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Author: Admin | 2025-04-28
All that said, which medications are most effective in treating agitation? Let’s run down the list.AntipsychoticsHaloperidol (Haldol) and the haloperidol cocktailsHaloperidol has long been the gold standard for treating agitation. No other drug has been found to be more effective than haloperidol, and most studies of other agents use haloperidol as the comparison. Haloperidol has its disadvantages, including side effects like dystonia and Parkinsonism, but given its long track record (since 1967), we still consider it the first-line agent for agitation. However, we never prescribe haloperidol alone because in these circumstances the rate of dystonia is close to 50%—and one review considers the use of haloperidol alone to be unethical due to the high rate of EPS (Ostinelli EG et al, Cochrane Database Syst Rev 2017;7(7):CD009377).That brings us to the haloperidol cocktail and its variants. The typical agitation cocktail is haloperidol 5–10 mg/lorazepam 1–2 mg/diphenhydramine 50 mg (or benztropine 1–2 mg), given either IM or orally. The commonsense rationale behind the cocktail is as follows: Haloperidol targets both psychosis and agitation; lorazepam adds a second mechanism to target agitation; and diphenhydramine prevents a dystonic reaction from the haloperidol and adds a sedating effect. Yet no studies have compared this three-medication combination with other options. Furthermore, it’s an open question whether anticholinergic agents like diphenhydramine are really necessary. A recent meta-analysis showed that benzodiazepines might suffice to prevent EPS: Rates of dystonia and EPS were 3% and 5%, respectively, for haloperidol plus lorazepam, vs 0% (dystonia) and 0%–84% (EPS) for haloperidol plus the antihistamine promethazine (Bak M et al, Eur Psychiatry 2019;57:78–100). Many guidelines recommend using a combination of haloperidol plus anticholinergic or haloperidol plus benzodiazepine, but not all three agents combined (Wilson MP et al, West J Emerg Med 2012;13(1):26–34). An advantage of haloperidol plus lorazepam is that these meds can be administered in one syringe. When diphenhydramine or benztropine are mixed with haloperidol, a precipitate forms within minutes, leading most hospital pharmacies to recommend separate syringes.Olanzapine (Zyprexa)Olanzapine is an effective option whether given orally (especially in its ODT form, Zyprexa Zydis) or IM. We like it because it has
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