Psychomotor agitation can occur in a range of physical and psychiatric conditions. High potency antipsychotics ( often with benzodiazepines), SGAs like olanzapine, aripiprazole and ziprasidone, are effective in controlling this. Combination of promethazine with haloperidol is commonly used in many countries. Sedation induced by these treatments can prevent evaluation of conditions underlying the agitation.The goal of pharmacological intervention should be to induce tranquilization.(= calmness, ie reduction in symptoms of agitation and aggression, without the induction of deep or prolonged sedation).
Celia Mantovani and team compared the efficacy and safety of 4 low-dose intramuscular interventions (1.haloperidol (2.5 mg) combined with promethazine (25 mg), (2) haloperidol (2.5 mg) combined with midazolam (7.5 mg), (3) ziprasidone (10 mg), and (4) olanzapine (10 mg) in a randomised study (with 100 adult patients) with patients selected from a psychiatric emergency unit in Brasil. Those with serious general medical conditions/ an established diagnosis of delirium were excluded.Calming Agitation-Evaluating Scale (ACES: rated 1-9 levels) was used to rate agitation levels and a difference of at least 2 points on the ACES was considered as meaningful for clinical purposes. 21/100 were diagnosed psychotic disorder, 36 with bipolar disorder/manic episodes, 15 with disorders related to substance abuse, and 28 with other disorders, such as personality disorder and mental retardation. Groups were comparable in diagnostic category, age and medical comorbidity.
Haloperidol midazolam combination and olanzapine were more effective than others at 90 minutes. Olanzapine and haloperidol plus midazolam did not differ in efficacy.22 % required an additional dose ( given at 30 minutes based on clinical judgement) and the groups did not differ in this need.Patients treated with HLP + PMZ had an increased risk of developing extrapyramidal symptoms than those treated with HLP + MID, with no significant effects for other treatments.
Low dose high potency antipsychotics along with benzodiazepines or low dose SGAs are effective in controlling agitation.
Study was not funded by pharma. Sample size may not be enough for multiple analysis.
Mantovani C, Labate CM, Sponholz A Jr, de Azevedo Marques JM, Guapo VG, de Simone Brito Dos Santos ME, Pazin-Filho A, Del-Ben CM. J Clin Psychopharmacol. 2013 Jun;33(3):306-12.