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Current and Potential Pharmacologic Therapies for Traumatic Brain Injury. Pharmaceuticals (Basel) 2022; 15:ph15070838. [PMID: 35890136 PMCID: PMC9323622 DOI: 10.3390/ph15070838] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
The present article reviewed the pharmacologic therapies of traumatic brain injury (TBI), including current and potential treatments. Pharmacologic therapies are an essential part of TBI care, and several agents have well-established effects in TBI care. In the acute phase, tranexamic acid, antiepileptics, hyperosmolar agents, and anesthetics are the mainstay of pharmacotherapy, which have proven efficacies. In the post-acute phase, SSRIs, SNRIs, antipsychotics, zolpidem and amantadine, as well as other drugs, have been used to manage neuropsychological problems, while muscle relaxants and botulinum toxin have been used to manage spasticity. In addition, increasing numbers of pre-clinical and clinical studies of pharmaceutical agents, including potential neuroprotective nutrients and natural therapies, are being carried out. In the present article, we classify the treatments into established and potential agents based on the level of clinical evidence and standard of practice. It is expected that many of the potential medicines under investigation will eventually be accepted as standard practice in the care of TBI patients.
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Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE. Risk Factors for Sedation-related Events During Acute Agitation Management in the Emergency Department. Acad Emerg Med 2019; 26:1135-1143. [PMID: 31265756 DOI: 10.1111/acem.13826] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/04/2019] [Accepted: 06/25/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective was to describe the incidence, nature, and risk factors for adverse events (AEs) among patients who received parenteral sedation for acute agitation in an emergency department (ED) setting. METHODS We undertook a prospective observational study and a clinical trial of parenteral sedation for the management of acute agitation. We included agitated adult patients who required parenteral sedation from 2014 to 2017 in 12 Australian EDs, excluding those with incomplete information or aged under 18 years. The primary outcome was the number of patients who experienced at least one AE. Multivariable logistic regression was used to determine factors associated with AEs. RESULTS A total of 904 patients were included in the analyses (62.3% male; median age = 34 years, range = 18 to 95 years). Of these, 144 (15.9%) patients experienced at least one AE. The most common AEs were oxygen desaturation (7.4%), airway obstruction (3.6%), bradycardia (1.9%), hypotension (1.7%), and prolonged QTc interval (1.3%). No deaths or serious AEs were reported. The following factors had an increased adjusted odds ratio (OR) for experiencing an AE: age 65 years and older (OR = 2.8, 95% confidence interval [CI] = 1.2 to 7.2), more than one type of parenteral sedation administered within 60 minutes (OR = 2.1, 95% CI = 1.4 to 3.1), and alcohol intoxication (OR = 1.8, 95% CI = 1.2 to 2.6). CONCLUSIONS Sedation-related AEs are common, especially respiratory events. Elderly patients, sedation with multiple sedatives within 60 minutes, and alcohol intoxication increased the risk.
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Affiliation(s)
- Celene Y. L. Yap
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Integrated Critical Care Department of Medicine and Radiology Melbourne Medical School The University of Melbourne Parkville Victoria
- Emergency Department The Royal Melbourne Hospital Parkville Victoria
- Centre for Medicine Use and Safety Monash University Parkville Victoria
| | - David McD. Taylor
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Integrated Critical Care Department of Medicine and Radiology Melbourne Medical School The University of Melbourne Parkville Victoria
- Emergency DepartmentAustin Health HeidelbergVictoria
| | - David C. M. Kong
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Medicine Use and Safety Monash University Parkville Victoria
- Pharmacy Department Ballarat Health Services Ballarat Victoria Australia
| | - Jonathan C. Knott
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Integrated Critical Care Department of Medicine and Radiology Melbourne Medical School The University of Melbourne Parkville Victoria
- Emergency Department The Royal Melbourne Hospital Parkville Victoria
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Williamson D, Frenette AJ, Burry LD, Perreault M, Charbonney E, Lamontagne F, Potvin MJ, Giguère JF, Mehta S, Bernard F. Pharmacological interventions for agitated behaviours in patients with traumatic brain injury: a systematic review. BMJ Open 2019; 9:e029604. [PMID: 31289093 PMCID: PMC6615826 DOI: 10.1136/bmjopen-2019-029604] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The aim of this systematic review was to assess the efficacy and safety of pharmacological agents in the management of agitated behaviours following traumatic brain injury (TBI). METHODS We performed a search strategy in PubMed, OvidMEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science and Prospero (up to 10 December 2018) for published and unpublished evidence on the risks and benefits of 9 