Pharmacological management of agitation among individuals with moderate to severe acquired brain injury: A systematic review

Abstract

Studies consistently demonstrated that pharmacological treatment was effective in reducing agitation post ABI; however, there was insufficient information to develop a conclusion due to the limited number of studies and overall weakness of evidence for each individual medication.

The Efficacy and Harms of Pharmacological Interventions for Aggression After Traumatic Brain Injury—Systematic Review

“…With respect to the findings from previous reviews, all have agreed that no strong conclusions could be drawn due to the limited number of studies and overall weakness of the evidence for each class of medication (34, 39, 41). Notwithstanding this, there was a general consensus that the current best evidence for treatment of aggression post TBI supports the use of amantadine and beta-blockers, with typical neuroleptics only to be prescribed with caution due to concern regarding adverse events (34, 36, 38, 41, 42, 44–47). Many other drugs have also been listed as possible options including anticonvulsants (mostly carbamazepine, valproic acid), specific serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCA), atypical antipsychotics, methylphenidate, and lithium (40–42, 44, 46, 47).…”

“…Pharmacological methods are more commonly used. Given there are no FDA (Food and Drug Administration) approved medications for aggression post TBI, all medication is prescribed off-label (34, 35). As such, clinicians must rely on their clinical expertise, experience in treating similar conditions, extrapolation of aggression management from non-TBI populations, and consideration of other factors that may preclude certain medications such as availability and cost (34, 36).…”

“…Given there are no FDA (Food and Drug Administration) approved medications for aggression post TBI, all medication is prescribed off-label (34, 35). As such, clinicians must rely on their clinical expertise, experience in treating similar conditions, extrapolation of aggression management from non-TBI populations, and consideration of other factors that may preclude certain medications such as availability and cost (34, 36). This has facilitated wide variation in prescribing practices, with anti-convulsants, anti-depressants, and anti-psychotics being the most commonly prescribed (35, 37).…”

“…Although this topic has attracted a number of previous reviews, many are outdated and their conclusions are limited by methodological issues, for example, lack of key systematic review components (no comprehensive search for published and unpublished data; lack of comprehensive evidence tables; no methodological assessment for risk of bias) (36, 38–43), failure to examine harms (40), and absence of a clear delineation between studies in which participants were in or out of PTA (34, 36, 44, 45). With respect to the findings from previous reviews, all have agreed that no strong conclusions could be drawn due to the limited number of studies and overall weakness of the evidence for each class of medication (34, 39, 41). Notwithstanding this, there was a general consensus that the current best evidence for treatment of aggression post TBI supports the use of amantadine and beta-blockers, with typical neuroleptics only to be prescribed with caution due to concern regarding adverse events (34, 36, 38, 41, 42, 44–47).…”

Risperidone versus placebo for aggression following traumatic brain injury: a feasibility randomised controlled trial

“…8 Evidence on pharmacological intervention for post-TBI aggression Since Deb and Crownshaw's 9 original systematic review on the effectiNeuropsychiatry Inventory-Aggressionveness of psychotropics on neurobehavioural symptoms of TBI, several reviews have been published on this. [10][11][12][13][14][15][16][17][18][19] Findings from all the RCTs on pharmacotherapy for post-TBI aggression are summarised in table 2. A number of studies have shown methylphenidate's (MPH) effectiveness in improving post-TBI cognitive impairment and sometimes apathy symptoms.…”