In this episode I’ll:
1. Review an article I used to answer the drug information question “Can olanzapine be given IV?”
2. Share a resource for finding free open access medical education content
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Article
Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient
Lead author: Esther W. Chan
Published in Annals of Emergency Medicine January 2013
Background
Olanzapine is labelled in the US for intramuscular use only but intravenous adminstration is often preferred to intramuscular due to a faster onset of action and less discomfort.
Purpose
The purpose of the study was to determine the efficacy and safety of intravenous droperidol or olanzapine as an adjunct to intravenous midazolam for rapid sedation of acutely agitated patients.
Methods
The authors undertook a randomized, double-blind, placebo-controlled, double-dummy, clinical trial in 3 Emergency Departments in Australia from August 2009 to March 2011. 336 adult patients requiring intravenous drug sedation for acute agitation were randomized to receive placebo, droperidol 5 mg, or olanzapine 5 mg via IV bolus. This was immediately followed by incremental IV midazolam boluses of 2.5 to 5 mg until sedation was achieved. The primary outcome was time to sedation. Secondary outcomes were the need for rescue sedatives and adverse events.
Results
Baseline characteristics were similar across groups. The differences in medians for times to sedation between the control and droperidol and control and olanzapine groups were 4 minutes and 5 minutes, respectively. At any point, patients in the droperidol and olanzapine groups were approximately 1.6 times more likely to be sedated compared with controls. Patients in the droperidol and olanzapine groups required less rescue or alternative drug use after initial sedation. The 3 groups’ adverse event profiles and lengths of stay did not differ.
The authors concluded that intravenous droperidol or olanzapine as an adjunct to midazolam is effective and decreases the time to adequate sedation compared with midazolam alone.
Discussion
In this study, no adverse consequence associated with IV administration of olanzapine was identified. Unfortunately the study was not powered to detect differences in adverse event rates. A significant number of patients did not have a repeat EKG, which is not surprising given the challenges of caring for acutely agitated patients. Because of this, QTc prolongation may not have been identified.
Occasionally, when parenteral olanzapine appears to be the best choice of medication for a patient, I will recommend intravenous over intramuscular administration of olanzapine. The data is not sufficient in my opinion to recommend IV olanzapine routinely when other agents or routes of administration that have been studied more extensively are an option.
I’d love to hear what you think about using olanzapine IV! Is this something you already do or would you wait until more data is available? Use the Speakpipe widget at the end of these show notes and send me a voicemail with your thoughts!
Resource
A great resource for new free open access medical education content is the FOAMed subreddit on the social media site Reddit.com. The FOAMed subreddit aims to harness the constant stream of free medical education content across the web in a more accessible fashion than twitter or RSS feeds. I always find several informative links when I visit the FOAMed subreddit.
The Pharmacy Nation Slack group is a free group with other pharmacists from around the world collaborating with each other using real-time messaging to help better care for patients. I invite you to join me and the over 100 other Pharmacy Nation members there. You can sign up at pharmacynation.org.
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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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