prespecified medications classes used to control agitated behaviours following TBI. We included all randomised controlled trials, quasi-experimental and observational studies examining the effects of medications administered to control agitated behaviours in TBI patients. Included studies were classified into three mutually exclusive categories: (1) agitated behaviour was the presenting symptom; (2) agitated behaviour was not the presenting symptom, but was measured as an outcome variable; and (3) safety of pharmacological interventions administered to control agitated behaviours was measured. RESULTS Among the 181 articles assessed for eligibility, 21 studies were included. Of the studies suggesting possible benefits, propranolol reduced maximum intensities of agitation per week and physical restraint use, methylphenidate improved anger measures following 6 weeks of treatment, valproic acid reduced weekly agitated behaviour scale ratings and olanzapine reduced irritability, aggressiveness and insomnia between weeks 1 and 3 of treatment. Amantadine showed variable effects and may increase the risk of agitation in the critically ill. In three studies evaluating safety outcomes, antipsychotics were associated with an increased duration of post-traumatic amnesia (PTA) in unadjusted analyses. Small sample sizes, heterogeneity and an unclear risk of bias were limits. CONCLUSIONS Propranolol, methylphenidate, valproic acid and olanzapine may offer some benefit; however, they need to be further studied. Antipsychotics may increase the length of PTA. More studies on tailored interventions and continuous evaluation of safety and efficacy throughout acute, rehabilitation and outpatient settings are needed. PROSPERO REGISTRATION NUMBER CRD42016033140.
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Affiliation(s)
- David Williamson
- Pharmacy, Université de Montréal, Montreal, Quebec, Canada
- Pharmacy, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | | | - Lisa D Burry
- Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto Leslie Dan, Toronto, Ontario, Canada
| | - Marc Perreault
- Pharmacy, Université de Montréal, Montreal, Quebec, Canada
- Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Marie-Julie Potvin
- Psychology, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Jean-Francois Giguère
- Neurosurgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
- Médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Francis Bernard
- Médecine, Université de Montréal, Montreal, Quebec, Canada
- Critical Care, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
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Kim S, Mortera M, Hu X, Krishnan S, Hoffecker L, Herrold A, Terhorst L, King L, Machtinger J, Zumsteg JM, Negm A, Heyn P. Overview of pharmacological interventions after traumatic brain injuries: impact on selected outcomes. Brain Inj 2019; 33:442-455. [DOI: 10.1080/02699052.2019.1565896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Sonya Kim
- Department of Neurology and Department of Rehabilitation Medicine, NYU School of Medicine, New York, USA
| | - Marianne Mortera
- NYU Steinhardt, Department of Occupational Therapy, New York University, New York, USA
| | - Xiaolei Hu
- Department of Community Medicine and Rehabilitation, Umeå University, Sweden
| | - Shilpa Krishnan
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University, Atlanta, Georgia, USA
| | - Lilian Hoffecker
- Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy Herrold
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Lauren Terhorst
- Department of Occupational Therapy, School of Health and Rehabilitation Services, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laurie King
- Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph Machtinger
- Department of Neurology, Division of Multiple Sclerosis, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer M. Zumsteg
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Ahmed Negm
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, USA
| | - Patricia Heyn
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Polich G, Iaccarino MA, Zafonte R. Psychopharmacology of traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:253-267. [PMID: 31727216 DOI: 10.1016/b978-0-444-64012-3.00015-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The pathophysiology of traumatic brain injury (TBI) can be highly variable, involving functional and/or structural damage to multiple neuroanatomical networks and neurotransmitter systems. This wide-ranging potential for physiologic injury is reflected in the diversity of neurobehavioral and neurocognitive symptoms following TBI. Here, we aim to provide a succinct, clinically relevant, up-to-date review on psychopharmacology for the most common sequelae of TBI in the postacute to chronic period. Specifically, treatment for neurobehavioral symptoms (depression, mania, anxiety, agitation/irritability, psychosis, pseudobulbar affect, and apathy) and neurocognitive symptoms (processing speed, attention, memory, executive dysfunction) will be discussed. Treatment recommendations will reflect general clinical practice patterns and the research literature.
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Affiliation(s)
- Ginger Polich
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Mary Alexis Iaccarino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States.
