Intramuscular olanzapine versus intramuscular haloperidol plus lorazepam for the treatment of acute schizophrenia with agitation: An open-label, randomized controlled trial

Quantifying the effects of practicing a semantic task according to subclinical schizotypy

The learning ability of individuals within the schizophrenia spectrum is crucial for their psychosocial rehabilitation. When selecting a treatment, it is thus essential to consider the impact of medications on practice effects, an important type of learning ability. To achieve this end goal, a pre-treatment test has to be developed and tested in healthy participants first. This is the aim of the current work, which takes advantage of the schizotypal traits present in these participants to preliminary assess the test's validity for use among patients. In this study, 47 healthy participants completed the Schizotypal Personality Questionnaire (SPQ) and performed a semantic categorization task twice, with a 1.5-hour gap between sessions. Practice was found to reduce reaction times (RTs) in both low- and high-SPQ scorers. Additionally, practice decreased the amplitudes of the N400 event-related brain potentials elicited by semantically matching words in low SPQ scorers only, which shows the sensitivity of the task to schizotypy. Across the two sessions, both RTs and N400 amplitudes had good test-retest reliability. This task could thus be a valuable tool. Ongoing studies are currently evaluating the impact of fully deceptive placebos and of real antipsychotic medications on these practice effects. This round of research should subsequently assist psychiatrists in making informed decisions about selecting the most suitable medication for the psychosocial rehabilitation of a patient.

Second-Generation Parenteral Antipsychotic (Olanzapine) as a First-Line Treatment for Acute Undifferentiated Agitation in the Emergency Department in Comparison With Haloperidol

Background Acutely agitated patients are common in the emergency department (ED). Given the myriad aetiologies of the clinical conditions that can produce agitation, such a high prevalence is unsurprising. Agitation is a symptomatic presentation, not a diagnosis, secondary to a psychiatric, medical, traumatic, or toxicological condition. Most literature on the emergency management of agitated patients is from psychiatric populations, not generalised to EDs. Benzodiazepines, antipsychotics, and ketamine have been used to treat acute agitation. However, a clear consensus is lacking. Objectives The objectives are to study the effectiveness of intramuscular (IM) olanzapine as a first-line treatment for rapid tranquillisation in undifferentiated acute agitation in the ED and compare the effectiveness of sedatives to control agitation in etiologically divided groups per the following preassigned protocols: Group A: Alcohol/drug intoxication (olanzapine vs haloperidol), Group B: Traumatic brain injury (TBI) with or without alcohol intoxication (olanzapine vs haloperidol), Group C: Psychiatric conditions (olanzapine vs haloperidol and lorazepam), and Group D: Agitated delirium, organic causes (olanzapine vs haloperidol). Methods This 18-month prospective study included acutely agitated ED patients between 18 and 65. Results A total of 87 patients between 19 and 65 were included, all with a Richmond Agitation Sedation Scale (RASS) score between +2 and +4 at presentation. Nineteen of the 87 patients were managed as acute undifferentiated agitation, and 68 were assigned to one of the four groups. In acute undifferentiated agitation, IM olanzapine 10 mg effectively sedated 15 (78.9%) patients within 20 minutes, whereas the remaining four (21.1%) were sedated with a repeat IM olanzapine 10 mg over the next 25 minutes. In 13 patients with agitation due to alcohol intoxication, zero out of three with olanzapine and four out of 10 (40%) with IM haloperidol 5 mg were sedated within 20 minutes. In patients with TBI, two out of eight (25%) receiving olanzapine and four out of nine (44.4%) receiving haloperidol were sedated within 20 minutes. In acute agitation secondary to psychiatric disease, olanzapine sedated nine out of 10 (90%), and haloperidol with lorazepam sedated 16 out of 17 (94.1%) within 20 minutes. In patients with agitation secondary to organic medical conditions, olanzapine rapidly sedated 19 out of 24 (79.1%), whereas haloperidol sedated one out of four (25%). Interpretation and conclusion IM olanzapine 10 mg is effective for rapid sedation in acute undifferentiated agitation. Olanzapine is superior to haloperidol in agitation secondary to organic medical conditions and is as efficacious as haloperidol with lorazepam in agitation due to psychiatric diseases. However, in agitation due to alcohol intoxication and TBI, haloperidol 5 mg is slightly better, although not statistically significant. Olanzapine and haloperidol were well tolerated by Indian patients in the current study, with minimal side effects.

Evaluation of the ventilatory effects on human subjects in prolonged hip-flexed/head-down restraint position

BACKGROUND

The restraint chair is a tool used by law enforcement and correction personnel to control aggressive, agitated individuals. When initiating its use, subjects are often placed in a hip-flexed/head-down (HFHD) position to remove handcuffs. Usually, this period of time is less than two minutes but can become more prolonged in particularly agitated patients. Some have proposed this positioning limits ventilation and can result in asphyxia. The aim of this study is to evaluate if a prolonged HFHD restraint position causes significant ventilatory compromise.

