Ziprasidone, haloperidol and clonazepam intramuscular administration in the treatment of agitation symptoms in Chinese patients with schizophrenia: A network meta-analysis

"Pharmacological management of acute agitation in psychiatric patients: an umbrella review"

BACKGROUND

The main characteristics present in patients with psychomotor agitation include restlessness, excessive motor activity, irritability, and heightened responsiveness to internal and external stimuli. This umbrella review evaluates the efficacy and safety of pharmacological interventions for patients with psychiatric disorders presenting psychomotor agitation, aged 18 years or older. A comprehensive literature search was conducted to identify umbrella reviews that met our study's inclusion criteria. However, no reviews were found that specifically investigated the efficacy and safety of pharmacological interventions for agitated psychiatric patients presenting with both behavioral and psychological symptoms, such as emotional lability, decreased attention span, and cognitive and behavioral alterations. The primary objective is to assess the effectiveness of pharmacological interventions in controlling patients within a short time frame, measured in hours rather than days. The focus was placed on studies addressing treatment in emergency settings, whether in general hospitals or psychiatric facilities, with an emphasis on managing acute psychomotor agitation rather than long-term maintenance treatment.

METHOD

A comprehensive literature search for meta-analyses and systematic reviews assessing the efficacy and safety of pharmacological treatment for psychomotor agitation in psychiatric inpatients and emergency department patients was conducted across various databases such as PubMed, Scopus, EMBASE, Web of Science and COCHRANE Central database. Included reviews comprised those that incorporated randomized controlled trials (RCTs) or non-randomized controlled trials (NRCTs) comparing the efficacy and safety of pharmacological interventions for agitated psychiatric patients (with both psychological and behavioral symptoms).

RESULTS

Loxapine (10 mg) demonstrated superior efficacy over 5 mg in reducing agitation within 120 min, with inhaled formulations providing rapid relief in patients with acute psychosis. Aripiprazole was effective and caused less sedation compared to Olanzapine, although Haloperidol required fewer additional doses but was less effective at 60 min. Ziprasidone, administered intramuscularly, offered a faster onset and was better tolerated than Haloperidol. Lorazepam proved effective with fewer side effects than antipsychotics and showed enhanced efficacy when combined with them. Midazolam provided rapid sedation but posed risks of severe side effects, especially in older adults. Droperidol was as effective as Olanzapine but provided faster sedation. Combination therapy, such as Haloperidol with Promethazine, effectively reduced aggression with a lower incidence of adverse effects.

CONCLUSION

This umbrella review offers a comprehensive overview of the pharmacological management of psychomotor agitation in patients with psychiatric disorders. Among the most frequently used medications in the reviewed studies were haloperidol, olanzapine, and lorazepam. The findings underscore the importance of tailored treatment approaches and the need for further research to refine the management of psychomotor agitation in psychiatric settings.

The safety and efficacy of sequential intramuscular/oral ziprasidone treatment of acute episode in patients with schizophrenia: a multicenter, open-labeled study

BACKGROUND

Ziprasidone mesylate injection is an atypical antipsychotic drug which is recently approved in China. In combination with its oral formulation, sequential therapy with ziprasidone brings new interventions to patients with agitation in the acute phase of schizophrenia. The purpose of this 7-day multicenter study conducted in China was to evaluate the efficacy and safety of ziprasidone sequential treatment through intramuscular/oral routes in agitated patients with schizophrenia.

METHODS

A total of 95 patients were enrolled from three centers in this study. The study duration was 7 days. In the first 3 days, subjects were administered an intramuscular injection of ziprasidone 10-40 mg daily and started sequentially with oral ziprasidone 40-80 mg at dinner (or lunch) from the day of the last intramuscular injection. In the following 4 days, according to the severity of the symptoms and the drug response, 120-160 mg of ziprasidone was orally administered daily. In total, six visits were scheduled to assess the Positive and Negative Syndrome Scale (PANSS), the Behavioral Activity Rating Scale (BARS), the Clinical Global Impression of Severity (CGI-S), and Improvement (CGI-I) scores throughout the procedure. Lastly, adverse events were recorded during treatment.

RESULTS

Out of the 95 patients that were enrolled, 83 cases were effectively completed. Visits 3, 4, 6, PANSS, and PANSS-excited component (PANSS-EC) subscale points, and Visit 2-Visit 6 viewpoints, BARS scale points, and baseline scores denote a progressive downward trend (P < 0.001). In this study, 62 adverse events were reported. The most common adverse events were extrapyramidal symptoms (EPS) (23 cases) and excessive sedation(10 cases), and 13 cases of prolonged QTc interval were reported.

CONCLUSIONS

Ziprasidone IM demonstrated significant and rapid reduction in agitation, and sequential oral formulation keep stability and continuation of the treatment can further ensure efficacy. Ziprasidone sequential therapy may provide a new approach to acute agitation in schizophrenic patients.

TRIAL REGISTRATION

The Chinese Clinical Trials Registry; URL: https://www.chictr.org.cn : ChiCTR-OIC-16007970.

Dosing antipsychotics in special populations of patients with schizophrenia: severe psychotic agitation, first psychotic episode and elderly patients

Antipsychotic (AP) dosing is well established in nonelderly patients with acute exacerbations of schizophrenia, but not in special populations.This review describes the AP dosing procedures that have been used in clinical studies for acute psychotic agitation, a first episode of psychosis (FEP), and elderly patients. AP dosing data was extracted from the databases of drug regulatory authorities, and from clinical studies available in the medical literature. In acute psychotic agitation, intramuscular and oral APs are frequently prescribed in higher doses than those that saturate D2 receptors. Supersaturating doses of APs should be avoided due to an increased risk of adverse effects. In FEP, many studies showed efficacy of low doses of APs. Studies with risperidone and haloperidol suggested a dose reduction of approximately one third. Titration with a lower starting dose is recommended in elderly patients, due to possible decreases in pharmacokinetic clearance, and due to the risk of concomitant diseases and drug interactions. Exposure to some APs has been associated with QTc prolongation and arrhythmias, and a small but significant increase in the risk of stroke and mortality with APs has been seen, particularly in older people with dementia-related psychosis.