1.9 Use of Sedatives and Antipsychotic Medications

On the rehabilitation unit, the patient is on the following medications:

  • Nozinan 10mg TID + 20mg HS
  • Trazodone 50mg HS
  • Nurses have also asked for: Ativan, Haldol, Olanzapine, and Risperidone which he has received on an as need basis, outside of the treatment plan.

Describe the evidence including pros and cons of these medications.

  • There is some evidence that Nozinan is a safe and effective treatment for controlling agitation post ABI. There is concern about how the drug could negatively impact neurorecovery.
     
  • There is evidence that early treatment with Trazadone is a safe and effective treatment for controlling agitation post TBI. There is concern about how the drug could negative impact neurorecovery.
     
  • There is strong evidence that Lorazepam is effective in treating insomnia post ABI.
     
  • There is some evidence that Haldol when used for agitation post ABI does nto seem to negatively affect rehabilitation.
     
  • There is very limited evidence (mostly case studies) that the atypical antipsychotics, Olanzepine and Risperidone can be used to treat psychosis after ABI.

Nozinan  (Methotrimeprazine)

  • Is a psychotropic medication (mediated by dopamine blocking), tranquilizing, and analgesic properties.
     
  • It appears to have an effect on opiate (pain) receptors as well 44.
     
  • In a study by Maryniak et al.45 they found that methotrimeprazine may be safe and effective for controlling agitation following ABI. 
     
  • ERABI36 concluded there was Level 4 evidence that methotrimeprazine may be safe and effective for controlling agitation following ABI.

Trazodone

  • Trazodone is antidepressant with a sedation effect and may useful for the treating of insomnia after TBI46.
     
  • Rosati38 found trazodone was effective for in the early treatment of post-traumatic brain injury agitation. 
     
  • According to the ERABI36 there is Level 4 evidence that early multiple neuropharmacological treatment that including trazodone may be effective for agitation after TBI.

Ativan (Lorazepam)

  • Lorazepam is a benzodiazepine anti-anxiety medication which, because of its sedative effects, it also has been used for treatment of insomnia47

Haldol (Haloperidol)

  • Haloperidol is a psychotropic treatment that assists in reducing agitation.
     
  • In a study conducted by Rao et al.48 they found no differences between the two groups of ABI patients regarding the success of rehabilitation.
     
  • According to the ERABI, there is Level 4 evidence that haloperidol does not negatively effect the success of rehabilitation.

Olanzapine and Risperidone

  • Atypical antipsychotic drugs such as Olanzapine and Risperidone are increasingly being used as first line treatment for individuals with psychotic disorders and increasingly are being used for decreasing agitation and aggression. 
     
  • According to Volavka et al.49 studies conducted have reported that these drugs can be effective for some patients with traumatic brain injury.
    • It was recommended that one start with dose of olanzapine 2.5-5 mg QHS or BID and then increase in increments of 2.5-5 mg up to 20 mg/day. 
       
    • Risperidone would start with 0.5 mg QHS or BID and increase in increments of 0.5-1mg up to 4-6 mg/day46.

For a more detailed discussion on the use of sedatives and antipsychotics post ABI please see ERABI/Mental Health Issues Post ABI.

 

Summary of Medications Used in the Treatment of Agitation and Anxiety Post ABI 50

Name and Description

             Pros                     

              Cons

Nozinan
(methotrimeprazine),
neuroleptic

Methotrimeprazine possesses antipsychotic, tranquilizing, anxiolytic, sedative and analgesic.

 

In high doses orthostatic hypotension can occur. Side effects include drowsiness; this may appear early in treatment but will gradually disappear during the first weeks or with an adjustment in the dosage.

Trazodone
antidepressant

Prescribed for insomnia and depression

Side effects include “drowsiness, seizures, anticholinergic effects, priapism in males (rare)” (Woo & Nesathurai 2000).

Ativan (lorazepam),
benzodiazepine

Well tolerated in patients with severe liver disease as it has short half-life of 6 to 8 hours. Can be administered intravenously or intramuscularly.
In most patients, the risk of dependency is low.

Benzodiazepines should be avoided in patients with known or possible sleep apnea. Smaller doses needed in elderly patients.
When the medication is suddenly withdrawn may develop rebound insomnia.

Haldol (Haloperidol),
antipsychotic

Used for treatment of mental conditions, to control movements and reduce agitation. There is Level 4 evidence that haloperidol does not have a negative effect on the success of rehabilitation.

There have been cases of sudden death, QT prolongation and Torsades de Pointes (TdP) especially when haloperidol given intravenously, or at doses higher than recommended. Haloperidol is only approved for intramuscular injection (U.S.Food and Drug Administration, 2007). Intravenous administration is a common off-label clinical practice.

Olanzapine,
atypical antipsychotic

“Monotherapy with an antipsychotic such as olanzapine may be sufficient”. Medical Specialty Society (2002).

 “The Medicines and Healthcare products Regulatory Agency (MHRA) has warned against the use of risperidone or olanzapine in the treatment of behavioural symptoms of dementia, due to increased risk of stroke and death. Olanzapine or risperidone should not be used for the management of disturbed/violent behaviour in service users with dementia”
(National Collaborating Centre for Nursing and Supportive Care 2005)

Risperidone,
antipsychotic

Can be administered once daily. Available in long-acting form. Sublingual form (Risperdal M-Tab). Used off-label to treat anxiety disorders. Effective and is well tolerated at low doses.