METHODS

Subjects exercised on a stationary bicycle until they reached 85% of their predicted maximal heart rate. They were then handcuffed with their hands behind their back and placed into a HFHD seated position for five minutes. The primary outcome measurement was maximal voluntary ventilation (MVV). This was measured at baseline, after initial placement into the HFHD position, and after five minutes of being in the position while still maintaining the HFHD position. Baseline measurements were compared with final measurements for statistically significant differences.

RESULTS

We analyzed data for 15 subjects. Subjects had a mean MVV of 165.3 L/min at baseline, 157.8 L/min after initially being placed into the HFHD position, and a mean of 138.7 L/min after 5 min in the position. The mean baseline % predicted MVV was 115%; after 5 min in the HFHD position the mean was 96%. This 19% absolute difference was statistically significant (p = 0.001).

CONCLUSIONS

In healthy seated male subjects with recent exertion, up to five minutes in a HFHD position results in a small decrease in MVV compared with baseline MVV levels. Even with this decrease, mean MVV levels were still 96% of predicted after five minutes. Though a measurable decrease was found, there was no clinically significant change that would support that this positioning would lead to asphyxia over a five-minute time period.

Treatment of Agitation With Lorazepam in Clinical Practice: A Systematic Review

Acute agitation is a frequent occurrence in both inpatient and outpatient psychiatric settings, and the use of medication to calm a patient may be warranted to mitigate the situation. Lorazepam is a benzodiazepine that is widely used for management of acute agitation. Despite its widespread use, there is remarkably little clinical evidence for the benefits of lorazepam in acute agitation. We performed a systematic review with focus on lorazepam, including all randomized clinical trials on lorazepam in mental and behavioral disorders, excluding studies on dementia and pediatric patients and in mixed conditions. A total of 11 studies met inclusion criteria, and all were in patients with mental and behavioral disorders. Most trials generally found improvements across a variety of outcomes related to agitation, although there was some disparity if specific outcomes were considered. In the five studies with haloperidol, the combination of lorazepam and haloperidol was superior to either agent alone, but with no differences between monotherapy with the individual agents. In the study comparing lorazepam to olanzapine, olanzapine was superior to lorazepam, and both were superior to placebo. As expected, the safety of lorazepam among the different studies was consistent with its well-characterized profile with dizziness, sedation, and somnolence being the most common adverse events. Based on this structured review, lorazepam can be considered to be a clinically effective means of treating the acutely agitated patient.

A Case of Schizophrenia in a Young Male Adult with no History of Substance Abuse: Impact of Clinical Pharmacists' Interventions on Patient Outcome

Schizophrenia is a chronic and severe mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behaviour. This report presents the role of clinical pharmacists in the management of a patient diagnosed with schizophrenia with symptoms of paranoia. A gainfully employed young African male adult reported to be roaming around town moving from one bank to another was arrested. The patient was referred to the psychiatric unit of a hospital and diagnosed with schizophrenia. Key interventions offered included rapid tranquilization, electroconvulsive therapy, and psychotherapy. Medications administered to the patient while on admission included IV diazepam, IM haloperidol, IV Ketamine, IM flupentixol, olanzapine tablets, and trihexyphenidyl tablets. Issues raised by clinical pharmacists during the patient's admission included need for alternative medication for rapid tranquilization, need for initial investigations and documentation of the patient's vitals, initiation of antipsychotic therapy without initial monitoring and screening for substance abuse, inappropriate dose at initiation of antipsychotic medications, untreated indication, and incidence of missed doses. Interventions by the clinical pharmacists contributed to improvement in the patient's symptoms prior to hospital discharge. The case proves that it is critical for clinical pharmacists to be involved in the multidisciplinary team during management of patients with psychosis.

Polypharmacy in schizophrenia

Schizophrenia is a severe mental disorder characterized by a heterogeneous symptom profile which comprises a clinical platform for widespread use of polypharmacy even though antipsychotic monotherapy is the recommended treatment regimen. This narrative review provides a summary of the current gap between evidence and practice for use of antipsychotic combination therapy in patients with schizophrenia. Antipsychotic polypharmacy is frequently prescribed instead of following international consensus of clozapine monotherapy in treatment-resistant patients. Antipsychotic-benzodiazepine combination therapy clearly has a role in the treatment of acute agitation whereas there is no evidence to support an effect on core schizophrenia symptoms when chronically prescribed. Antidepressants are typically added to antipsychotic treatment in case of persistent negative symptoms. Available evidence suggests that antidepressants may improve negative symptom control in schizophrenia. Combining an antipsychotic with an antiepileptic is not supported by any firm evidence, but individual mood stabilizers have come out positively in single trials. Generally, the evidence base for polypharmacy in schizophrenia maintenance treatment is sparse but may be warranted in certain clinical situations. Therapeutic benefits and side effects should be carefully monitored and considered to ensure a beneficial risk-benefit ratio if prescribing polypharmacy for specific clinical indications.

