After reading “A case of sudden psychosis” (Cases That Test Your Skills, Current Psychiatry), I wondered why the authors administered ziprasidone IM and olanzapine IM when haloperidol and lorazepam IM would have been effective for a lower cost. I have seen clinicians use ziprasidone and lorazepam instead of haloperidol and lorazepam for acute agitation, but there is little evidence that it is better.
In a naturalistic study, Preval et al1 reported that ziprasidone is as effective as haloperidol plus lorazepam, and observed that ziprasidone patients wake up sooner and therefore can be triaged more quickly, but this statement may be premature.
I think there are few, if any, reasons to use ziprasidone or olanzapine IM instead of haloperidol, 5 mg, and lorazepam IM, 2 mg every 6 hours as needed, in an emergency setting. I am curious if anyone has a different opinion based on scientific evidence.
Corey Yilmaz, MD
Southwest Behavioral Health Services
Tolleson, AZ
Reference
1. Preval H, Klotz SG, Southard R, et al. Rapid-acting IM ziprasidone in a psychiatric emergency service: a naturalistic study. Gen Hosp Psychiatry. 2005;27(2):140-144.
The authors respond
At 2 of our local hospital pharmacies, the cost of haloperidol combined with lorazepam is approximately $9 less than ziprasidone per administration: $1.51 vs $10.29 and $3.08 vs $12.23, respectively. Certainly, imagining this cost difference on a larger scale highlights the importance of cost efficiency, but herein enters the fear of sacrificing optimal patient care for the sake of budgeting.
With respect to efficacy, ziprasidone IM has been found to be superior to haloperidol IM in the acute setting.1 In a recent study of severe agitation in adolescent patients, ziprasidone monotherapy was as effective as haloperidol plus lorazepam.2 Regarding side effects, ziprasidone has demonstrated greater safety in terms of extrapyramidal symptoms and akathisia when objectively measured with the Extrapyramidal Symptom Rating Scale and Barnes Akathisia Scale.3 Change in QTc generally was comparable between the 2 medications; however, a more substantial change with haloperidol was seen at 24 hours, given its longer half-life.
Finally, as Dr. Yilmaz mentions, less sedation with ziprasidone vs haloperidol is a marked advantage in the emergency room, which is where our patient initially received these medications. In the case of our previously healthy patient presenting with new-onset psychiatric symptoms, return to a lucid state was important to elucidate an accurate diagnosis and implement appropriate treatment promptly.
Cathy Southammakosane, MD
Pediatrics/psychiatry/child psychiatry resident
Cincinnati Children’s Hospital Medical Center
Anthony Cavalieri, MD
General psychiatry resident
Christopher White, MD, JD, FCLM
Assistant professor of psychiatry and family medicine
University of Cincinnati
Cincinnati, OH