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Mehta S, McIntyre A, Janzen S, Iruthayarajah J, Bateman A, Teasell R. Pharmacological management of agitation among individuals with moderate to severe acquired brain injury: A systematic review. Brain Inj 2018; 32:287-296. [DOI: 10.1080/02699052.2017.1419377] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Swati Mehta
- Lawson Health Research Institute, London, ON, Canada
- Parkwood Institute Research, Parkwood Institute, London, ON, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada
| | - Amanda McIntyre
- Lawson Health Research Institute, London, ON, Canada
- Parkwood Institute Research, Parkwood Institute, London, ON, Canada
| | - Shannon Janzen
- Lawson Health Research Institute, London, ON, Canada
- Parkwood Institute Research, Parkwood Institute, London, ON, Canada
| | - Jerome Iruthayarajah
- Lawson Health Research Institute, London, ON, Canada
- Parkwood Institute Research, Parkwood Institute, London, ON, Canada
| | - Ali Bateman
- Parkwood Institute Research, Parkwood Institute, London, ON, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada
| | - Robert Teasell
- Lawson Health Research Institute, London, ON, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada
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Cheng JP, Leary JB, O'Neil DA, Meyer EA, Free KE, Bondi CO, Kline AE. Spontaneous recovery of traumatic brain injury-induced functional deficits is not hindered by daily administration of lorazepam. Behav Brain Res 2017; 339:215-221. [PMID: 29203336 DOI: 10.1016/j.bbr.2017.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/02/2017] [Accepted: 11/30/2017] [Indexed: 10/18/2022]
Abstract
Agitation and aggression are common sequelae of traumatic brain injury (TBI) and pose a challenge to physicians and other health providers during acute patient care and subsequent neurorehabilitation. Antipsychotic drugs (APDs) are routinely administered to manage TBI patients displaying such maladaptive behaviors despite several clinical and preclinical studies demonstrating that they hinder recovery. A potentially viable alternative to APDs may be the benzodiazepines, which have differing mechanisms of action. Hence, the aim of the study was to test the hypothesis that lorazepam (LOR) would not impede recovery after TBI. Anesthetized adult male rats received a cortical impact or sham injury and then were intraperitoneally administered LOR (0.1mg/kg, 1.0mg/kg, or 2.0mg/kg) or vehicle (VEH; 1mL/kg) commencing 24-h after surgery and once daily for 19days. Motor and cognitive outcomes were assessed on post-operative days 1-5 and 14-19, respectively. No differences were revealed among the four sham control groups and thus they were pooled into one inclusive SHAM group. The SHAMs performed better than all TBI groups on all assessments (p<0.05). Regarding TBI, the 2.0mg/kg LOR group performed better than the VEH and 0.1mg/kg or 1.0mg/kg LOR groups on every task (p<0.05); no differences were observed among the latter three groups on any endpoint (p>0.05). Overall, these preclinical behavioral data support the hypothesis and reveal a therapeutic benefit with the higher dose of LOR. The findings suggest that LOR may be an alternative, to APDs, for controlling agitation without compromising spontaneous recovery and perhaps could afford a dual benefit by also promoting therapeutic efficacy.
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Affiliation(s)
- Jeffrey P Cheng
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Jacob B Leary
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Darik A O'Neil
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Elizabeth A Meyer
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Kristin E Free
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Corina O Bondi
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Neurobiology, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, 15213, United States
| | - Anthony E Kline
- Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, United States; Psychology, University of Pittsburgh, PA, 15213, United States.
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Plantier D, Luauté J. Drugs for behavior disorders after traumatic brain injury: Systematic review and expert consensus leading to French recommendations for good practice. Ann Phys Rehabil Med 2016; 59:42-57. [PMID: 26797170 DOI: 10.1016/j.rehab.2015.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/12/2015] [Accepted: 10/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE There are no handbook or recommendations for the use of pharmacological agents to treat neurobehavioral disorders after traumatic brain injury (TBI). This work proposes a systematic review of the literature and a user guide on neuroleptics, antidepressants, beta-blockers, mood stabilizers and other medications for irritability, aggressiveness, agitation, impulsivity, depression, apathy… METHOD Steering, working and reading groups (62 people) were formed under the control of the French High Authority for Health (HAS) in collaboration with the SOFMER scientific society (French Society of Physical and Rehabilitation Medicine). Articles were searched by HAS officers in the Medline database from 1990 to 2012, crossing TBI and pharmacological agents. The HAS method to select, read and analyze papers is close to the PRISMA statements. RESULTS Out of 772 references, 89 were analyzed, covering a total of 1306 people with TBI. There is insufficient evidence to standardize drug treatments for these disorders. There are however some elements to establish consensus recommendations for good clinical practice. Propranolol can improve aggression (B grade). Carbamazepine and valproate seem effective on agitation and aggression and are recommended as first line treatment (Expert Consensus [EC]). There is no evidence of efficacy for neuroleptics. Their prescription is based on emergency situation for a crisis (loxapine) but not for long-term use (EC). Antidepressants are recommended to treat depression (EC) with a higher standard of proof for Selective Serotonin Reuptake Inhibitors (SSRI, grade B). Other products are described. CONCLUSION The choice of treatment depends on the level of evidence, target symptoms, custom objectives, clinical experience and caution strategies.