Determination of combination therapy prescribing patterns for the treatment of acute agitation in psychiatric patients: A regression model of patient diagnoses and demographics

Introduction

Guidelines for the treatment of acute agitation typically recommend monotherapy with an antipsychotic or a benzodiazepine, but combination therapy is frequently used in practice. We created a regression model to identify which factors lead to the prescribing of combination therapy for acute agitation on a psychiatry unit.

Methods

We collected retrospective data from hospitalized patients in the psychiatry unit. An a priori alpha of 0.05 was used for binary logistic regression models to determine if and how the number of prescribed medications for acute agitation was influenced by: age, sex, race, cardiovascular comorbidities, and psychiatric diagnoses.

Results

We identified 1998 encounters from 1200 patients. Patients are significantly more likely to be prescribed combination therapy if they are young, male, and of non-white race or have a diagnosis of central nervous system stimulant use, hallucinogen use, depression, bipolar, cluster B personality, or psychosis. Patients are significantly more likely to be prescribed monotherapy if they have cardiovascular comorbidity or have neurocognitive disorder.

Discussion

Several demographic or diagnostic factors predict combination therapy prescribing. Acute agitation guidelines should be reviewed to include more clear instructions on combination therapy use.

The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis

Introduction:

Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.

Method:

A search in Pubmed and Embase was done to isolate RCT’s considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.

Results:

Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.

Conclusion:

Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital.

Rapid tranquillisation: the science and advice

‘Rapid tranquillisation’ refers to the use of medication to calm highly agitated individuals experiencing mental disorder who have not responded to non-pharmacological approaches. Commonly it is the initial stage in the treatment of severe and enduring illness. Using medication in this way requires particularly robust evidence of efficacy and the management of side-effects. This article attempts to integrate current understanding of the neurochemical mechanisms of underlying illness and drug actions with therapeutic interventions. It distinguishes arousal from agitation, and effects on sedation from tranquillisation. It reviews critically the practice of rapid tranquillisation in the light of new evidence, changes in the NICE guidelines and British National Formulary recommendations and a national audit (POMH-UK). Broader aspects of management, known as ‘restrictive practices’ (such as control and restraint and seclusion), psychological support of team members, incident reporting, risk assessment, monitoring and medico-legal aspects are not covered.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

A prospective naturalistic multicenter study on choice of parenteral medication in psychiatric emergency settings in Japan

Aim

To provide information about psychiatric emergency situations in Japan, we examined psychiatrists’ preference among parenteral medication since intramuscular (IM)‐olanzapine became available and clinical characteristics in patients given IM‐olanzapine compared to those given other parenteral medication.

Methods

We conducted a naturalistic study proceeding over a 1‐year period in 9 psychiatric emergency departments.

Results

Among 197 patients, the distribution of IM‐injections (n = 89) was as follows: IM‐olanzapine, 66 patients (74.2%), IM‐levomepromazine, 17 patients (19.1%), IM‐haloperidol, 5 patients (5.6%), and IM‐diazepam, 1 patient (1.1%). The distribution of intravenous (IV)‐injections (n = 108) was as follows: IV‐haloperidol, 78 patients (72.2%), and IV‐benzodiazepines (diazepam, flunitrazepam, or midazolam), 30 patients (27.8%). Advantages of IM‐olanzapine over other parenteral medications in efficacy were found as follows: less frequent needs of an additional injection despite no difference in duration until a patient became cooperative for oral administration, and less frequent needs of restraint after the injection. Furthermore, advantages of IM‐olanzapine over other injections in safety were found as follows: less frequent appearance of extrapyramidal symptoms, no occurrence of ECG abnormality and other serious adverse events except a fall, less frequent needs of an adjunctive anticholinergic drug, and less frequent needs of another kind of drug additionally injected.

Conclusions

Olanzapine has rapidly become the first choice of intramuscular medication in psychiatric emergency situations since it became available in Japan, probably due to the advantages in both efficacy and safety. This study reflecting psychiatric emergency practice in Japan may contribute to periodic international comparison of psychiatric emergency practice.

Safety and effectiveness of rapid-acting intra-muscular olanzapine for agitation associated with schizophrenia - Japan postmarketing surveillance study

OBJECTIVE

The objective of this study was to evaluate the safety and effectiveness of rapid-acting intramuscular (IM) olanzapine in the treatment of acute agitation associated with schizophrenia in real-world clinical settings in Japan.

