Antipsychotics in acute agitation

Sir: The pharmacological management of acute agitation, a common clinical problem faced by physicians and psychiatrists, is associated with significant risk. Antipsychotics are frequently used in management but there have been recent reports of dangers associated with some classes of antipsychotics, in particular droperidol and thioridazine. These drugs are associated with QTc interval prolongation, arrhythmia's and sudden death (Reilly et al, 2000). In recent months thioridazine has been restricted to second-line use in psychosis (Breckenridge, 2000) and the manufacturers, because of these dangers, have withdrawn droperidol.

In May 2000 we carried out a survey of prescribing among psychiatrists in Newcastle. A questionnaire with a typical presentation of an acutely agitated young male was circulated to all psychiatrists. Respondents were asked for preferred first- and second-line management regimes. The response rate was 48%. Seventy-eight per cent of respondents indicated that droperidol plus lorazepam would be their first choice, followed by zuclopenthixol acetate (9%) and others (15%). The second-line choices were zuclopenthixol acetate (28%), droperidol (28%), lorazepam (28%) and others (16%).

If these results represent common practice in adult psychiatry, there is cause for concern. Withdrawal of droperidol therefore requires urgent revision of guidelines regarding acute agitation and consideration of alternatives. These could include olanzapine in intramuscular form (currently being used experimentally) and the more widespread use of intravenous sedation protocols. However, using the above would have considerable implications for already hard-pressed drug budgets and the level and skill of nursing observation available.