ERs Lag in Use of Newer Antipsychotics for Agitation

By Anne Harding

NEW YORK - The use of second-generation antipsychotics to treat acute agitation in the emergency room has not increased since 2004, new research shows.

While the field of psychiatry has made the move to the newer medications, replacing older drugs such as haloperidol and droperidol, "the emergency department does not follow the conventional wisdom of psychiatry in terms of the antipsychotics they prescribe," Dr. Michael Wilson of UC San Diego, the first author of the new study, told Reuters Health.

Dr. Wilson co-authored expert guidelines from 2012 recommending the use of second-generation antipsychotics (SGAs). The medications are generally considered to be safer and have fewer side effects than first-generation antipsychotics (FGAs).

To investigate the use of SGAs in emergency departments, Dr. Wilson and his colleagues looked at data on patients treated at two different university EDs between 2004 and 2011. Both were general adult-pediatric EDs.

They identified 1,680 patients with 1,779 ED visits, who received aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone. They also identified 2,470 patients treated with first-generation antipsychotics at 2,833 ED visits during the same time period.

As reported online March 20 in the Journal of Emergency Medicine, the researchers saw a trend toward a decline in the number of ED visits during which a patient received a second-generation antipsychotic (SGA), but the trend was not statistically significant.

The guidelines recommend oral administration of SGAs, which was done in 93% of cases. The most commonly used SGAs were risperidone (60%) and olanzapine (27%). On 21% of the visits, patients also received a benzodiazepine, usually lorazepam. And for 42 of the 199 visits in which patients had a positive test for alcohol, patients were given SGAs along with benzodiazepines. Among the patients given first-generation antipsychotics, those with positive alcohol tests received benzodiazepines 16.5% of the time.

There is evidence that when alcohol-intoxicated patients receive injected SGAs they have a drop in oxygen saturation that isn't seen with FGAs, Dr. Wilson noted in an interview. "That may be another reason that ED physicians have been slow to switch over from the older generation drugs," he said.

One problem with making the switch, he added, is that there hasn't been much research on SGAs in ED patients. He noted that the National Institutes of Mental Health declined to fund a study he and his colleagues proposed comparing SGAs to FGAs in the ED setting, because NIMH considered the superiority of the newer drugs to be a "done deal."

"I would like to see ED physicians using more second-generation antipsychotics," he said. "We're going to have to show them the research that it matters."


J Emerg Med 2014.

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