METHODS

In this multicenter, postmarketing surveillance (PMS) study, patients with acute agitation associated with schizophrenia were treated with IM olanzapine daily in a daily clinical setting. The observational period ranged from 1 to 7 days, including the day of initial administration. Safety was assessed by reporting treatment-emergent adverse events (TEAEs) and adverse drug reactions (ADRs). The Positive and Negative Syndrome Scale - Excited Component (PANSS-EC) score was used to evaluate effectiveness at baseline and at 2 hours (after each administration), 2 days, and 3 days (end of the observational period) from the last administration of the IM olanzapine injection.

RESULTS

The safety analysis set included 999 patients, and the initial dose of 10 mg was administered to 955 patients. TEAEs were reported in 28 patients (36 events), the most common of which were dyslalia (5 patients), akathisia and somno lence (4 patients each), hepatic function abnormal (3 patients), and constipation and dehydration (2 patients each). One serious adverse event of akathisia occurred during the observation period. The PANSS-EC score (mean ± standard deviation) was 23.3±6.4 (n=625) at baseline, 16.9±7.0 (n=522) at 2 hours after initial injection, and 14.9±6.5 (n=650) at the last observation carried forward.

CONCLUSION

The results of this Japanese PMS study demonstrated that IM olanzapine is safe and has a favorable effectiveness profile in the treatment of schizophrenia patients with acute agitation.

Treatment of agitation in the acute psychiatric setting. An observational study of the effectiveness of intramuscular psychotropic medication

BACKGROUND

Agitation is frequent in the acute psychiatric setting. The observation and treatment of agitation is important to avoid harm to patients or staff, to reduce distress of the patient, and to reduce the risk of coercion, especially physical restraint.

AIM

To evaluate the effect of intramuscular treatment with psychotropics on agitation in a non-selected acute psychiatric population.

METHODS

The Positive and Negative Syndrome Scale Excitement Component (PANSS-EC) was implemented in the acute psychiatric ward at Psychiatric Center Copenhagen to improve assessment and treatment of agitation. During a period of almost ~2 years the staff was requested to assess agitation before and after administration of intramuscular injections.

RESULTS

PANSS-EC was obtained at baseline and within 2 hours after injection for 135 injections with antipsychotics or benzodiazepines administered to 101 acute, non-selected psychiatric patients with high occurrence of co-morbid substance abuse. Mean PANSS-EC at baseline was 26.53 ± 4.87, and mean reduction in PANSS-EC was 14.99 ± 8.48 (p < 0.001). For 73% of injections PANSS-EC decreased with ≥40% (generally accepted definition of response). In 49% of cases patients were subjected to physical restraint. Patients subjected to restraint had a significantly higher PANSS-EC score. Patients who received a subsequent injection had a significantly lower decline in PANSS-EC score. Besides two cases of acute dystonia following haloperidol injections, no serious side-effects were observed.

CONCLUSIONS

Treatment of agitation with intramuscular injections of psychotropics was in general effective in this non-selected, highly agitated psychiatric population, and injections were well tolerated.

Intramuscular olanzapine for agitated patients: A systematic review and meta-analysis of randomized controlled trials

We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs) of intramuscular (IM)-olanzapine (OLA-IM) versus controls in agitated patients. The risk ratio, number-needed-to-treat/harm, and standardized mean difference based on a random effects model were calculated. We identified 13 RCTs (19 comparisons) as follows: 7 comparisons with 1059 patients for OLA-IM versus placebo; 5 comparisons with 613 patients for OLA-IM versus haloperidol (HAL)-IM; 2 comparisons with 108 patients for OLA-IM versus ziprasidone (ZIP)-IM; 2 comparisons with 110 patients for OLA-IM versus HAL-IM plus midazolam; and 3 comparisons with 412 patients for OLA-IM versus HAL-IM plus promethazine, 2 comparisons with 355 patients for OLA-IM versus lorazepam-IM (LOR-IM); and 1 comparison with 67 patients for OLA-IM versus HAL-IM plus LOR-IM. OLA-IM was superior to placebo in both Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) and Agitation-Calmness Evaluation Scale (ACES) scores 2 h after first injection, and had a comparable side effect profile, including over sedation, extrapyramidal symptoms, akathisia, and anticholinergic use. While there was no significant difference in PANSS-EC scores after 2 h between OLA-IM and HAL-IM, OLA-IM outperformed HAL-IM in ACES after 2 h. Compared with HAL-IM, OLA-IM was associated with fewer side effects, including anticholinergic use, akathisia, extrapyramidal symptoms, and dystonia, and marginally less QT prolongation compared with HAL-IM. Based on our findings, OLA-IM is preferable to HAL-IM for the treatment of agitated patients. However, comparator data for ZIP-IM, LOR-IM and HAL-IM combination therapy were insufficient.