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Affiliation(s)
- D Plantier
- Department of Physical Medicine and Rehabilitation (PM&R), Neurological Rehabilitation, Renée-Sabran Hospital, University Hospital of Lyon, boulevard Édouard-Herriot, 83400 Hyères, France.
| | - J Luauté
- Physical Medicine and Rehabilitation, Neurological Rehabilitation, Henry-Gabrielle Hospital, University Hospital of Lyon, 69230 Saint-Genis-Laval, France; Neuroscience Research Center of Lyon (CRNL) IMPACT team, Inserm U1028, CNRS, UMR5292, 69500 Bron, France
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Pangilinan PH, Giacoletti-Argento A, Shellhaas R, Hurvitz EA, Hornyak JE. Neuropharmacology in Pediatric Brain Injury: A Review. PM R 2010; 2:1127-40. [DOI: 10.1016/j.pmrj.2010.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 06/16/2010] [Accepted: 07/05/2010] [Indexed: 11/28/2022]
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Abstract
INTRODUCTION Droperidol is a controversial drug with multiple clinical applications. This report examines the use of droperidol in pediatric emergency department (ED) patients. METHODS An observational structured chart review was conducted of patients 21 years or younger receiving droperidol as part of their ED treatment. RESULTS Over a 32-month period, 79 ED records were identified for review. Patients' ages ranged from 15 to 21 years with a mean age of 19.4 (T0.2) years. Indications for droperidol included agitation, 68 (86%); nausea/vomiting, 7 (9%); headache, 2 (3%); and other pain, 2 (3%). Droperidol was the initial therapy in 63 patients (80%) and the rescue medication in 16 (20%). In nonagitated patients, droperidol was 100% effective in controlling patient's symptoms, whereas in agitated patients, droperidol alone was 86.6% effective as a single agent. Within the agitated patients, 35 (51.5%) were positive for drugs, 15 (22.1%) were positive for drugs and alcohol, and 12 (17.6%) were positive for alcohol alone. All patients were placed on continuous cardiac monitoring immediately after administration of the drug and for the duration of their active ED visit. No cardiac arrhythmias were noted. Thirty-eight patients (48%) were discharged from the ED, 35 (44%) were transferred to the psychiatric crisis unit for evaluation, 5 (6%) were admitted, and in 1 patient with biliary colic, the disposition was not recorded. No admissions were for droperidol-associated complications. CONCLUSIONS Droperidol is a safe and effective medication in the adolescent and young adult population.
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Deb S, Crownshaw T. Review of subjectThe role of pharmacotherapy in the management of behaviour disorders in traumatic brain injury patients. Brain Inj 2009; 18:1-31. [PMID: 14660233 DOI: 10.1080/0269905031000110463] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this paper was to systematically review the research published in English language on the effectiveness of drugs for the treatment of neurobehavioural disorders in patients with traumatic brain injury (TBI). A literature search using Medline, Pre-Medline, Embase, Psychlit and Cochrane Library databases between 1990 and January 2003 as well as a hand search of Brain Injury since 1996 were carried out. Phrases such as 'head injury', 'brain injury', 'drug treatment', 'drug trials' and 'randomized controlled trials' were used. Sixty-three papers were selected for data synthesis. Of these, 13 were randomized controlled trials, eight were prospective observational studies, four were retrospective studies, 25 were case series and 13 were single case studies. There was a dearth of type I-III evidence. There was no strong evidence either way to suggest that drugs are effective in the treatment of behaviour disorders in patients with TBI. However, there was weak evidence, primarily based on case studies that psychostimulants are effective in the treatment of apathy, inattention and slowness; high dose beta-blockers in the treatment of agitation and aggression; anti-convulsants and anti-depressants (particularly SSRIs) in the treatment of agitation and aggression, particularly in the context of an affective disorder; and possibly a specific neuroleptic methotrimeprazine in the treatment of agitation in the post-acute stage of Acquired Brain Injury. Some drugs that are effective in some patients have been shown to be ineffective in others. Some drugs, particularly lithium and dopaminergic drugs could cause adverse effects and deterioration in some patients.
