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Author: Admin | 2025-04-28
A low incidence of dystonia and we can safely use it as monotherapy. A four-way comparison of IM agents found that olanzapine was equally effective as the haloperidol/midazolam combination, and that both options were more effective than either ziprasidone or haloperidol plus promethazine (Mantovani C et al, J Clin Psychopharmacol 2013;33(3):306–312). Highly agitated patients may not respond to maximal doses of IM Zyprexa, in which case a benzodiazepine can be added, but with caution (Editor’s note: See the callout box below).Risperidone (Risperdal)For oral use, we like risperidone ODT (Risperdal M-Tab) because, despite its high potency, it has a lower risk for dystonia than haloperidol. While risperidone can be used alone, a study combining it with lorazepam found that the combination was as effective as haloperidol plus lorazepam (Currier GW et al, J Clin Psychiatry 2004;65(3):386–394). No studies have evaluated risperidone alone vs risperidone plus lorazepam, but in our experience, the combination of risperidone plus lorazepam is more effective.Ziprasidone (Geodon)IM ziprasidone appears less effective than IM olanzapine or the IM haloperidol/benzo combination (Mantovani et al, 2013). Ziprasidone was the least effective at reducing scores on the Positive and Negative Syndrome Scale Excited Component (PANSS-EC) in a meta-analysis of randomized controlled trials that examined various pharmacologic treatments for acute agitation (Bak et al, 2019). A concern with ziprasidone is that it increases the risk of QTc prolongation in patients with other risks for QTc prolongation.Aripiprazole (Abilify)Aripiprazole is no longer available in the short-acting IM version as it was withdrawn by the manufacturer due to poor sales. Drawbacks include the potential to be activating and a lower efficacy rate compared to other second-generation agents for managing agitation (Wilson et al, 2012).Chlorpromazine (Thorazine)Chlorpromazine, the first antipsychotic to be developed, has a long track record of use for agitation, especially in its IM form. This medication’s main advantage is a low EPS risk. Its drawbacks include a QTc prolongation similar to haloperidol’s, potential orthostatic dizziness, and a lowered seizure threshold. While these side effects lead some authorities to discourage its use, in the real world of inpatient psychiatry we find that many of our agitated
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