 and 10

    mg.

    Taylor,

    2017

    RCT

    n=349

    • IV midazolam 5 mg +

    droperidol 5 mg

    • IV olanzapine 10 mg

    • IV droperidol 10 mg

    Ten minutes after the first dose, significantly more patients in

    the midazolam-droperidol group were adequately sedated

    compared with the droperidol and olanzapine groups.

    Patients in the midazolam-droperidol group required fewer

    additional doses or alternative drugs to achieve adequate

Conclusions

    • Klein LR, et al. Ann Emerg Med. 2018;72(4):374-385.

    • Martel M, et al. Acad Emerg Med. 2006 Feb;13(2):233.

    • Wright P, et al. Am J Psychiatry. 2001;158(7):1149-1151.

  • Taylor DM, et al. Ann Emerg Med. 2017;69(3):318-326.e1
  • Hsu W, et al. J Clin Psychopharmacol. 2010;30(3):230-234.
  • Thomas H, et al. Ann Emerg Med. 1992;21(4):407-413.
  • Nobay Fet al,. Acad Emerg Med. 2004;11(7):744-749.

References

    • Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Accessed 2020, September 15.

    http://www.micromedexsolutions.com/

    • Zun LS. J Emerg Med. 2018;54(3):364-374.

    • Mattson A, et al. Am J Health Syst Pharm. 2020

    • Miceli JJ, et al. Clin Ther. 2010;32(3):472-491

    • Yimcharoen P, et al. Gastrointest Endosc. 2006;63(7):979-985.

    • Haddad PM, Anderson IM. Drugs. 2002;62(11):1649-1671

    • Klein LR, et al. Ann Emerg Med. 2018;72(4):374-385.

    • Martel M, et al. Acad Emerg Med. 2006 Feb;13(2):233.

    • Wright P, et al. Am J Psychiatry. 2001;158(7):1149-1151.

  • Taylor DM, et al. Ann Emerg Med. 2017;69(3):318-326.e1
  • Hsu W, et al. J Clin Psychopharmacol. 2010;30(3):230-234.
  • Thomas H, et al. Ann Emerg Med. 1992;21(4):407-413.
  • Nobay Fet al,. Acad Emerg Med. 2004;11(7):744-749.
Tags:antipsychotics acute agitation haloperidol olanzapine

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Antipsychotics for Acute Agitation. Pharmacy Friday Pearls. 09-18-2020.pdf