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Affiliation(s)
- Shoumitro Deb
- Division of Neuroscience, Department of Psychiatry, University of Birmingham, UK.
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Fleminger S, Greenwood RJ, Oliver DL. Pharmacological management for agitation and aggression in people with acquired brain injury. Cochrane Database Syst Rev 2006:CD003299. [PMID: 17054165 DOI: 10.1002/14651858.cd003299.pub2] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management. OBJECTIVES To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other electronic databases. We also searched the reference lists of included studies and recent reviews. In addition we handsearched the journals Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions. The searches were last updated in June 2006. SELECTION CRITERIA Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age. DATA COLLECTION AND ANALYSIS We independently extracted data and assessed trial quality. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused. MAIN RESULTS Six RCTs were identified and included in this review. Four of theses evaluated the beta-blockers, propranolol and pindolol, one evaluated the central nervous system stimulant, methylphenidate and one evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking. AUTHORS' CONCLUSIONS Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.
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Affiliation(s)
- S Fleminger
- Maudsley Hospital, Lishman Brain Injury Unit, Denmark Hill, London, UK.
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Gordon WA, Zafonte R, Cicerone K, Cantor J, Brown M, Lombard L, Goldsmith R, Chandna T. Traumatic brain injury rehabilitation: state of the science. Am J Phys Med Rehabil 2006; 85:343-82. [PMID: 16554685 DOI: 10.1097/01.phm.0000202106.01654.61] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Wayne A Gordon
- Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, New York 10029-6574, USA
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Abstract
Acute agitation occurs in a variety of medical and psychiatric conditions, and when severe can result in behavioural dyscontrol. Rapid tranquillisation is the assertive use of medication to calm severely agitated patients quickly, decrease dangerous behaviour and allow treatment of the underlying condition. Intramuscular injections of typical antipsychotics and benzodiazepines, given alone or in combination, have been the treatment of choice over the past few decades. Haloperidol and lorazepam are the most widely used agents for acute agitation, are effective in a wide diagnostic arena and can be used in medically compromised patients. Haloperidol can cause significant extrapyramidal symptoms, and has rarely been associated with cardiac arrhythmia and sudden death. Lorazepam can cause ataxia, sedation and has additive effects with other CNS depressant drugs.Recently, two fast-acting preparations of atypical antipsychotics, intramuscular ziprasidone and intramuscular olanzapine, have been developed for treatment of acute agitation. Intramuscular ziprasidone has shown significant calming effects emerging 30 minutes after administration for acutely agitated patients with schizophrenia and other nonspecific psychotic conditions. Intramuscular ziprasidone is well tolerated and has gained widespread use in psychiatric emergency services since its introduction in 2002. In comparison with other atypical antipsychotics, ziprasidone has a relatively greater propensity to increase the corrected QT (QTc) interval and, therefore, should not be used in patients with known QTc interval-associated conditions. Intramuscular olanzapine has shown faster onset of action, greater efficacy and fewer adverse effects than haloperidol or lorazepam in the treatment of acute agitation associated with schizophrenia, schizoaffective disorder, bipolar mania and dementia. Intramuscular olanzapine has been shown to have distinct calming versus nonspecific sedative effects. The recent reports of adverse events (including eight fatalities) associated with intramuscular olanzapine underscores the need to follow strict prescribing guidelines and avoid simultaneous use with other CNS depressants. Both intramuscular ziprasidone and intramuscular olanzapine have shown ease of transition to same-agent oral therapy once the episode of acute agitation has diminished. No randomised, controlled studies have examined either agent in patients with severe agitation, drug-induced states or significant medical comorbidity. Current clinical experience and one naturalistic study with intramuscular ziprasidone suggest that it is efficacious and can be safely used in such populations. These intramuscular atypical antipsychotics may represent a historical advance in the treatment of acute agitation.
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Affiliation(s)
- John Battaglia
- Department of Psychiatry and Behavioural Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Abstract
Posttraumatic agitation is a challenging problem for acute and rehabilitation staff, persons with traumatic brain injury, and their families. Specific variables for evaluation and care remain elusive. Clinical trials have not yielded a strong foundation for evidence-based practice in this arena. This review seeks to evaluate the present literature (with a focus on the decade 1995-2005) and employ previous clinical experience to deliver a review of the topic. We will discuss definitions, pathophysiology, evaluation techniques, and treatment regimens. A recommended approach to the evaluation and treatment of the person with posttraumatic agitation will be presented. The authors hope that this review will spur discussion and assist in facilitating clinical care paradigms and research programs.
