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Antipsychotics in acute agitation

Published online by Cambridge University Press:  02 January 2018

J. P. Richardson
Affiliation:
Wolfson Research Centre, Newcastle General Hospital, Westgate Road, Newcastle-upon-Tyne NE4 8BE
S. Joseph
Affiliation:
Wolfson Research Centre, Newcastle General Hospital, Westgate Road, Newcastle-upon-Tyne NE4 8BE
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Abstract

Type
The Columns
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © 2001. The Royal College of Psychiatrists

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 (Reference Reilly, Avis and FerrierReilly et al, 2000). In recent months thioridazine has been restricted to second-line use in psychosis (Reference BreckenridgeBreckenridge, 2000) and the manufacturers, because of these dangers, have withdrawn droperidol.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.

References

Breckenridge, A. (2000) Thioridazine: restricted indications and new warnings on cardiotoxicity. Committee on Safety of Medicines. http://www.open.gov.uk/mca/ourwork/monitorsafequalmed/safetymessages/thiolet.Google Scholar
Reilly, J. G., Avis, S. A., Ferrier, N., et al (2000) QTc-interval abnormalities and psychotropic drug therapy in psychiatric patients. Lancet, 355, 10481052.CrossRefGoogle ScholarPubMed
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