Case Report: Use of Subcutaneous Midazolam During an Episode of Catatonia

Abstract

Midazolam is a benzodiazepine (BZD) mainly used in anesthetic induction due to its pharmacokinetic features. Its place in the therapeutic management of catatonia remains to be determined. Here we present the case of a 65-year-old man who presented with a first episode of catatonia with opposition to any form of oral treatment, where a single dose of 1 mg of subcutaneous (SC) Midazolam permitted clinical improvement allowing oral treatment to be given. The patient's history notably included a renal transplant linked to Polycystic Kidney Disease (PKD) and no history of psychiatric illness nor of any use of psychotropic drugs. As the patient refused to drink or eat and ceased answering basic questions, a psychiatric assessment was required. A diagnosis of Catatonic disorder due to a general medical condition [DSM 5–293.89/ ICD10 [F06.1]] was made. A Bush-Francis Catatonia Rating Scale (BFCRS) analysis returned a score of 15 out of 62, with stupor, mutism, negativism, staring, withdrawal, rigidity, and stereotypy. As the negativism prevented the patient from taking any form of oral treatment, after a brief discussion with the unit's physician, it was decided to administer 1 mg of SC Midazolam. One hour later, the patient was more responsive and compliant, and agreed to drink, eat, and take medication. Thus, the catatonic signs of mutism, negativism, staring, and withdrawal were resolved, but waxy flexibility and catalepsy appeared, leading to a new BFCRS score of 10 out of 62. Oral treatment with 2.5 mg Lorazepam, 4 times a day, was then initiated. Midazolam could be a safer choice compared with the other options available, such as other SC BZD, considering the complex safety profile of this patient with renal insufficiency. This situation represents the first report of using SC Midazolam as an injectable treatment for catatonia. More studies are needed to assess the clinical pertinence of SC Midazolam in the treatment of catatonia.

Catatonia in older adults: A systematic review

“…Lorazepam is recommended as the first-line medication, and it is extensively reported to be highly effective, irrespective of the underlying cause[ 5 , 6 , 143 , 144 ]. Other BZDs, such as diazepam[ 128 , 145 ], midazolam[ 146 , 147 ], alprazolam[ 148 ], oxazepam[ 128 ], flunitrazepam[ 139 ], temazepam[ 128 ] and clorazepate[ 108 ], have also been described as useful in older people. This treatment should be maintained until the catatonia etiology is identified and appropriately treated[ 1 , 28 ].…”

Surge of Midazolam Use in the Midst of Lorazepam Shortage

“…Catatonia: resolution IV or IM: 2-6 mg Maximum: 8-27 mg* per day 54,55 Case studies have demonstrated success of resolving catatonia, but further research is needed. [56][57][58] Lorazepam is the preferred drug to both resolve and confirm a diagnosis of catatonia, but success has been reported with use of diazepam, oxazepam, and clonazepam. 59 Catatonia: lorazepam challenge test IV: 2 mg 2 Case report demonstrates use of midazolam in confirmation of catatonia diagnosis.…”

“…59 Catatonia: lorazepam challenge test IV: 2 mg 2 Case report demonstrates use of midazolam in confirmation of catatonia diagnosis. 56 Treatment of COVID-induced catatonia is not only jeopardized by the shortage of lorazepam, the first-line drug of choice 69 but also may be impacted by the limitations on midazolam administration. Using the lowest conversion rate of lorazepam to midazolam of 1:1.5, the daily dose needed to treat catatonia can range from 3 to 40.5 mg/d.…”