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Affiliation(s)
- Lisa A Lombard
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Harmsen M, Geurts ACH, Fasotti L, Bevaart BJW. Positive behavioural disturbances in the rehabilitation phase after severe traumatic brain injury: an historic cohort study. Brain Inj 2004; 18:787-96. [PMID: 15204319 DOI: 10.1080/02699050410001671757] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PRIMARY OBJECTIVE To investigate the association of post-traumatic amnesia (PTA) with positive behavioural disturbances (PBD) in an historic cohort of patients with severe traumatic brain injury (TBI) and to evaluate the use and effects of neuroleptic drugs in this cohort. RESEARCH DESIGN Historic cohort study. METHODS The medical files of 60 patients with severe TBI, selected for inpatient rehabilitation during a period of 5.5 years, were independently examined for the presence of PTA and PBD at admission in the rehabilitation centre as well as for the concomitant use of neuroleptic drugs. All TBI patients with PBD at admission were subjected to special nursing measures consisting of a structured and safe environment, a minimum number of caregivers and provision of simple and consistent feedback. As a basic policy, the use of neuroleptic medication was minimized or stopped. RESULTS Of the 28 patients suffering from PTA at admission, 16 demonstrated PBD (positive predictive value 0.57 (95% CI 0.45-0.70)). In contrast, all the 32 patients without PTA but one did not show PBD (negative predictive value 0.97 (95% CI 0.93-1.00)). Seven of the 17 patients with PBD (41%) had been prescribed neuroleptic medication, of whom five patients (81%) experienced undesired side effects. Because of the special nursing measures, these drugs could be stopped or substituted by non-neuroleptic behaviour-modifying drugs in all patients within 3 weeks, without aggravation of their PBD. CONCLUSIONS These results suggest that impaired attention and memory may play a critical role in the development of PBD in patients with severe TBI. From this perspective, maximum effort must be made to improve TBI patients' level of attention, memory and orientation instead of using mechanical or chemical restraints.
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Affiliation(s)
- M Harmsen
- Department of Rehabilitation Medicine, St. Maartenskliniek, Nijmegen, The Netherlands
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Abstract
Droperidol is an antipsychotic and antiemetic drug that has been used extensively by emergency physicians, psychiatrists, and anesthesiologists worldwide since 1967. It also has been used effectively for other diverse conditions, such as treatment of headache and vertigo. As of January 2001, Droperidol was no longer available in Europe after its founder, Janssen-Cilag Pharmaceuticals, discontinued its distribution. In December 2001, the United States Food and Drug Administration (FDA) placed a black box warning on the use of Droperidol in response to an association between Droperidol and fatal cardiac dysrhythmias, such as torsade de pointes, resulting from prolongation of the QT interval. In this review we closely examine the pharmacology, indications, use, and complications associated with Droperidol, and speculate on its future use in the Emergency Department.
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Affiliation(s)
- John R Richards
- Division of Emergency Medicine and Toxicology, University of California, Davis Medical Center, Sacramento, California, USA
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Fleminger S, Greenwood RJ, Oliver DL. Pharmacological management for agitation and aggression in people with acquired brain injury. Cochrane Database Syst Rev 2003:CD003299. [PMID: 12535468 DOI: 10.1002/14651858.cd003299] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management. OBJECTIVES To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI). SEARCH STRATEGY We searched MEDLINE (1966-2002), EMBASE (1980-2002) and the Cochrane Controlled Trials Register (1996-2002), Web of Science Citation Index, reference lists of papers meeting the inclusion criteria and recent reviews. We handsearched Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age. Studies using lower levels of evidence (i.e. case series studies, single case studies and controlled group comparison studies), were collated in an appendix. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed trial quality. Authors were contacted where necessary for additional information. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused. MAIN RESULTS Six randomised controlled trials were identified. Four RCTs evaluated the beta-blockers, propranolol and pindolol, one RCT evaluated the central nervous system stimulant, methylphenidate and one RCT evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking. REVIEWER'S CONCLUSIONS Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.
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Affiliation(s)
- S Fleminger
- Lishman Brain Injury Unit, Maudsley Hospital, Denmark Hill, London, UK, SE5 8AZ.
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