Delirium & Agitation
Despite being used extensively in medical settings for nearly 40 years, intravenous (IV) haloperidol never received approval from the FDA and remains an agent surrounded by controversy. Over the years, IV haloperidol has been the subject of much debate, even among consultation psychiatrists, and some institutions have gone so far as to severely restrict the use of the medication. On inpatient consultation psychiatry services, psychiatrists frequently find themselves in the position of having to defend IV haloperidol, especially to their neurology and cardiology colleagues, who worry about the potential extrapyramidal and QT-prolonging effects. In this symposium, we will present a balanced view of the evidence for IV haloperidol, including reviewing literature regarding its use and efficacy in treating delirium among hospitalized patients, its effects on extrapyramidal symptoms, catatonia and neuroleptic malignant syndrome and its cardiac effects. Much of the presentation will be based on a pair of reviews, conducted by the authors, regarding the efficacy and side effects of intravenous haloperidol. The course will be a mixture of didactic presentation, case review, and question and answer periods, and is intended to be an interactive experience.
Anne Gross, Director of Psychiatric Emergency Services at Oregon Health and Sciences University, will review the history of intravenous haloperidol, including its early use, presumed mechanism of action, evolving controversy and restrictions placed on its use at some academic institutions.
John Taylor, Director of Urgent Care Psychiatry at Massachusetts General Hospital, will review the evidence for the use of IV haloperidol in delirium. He will discuss the recent controversy regarding the lack of efficacy in “treating” delirium, as well as the evidence to support its use in “managing” sequelae of delirium and its comparison to other antipsychotic agents.
Kim Hartney, Chief of Psychiatry at Tampa General Hospital, will discuss the potential impacts of IV haloperidol on extrapyramidal symptoms, catatonia and neuroleptic malignant syndrome. Dr. Hartney will review the literature that hypothesizes why the intravenous form may be safer than other forms in this regard.
Scott Beach, Program Director of the MGH/McLean Adult Psychiatry Residency, will review the evidence for QT prolongation and torsades de pointes with intravenous haloperidol. This will include a systematic review of the literature as well as an in-depth exploration of the FDA’s black box warning in 2007. Dr. Beach will also explore the belief that other antipsychotic agents are safer than IV haloperidol in terms of cardiac effects.
Finally, James Rundell, Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences School of Medicine, will introduce and moderate the session.