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Ziprasidone for sedation of the agitated ED patient

      To the Editor:—Recently, the Food and Drug Administration added a black box warning restricting the use of droperidol (Inapsine, Akorn Pharmaceuticals, Buffalo Grove, IL) citing “reports of deaths associated with QT prolongation and torsade de pointes in patients treated with doses of Inapsine above, within, and even below the approved range.” This warning has resulted in significant changes for EPs in treating several common conditions encountered in ED practice. Of primary concern is the management of the acutely agitated patient.
      Current recommendations from Akorn Pharmaceuticals reserve droperidol “for use in the treatment of patients who fail to show an acceptable response to other adequate treatments, …[and] all patients should undergo a 12-lead ECG prior to the administration of Inapsine to determine if a prolonged QT interval … is present.” Further recommendations include “ECG monitoring should be performed prior to treatment and continued for 2–3 hours after completing treatment to monitor for arrhythmias.”
      Many EPs have had droperidol removed from their hospital’s formulary; or, in cases in which agitation precludes the determination of the QT interval, EPs are forced to use alternative, less desirable treatments. These could include longer-acting antipsychotics, prolonging ED stays, or medications such as benzodiazepines, which carry a higher risk of respiratory depression.
      A new class of antipsychotic has recently been approved for use in the acutely agitated, psychotic patient. Ziprasidone (Geodon; Pfizer Inc., New York, NY) has been shown effective in the management of acute psychotic agitation.
      • Keck P.E
      • Reeves K.R
      • Harrigan E.P
      Ziprasidone in the short-term treatment of patients with schizoaffective disorder results from two double-blinded, placebo-controlled, multicenter studies.
      ,
      • Brook S
      • Lucey J.V
      • Gunn K.P
      Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis.
      ,
      • Daniel D.G
      • Potkin S.G
      • Reeves K.R
      • Swift R.H
      • Harrigan E.P
      Intramuscular ziprasidone 20 mg is effective in reducing acute agitation associated with psychosis a double-blinded, randomized trial.
      We have successfully used ziprasidone in the ED for the management of agitation in approximately 10 cases. Control of agitation is generally within 15 minutes of a single 20-mg intramuscular dose. This could be repeated for a total of 40 mg (total recommended daily dose) if indicated. Sedation is generally less prominent than with other antipsychotics, but treatment was effective in controlling agitation.
      The primary limitation we have seen with the use of ziprasidone in the ED has been preparation for injection. Ziprasidone for injection is in the lyophilized form and must be reconstituted with sterile water. In practice, this takes approximately 3 minutes, and without preservative or bacteriostatic additives, must be prepared before each use or refrigerated for less than 1 week.
      Our limited experience suggests that ziprasidone could be useful in the management of the acutely agitated ED patient. Future research could substantiate these findings and provide a new method for EPs to manage the acutely agitated ED patient.

      References

        • Keck P.E
        • Reeves K.R
        • Harrigan E.P
        Ziprasidone in the short-term treatment of patients with schizoaffective disorder.
        J Clin Psychopharmacol. 2001; 21: 27-35
        • Brook S
        • Lucey J.V
        • Gunn K.P
        Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis.
        J Clin Psychiatry. 2000; 61: 933-941
        • Daniel D.G
        • Potkin S.G
        • Reeves K.R
        • Swift R.H
        • Harrigan E.P
        Intramuscular ziprasidone 20 mg is effective in reducing acute agitation associated with psychosis.
        Psychopharmacology. 2001; 155: 128-134