Despite Expert Recommendations, Second-generation Antipsychotics Are Not Often Prescribed in the Emergency Department

Wilson, Michael P.; Minassian, Arpi; Bahramzi, Maria; Campillo, Ashleigh; Vilke, Gary M.

doi:10.1016/j.jemermed.2014.01.017

Cited by 31 publications

(17 citation statements)

References 29 publications

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“…Of note, although the frequency of droperidol use remained static, the frequency of haloperidol use increased significantly over the study period. The use of secondgeneration antipsychotics as a class has been decreasing in a statistically nonsignificant fashion during this exact period (5).…”

Section: Discussionmentioning

confidence: 94%

First-generation Antipsychotics Are Often Prescribed in the Emergency Department but Are Often Not Administered with Adjunctive Medications

Campillo¹,

Castillo

Vilke

et al. 2015

The Journal of Emergency Medicine

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, Abstract-Background: Although first-generation antipsychotics (FGAs) have long been used in the emergency department (ED) to treat acute agitation, little is known about how these medications are used in modern clinical practice. In particular, little work has been published about whether ED clinicians administer FGAs with adjunctive medications in accordance with expert guidelines or the prescribing practices of FGAs over time. Objectives: 1) To provide a comparison of the frequency with which FGAs are administered with adjunctive benzodiazepines or anticholinergic medications. 2) To analyze the prescribing trends for FGAs over time, particularly in the years after the U.S. Food and Drug Administration (FDA) black-box warning for droperidol. Methods: This is a structured review of a retrospective cohort of patients receiving haloperidol or droperidol in two EDs over a 7-year period. Results: Haloperidol or droperidol was administered on 2833 patient visits during the study period, with haloperidol being administered most often. Adjunctive medications are administered less than half of the time. The use of droperidol has remained relatively static, whereas the use of haloperidol has increased. Conclusions: First-generation antipsychotics are still widely utilized in the ED. When administered, these medications are used with adjunctive medications that may decrease side effects less than half of the time. Droperidol use has remained unchanged in the years after the FDA black-box warning, whereas use of haloperidol has continued to rise. Ó 2015 Elsevier Inc.

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Section: Discussionmentioning

confidence: 94%

First-generation Antipsychotics Are Often Prescribed in the Emergency Department but Are Often Not Administered with Adjunctive Medications

Campillo¹,

Castillo

Vilke

et al. 2015

The Journal of Emergency Medicine

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“…This increased LOS is present despite the fact that agitation, which is the most common reason medications are administered, is itself not associated with longer stays. It is tempting to speculate that use of overly sedating medications, particularly delivered intramuscularly or intravenously by emergency medicine clinicians, might increase LOSs [25][26][27]. However, this awaits more prospectively collected data.…”

Section: Discussionmentioning

confidence: 99%

“…One additional factor that might be important is the type of medication that is used by ED clinicians. Nonsedating oral medication, for example, would be expected to decrease LOSs but is infrequently used by ED clinicians [26,27]. However, given the multiplicity of doses and types of medication in the ED, it is difficult to compare across medications, routes of administration, and doses in this study.…”

Section: Limitationsmentioning

confidence: 99%

Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use

Wilson¹,

Brennan²,

Modesti³

et al. 2015

The American Journal of Emergency Medicine

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Background: Psychiatric patients experience longer treatment times (length of stay [LOS]) in the emergency department (ED) compared to nonpsychiatric patients. Although patients on involuntary mental health holds are relatively understudied, common wisdom would hold that times for these patients can only be affected by addressing systems issues because they are not free to leave. The objective of this study was to determine whether both selected ED and patient-specific factors were associated with longer LOS. We hypothesized that nonmodifiable factors (age, sex, agitation, presentation during evenings/nights, presentation during weekends, suicidal ideation) would prolong LOS but that potentially modifiable factors (such as use of medication) would reduce LOS. Methods: A historical cohort of patients (January 1, 2009-August 16, 2010) placed on involuntary mental health holds was studied in 2 general EDs. A regression model was used to calculate the effects of modifiable and nonmodifiable factors on LOS. Results: Six hundred forty patient visits met all inclusion/exclusion criteria. Longer LOSs were significantly associated with suicidal ideation, use of antipsychotics, and use of benzodiazepines, although agitation did not predict longer LOSs. Longer LOSs were also longer with presentation on the weekends. Conclusions: Lengths of stay for patients on involuntary mental health holds are associated with several factors outside the control of the typical ED clinician such as the ability to clear holds quickly due to day of week or placement of the hold for suicidal ideation. Lengths of stay are also increased by factors within the control of the typical ED clinician, such as administration of calming medication.

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“…While many clinicians still rely on first generation antipsychotics such as haloperidol, fluphenazine, and chlorpromazine for acute agitation, the American Association of Emergency Psychiatry recommends the use of second generation antipsychotics (SGAs) as first-line agents 5,6. Second generation antipsychotics have been shown to cause less extrapyramidal side effects than first generation antipsychotics, and appear to be as effective at controlling agitation 7-9…”

Section: Introductionmentioning

confidence: 99%

Coadministration of intramuscular olanzapine and benzodiazepines in agitated patients with mental illness

Williams

2018

Mental Health Clinician

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Introduction:Intramuscular antipsychotics are commonly used to manage agitated patients. In 2005, Eli Lilly placed a warning on olanzapine's prescribing information following post-marketing reports of fatal drug reactions when intramuscular olanzapine was used in the setting of benzodiazepines. Data is lacking examining this drug combination.Methods:A medication use evaluation was conducted at a county psychiatric hospital surveying the usage of concomitant intramuscular olanzapine and lorazepam from October 1, 2016, to July 20, 2017. A literature search was conducted to review available evidence.Results:Ninety-one instances of the drug combination were discovered, with no serious adverse events following administration. Of these 91 patients, 41 received both medications within 60 minutes of each other. No instances of hypotension, bradycardia, bradypnea, or oxygen desaturation occurred following administration. The literature review yielded 1 randomized, placebo-controlled clinical trial, 3 retrospective chart reviews, and several case studies.Discussion:Data detailing a causal relationship between olanzapine/benzodiazepine combinations and serious adverse effects is lacking. Available evidence does not consistently support a strong cause and effect relationship. The results of this medication use evaluation are not consistent with the Food and Drug Administration warning. Further controlled research is needed to help define the actual risk of using concomitant intramuscular olanzapine and benzodiazepines.

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Despite Expert Recommendations, Second-generation Antipsychotics Are Not Often Prescribed in the Emergency Department

Cited by 31 publications

References 29 publications

First-generation Antipsychotics Are Often Prescribed in the Emergency Department but Are Often Not Administered with Adjunctive Medications

First-generation Antipsychotics Are Often Prescribed in the Emergency Department but Are Often Not Administered with Adjunctive Medications

Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use

Coadministration of intramuscular olanzapine and benzodiazepines in agitated patients with mental illness

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