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2. Acute Agitation Requiring IM Antipsychotics
David N. Osser, MD,
Associate Professor of Psychiatry
Harvard Medical School
Brockton Division of the VA Boston Healthcare System
General Editor - Psychopharmacology Algorithm Project
Harvard South Shore Residency Training Program

3. Acute agitation Common behavioral emergency
High risk of violence and aggression

4. Evidence of efficacy

5. 31 trials Systematic review SGAs Haloperidol Midazolam Lorazepam
Effective (compared with placebo)
IM route more rapid onset than the oral route
Midazolam
Lorazepam
Zeller, S. L., et al(2010). Systematic reviews of assessment measures and pharmacologic treatments for agitation. Clinical therapeutics, 32(3),

6. Combination: haloperidol + lorazepam
Combination: more effective than either treatment alone
(Garza-Trevino 1989, Battaglia 1997, Breier 2002).

7. Combination: haloperidol + lorazepam
Low EPS risk
Anticholinergic use: appears unnecessary
Combination: more effective than either treatment alone
(Garza-Trevino 1989, Battaglia 1997, Breier 2002).

8. Industry-sponsored trials
Haloperidol
New IM SGAs: superior to haloperidol alone
IM SGAs
Ziprasidone
Olanzapine
Aripiprazole

9. Industry-sponsored trials
Haloperidol
New IM SGAs: superior to haloperidol alone
High rate of EPS
IM SGAs
Haloperidol
Lorazepam
Not studied
Ziprasidone
Olanzapine
Aripiprazole

10. RCT: IM treatments 100 agitated pts in an ER
Most of them had schizophrenia
Mantovani, C.,et a;. (2013). Are low doses of antipsychotics effective in the management of psychomotor agitation? A randomized, rated-blind trial of 4 intramuscular interventions. Journal of clinical psychopharmacology, 33(3),

11. RCT: IM treatments 100 agitated pts in an ER
Haloperidol
Benzodiazepine
RCT: IM treatments
Haloperidol
Antiparkinson
Olanzapine
100 agitated pts in an ER
Most of them had schizophrenia
Ziprasidone
Mantovani, C.,et a;. (2013). Are low doses of antipsychotics effective in the management of psychomotor agitation? A randomized, rated-blind trial of 4 intramuscular interventions. Journal of clinical psychopharmacology, 33(3),

12. RCT: IM treatments 100 agitated pts in an ER Similar efficacy
Haloperidol
Benzodiazepine
RCT: IM treatments
Haloperidol
Antiparkinson
Similar efficacy
Olanzapine
100 agitated pts in an ER
Most of them had schizophrenia
Ziprasidone
Mantovani, C.,et a;. (2013). Are low doses of antipsychotics effective in the management of psychomotor agitation? A randomized, rated-blind trial of 4 intramuscular interventions. Journal of clinical psychopharmacology, 33(3),

13. Side effects: 60% greater
Haloperidol
Benzodiazepine
RCT: IM treatments
Haloperidol
Antiparkinson
Similar efficacy
Olanzapine
Side effects: 60% greater
100 agitated pts in an ER
Most of them had schizophrenia
Ziprasidone
Mantovani, C.,et a;. (2013). Are low doses of antipsychotics effective in the management of psychomotor agitation? A randomized, rated-blind trial of 4 intramuscular interventions. Journal of clinical psychopharmacology, 33(3),

14. Recommendations

15. Recommendations Haloperidol 5 mg + Lorazepam 2 mg
Can be repeated once or twice every 30 to 60 minutes
Rapid, safe and cost-effective treatment

16. Chlorpromazine
Ahmed, U., Jones, H., & Adams, C. E. (2010). Chlorpromazine for psychosis induced aggression or agitation. The Cochrane Library.

17. Avoid IM chlorpromazine
High risk of sudden, serious hypotension
Ahmed, U., Jones, H., & Adams, C. E. (2010). Chlorpromazine for psychosis induced aggression or agitation. The Cochrane Library.

18. Avoid IM chlorpromazine
High risk of sudden, serious hypotension
Same effectiveness as haloperidol
Ahmed, U., Jones, H., & Adams, C. E. (2010). Chlorpromazine for psychosis induced aggression or agitation. The Cochrane Library.

19. Oral PRN antipsychotics:
Often used
Usually not necessary for less severe agitation
A benzodiazepine is just as effective

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