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Rapid tranquillisation: time for a reappraisal of options for parenteral therapy

Department of Psychiatry, University of Newcastle, Newcastle upon Tyne, UK

Correspondence: Dr R. H. McAllister-Williams, Department of Psychiatry, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NEI 4LP, UK. Tel: +44 (0) 191 232 5131 ext. 24336; fax: +44 (0) 191 227 5108; e-mail:r.h.mcallister-williams{at}ncl.ac.uk

Declaration of interest Sponsorship and speaker's fees received from a number of pharmaceutical companies, including AstraZeneca, Eli Lilly, GlaxoSmith Kline, Janssen, Lundbeck, Organon, Pfizer, Pharmacia & Upjohn, Sanofi-Synthelabo and Wyeth.

Background When parenteral treatments are indicated for acutely disturbed behaviour, previous guidelines have recommended droperidol or haloperidol in combination with benzodiazepines. However, there has been recent concern over cardiotoxicity and sudden death associated with some antipsychotic medication and droperidol has now been withdrawn.

Aims To ascertain what alternatives can be recommended to replace intramuscular droperidol.

Method Selective review of current guidelines and the literature pertaining to rapid parenteral tranquillisation.

Results Current guidelines recommend haloperidol as an alternative to droperidol. There is evidence of cardiotoxicity with haloperidol and it has a propensity to cause extrapyramidal side-effects that may exacerbate disturbed behaviour and reduce longer-term compliance. The rapid-acting intramuscular formulations of atypical antipsychotic agents show promise.

Conclusions It is recommended that the mainstay of pharmacological rapid tranquillisation should be parenteral benzodiazepines used with due care.

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