- Last edited on April 30, 2020
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meds:agitation [on May 16, 2019] |
meds:agitation [on January 25, 2022] (current) |
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- | {{tag>rx}} | + | ====== Pharmacological Management of Acute Behavioural Agitation ====== |
- | ====== Pharmacological Management of Acute Agitation ====== | + | |
{{INLINETOC}} | {{INLINETOC}} | ||
===== Primer ===== | ===== Primer ===== | ||
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<panel type="info" title="Haloperidol versus Loxapine" subtitle="Adapted from Procyshyn, Ric M., Kalyna Z. Bezchlibnyk-Butler, and J. Joel Jeffries. Clinical Handbook of Psychotropic Drugs. Hogrefe, 2017." no-body="true"> | <panel type="info" title="Haloperidol versus Loxapine" subtitle="Adapted from Procyshyn, Ric M., Kalyna Z. Bezchlibnyk-Butler, and J. Joel Jeffries. Clinical Handbook of Psychotropic Drugs. Hogrefe, 2017." no-body="true"> | ||
- | !^! ^ Description ^ Haloperidol ^ Loxapine ^ | + | <mobiletable 1> |
+ | ^ ^ Description ^ Haloperidol ^ Loxapine ^ | ||
^ Potency | The amount of medication that needs to be given | High | Intermediate | | ^ Potency | The amount of medication that needs to be given | High | Intermediate | | ||
^ D2 Antagonism | Amount of antipsychotic effect, and EPS risk | +++++ | ++++ | | ^ D2 Antagonism | Amount of antipsychotic effect, and EPS risk | +++++ | ++++ | | ||
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^ 5-HT2 Antagonism | Amount of anxiolytic effect/sedation | +/+++ | +++/++++ | | ^ 5-HT2 Antagonism | Amount of anxiolytic effect/sedation | +/+++ | +++/++++ | | ||
^ ACh M1 Antagonism | Mitigation of EPS, sedation | + | ++ | | ^ ACh M1 Antagonism | Mitigation of EPS, sedation | + | ++ | | ||
+ | </mobiletable> | ||
</panel> | </panel> | ||
- | <callout type="danger" title="TYPICAL ANTIPSYCHOTICS ARE CONTRAINDICATED in LBD" icon="true"> | + | <callout type="danger" title="Typical and High Potency Antipsychotics are CONTRAINDICATED in Lewy Body Dementia!" icon="true"> |
- | A severe sensitivity reaction occurs in an estimated 25-50% of [[geri:dementia:lewy-body|]] patients administered typical antipsychotic drugs (especially haloperidol). This results in cognitive impairment, sedation, increased/irreversible acute onset of parkinsonism, or symptoms resembling [[meds:antipsychotics:nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]]. If an antipsychotic must be used, then low potency atypical antipsychotics like clozapine or quetiapine should be used.[([[https://www.lbda.org/go/er|Lewy Body Dementia Association: Emergency Room Treatment of Psychosis]])] | + | A severe sensitivity reaction occurs in an estimated 25-50% of [[geri:dementia:lewy-body|]] patients administered typical antipsychotic drugs (especially haloperidol). This results in cognitive impairment, sedation, increased/irreversible acute onset of parkinsonism, or symptoms resembling [[meds:antipsychotics:nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]]. If an antipsychotic must be used, then low potency atypical antipsychotics like [[meds:antipsychotics:second-gen-atypical:7-clozapine|clozapine]] or [[meds:antipsychotics:second-gen-atypical:6-quetiapine|quetiapine]] should be used.[([[https://www.lbda.org/go/er|Lewy Body Dementia Association: Emergency Room Treatment of Psychosis]])] |
</callout> | </callout> | ||
==== Zuclopenthixol ==== | ==== Zuclopenthixol ==== | ||
- | <callout type="success">{{fa>arrow-circle-right?color=green}} See also main article: **[[meds:antipsychotics:first-gen-typical:4-zuclopenthixol]]**</callout> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
+ | See also main article: **[[meds:antipsychotics:first-gen-typical:4-zuclopenthixol]]** | ||
+ | </alert> | ||
===== Choosing a Benzodiazepine ===== | ===== Choosing a Benzodiazepine ===== | ||
<panel type="info" title="Emergency Benzodiazepine Use" no-body="true"> | <panel type="info" title="Emergency Benzodiazepine Use" no-body="true"> | ||
- | ^ ^ Onset of Action ^ Half-life ^ | + | ^ Benzodiazepine ^ Onset of Action ^ Half-life ^ |
- | ^ Lorazepam | Rapid | 12 hours | | + | ^ [[meds:benzos:4-lorazepam|Lorazepam]] | Rapid | 12 hours | |
- | ^ Clonazepam (PO) | Rapid | 12-48 hours | | + | ^ [[meds:benzos:2-clonazepam|Clonazepam]] | Rapid | 12-48 hours | |
- | ^ Diazepam | Rapid | 24-100 hours | | + | ^ [[meds:benzos:1-diazepam|Diazepam]] | Rapid | 24-100 hours | |
- | ^ Midazolam | Intermediate | 2-3 hours | | + | ^ [[meds:benzos:8-midazolam|Midazolam]] | Intermediate | 2-3 hours | |
- | ^ Alprazolam (PO) | Intermediate | 12 hours | | + | ^ [[meds:benzos:3-alprazolam|Alprazolam]] | Intermediate | 12 hours | |
</panel> | </panel> | ||
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</panel> | </panel> | ||
- | <panel type="info" t | + | <panel type="info" title="Benzodiazepines" no-body="true"> |
- | itle="Benzodiazepines" no-body="true"> | + | |
| Lorazepam 1-2mg PO/SL/IM q1h PRN for agitation (max 8mg/24hrs) | | | Lorazepam 1-2mg PO/SL/IM q1h PRN for agitation (max 8mg/24hrs) | | ||
</panel> | </panel> | ||
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===== Side Effects ===== | ===== Side Effects ===== | ||
==== Extrapyramidal Symptoms ==== | ==== Extrapyramidal Symptoms ==== | ||
- | <callout type="success">{{fa>arrow-circle-right?color=green}} See main article: **[[meds:antipsychotics:eps]]**</callout> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
+ | See main article: **[[meds:antipsychotics:eps]]** | ||
+ | </alert> | ||
+ | ===== Guidelines ===== | ||
+ | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
+ | See also: **[[teaching:clinical-practice-guidelines-cpg|]]** | ||
+ | </alert> | ||
+ | |||
+ | {{page>teaching:clinical-practice-guidelines-cpg#agitation&nouser&noheader&nodate&nofooter}} | ||
===== Resources ===== | ===== Resources ===== | ||
== For Providers == | == For Providers == | ||
- | * [[http://escholarship.org/uc/item/5fz8c8gs|Wilson, Michael P.; Pepper, David; Currier, Glenn W.; Holloman, Garland H.; & Feifel, David. (2012). The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine, 13(1).]] | + | * [[https://www.psychiatryadvisor.com/home/opinion/haloperidol-in-the-emergency-department-setting/|PsychiatryAdvisor: Haloperidol in the Emergency Department Setting]] |
+ | {{tag>rx}} | ||