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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" ​+<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 AgitationConsensus 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/|PsychiatryAdvisorHaloperidol in the Emergency ​Department Setting]]
  
 +{{tag>​rx}}