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Antipsychotics in acute agitation

Wolfson Research Centre, Newcastle General Hospital, Westgate Road, Newcastle-upon-Tyne NE4 8BE

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restricted to second-line use in psychosis (Breckenridge, 2000) and the manufacturers, because of these dangers, have withdrawn droperidol.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.

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 .

REILLY, J. G. AVIS, S. A., FERRIER, N., et al (2000) QTc-interval abnormalities and psychotropic drug therapy in psychiatric patients. Lancet, 355, 1048-1052.[CrossRef][Medline]

This Article Full Text (PDF) Submit an eLetter Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Richardson, J. P. Articles by Joseph, S. Search for Related Content PubMed Articles by Richardson, J. P. Articles by Joseph, S.