What's so great about Haldol?

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Chrismander

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I'm about 6 weeks into my internship. Been in an acute care unit in a county psych hospital. Mostly psychosis & mania.

So far using mostly atypicals or Haldol for psychosis, or for acute behavioral issues--aggression, agitation.

My question: what's so great about Haldol (or other high potency typicals) compared to the mid-potency typicals, especially for acute behavioral management, once you've made the decision typical vs. atypical? If perphenazine at some high enough dose will cause as much D2 blockade as 10 mg Haldol but with lower EPS and more sedation, wouldn't it be superior for someone who's out of control on a unit and a danger to themselves or others? I see the logic behind high potencies for a higher-functioning patient's day to day medicine, as it would leave them less sedated, but this is a different use. I tried to order stat perphenazine for an out of control patient two days ago, and they didn't even stock it on the unit--so i ordered haldol instead.

Is there a reason for Haldol's hallowed status?
 
It's the agent o' choice for delirium b/c of strong D2 blockade, almost no anticholinergic action, and very little toxicity when administered IV even in gram amounts. Personally, I rarely use it for schizophrenia.
 
Anasazi23 said:
Highly safe in trained hands.

Tons of research.

Works in a multitude of clinical modalities.

Formulation preps.

Transition to long-term therapy with efficacy in psychosis.

Certainly many more.
Click to expand...

So these are all great reasons to use Haldol, especially for long-term tx of psychosis. But what about acute agitation? Are mid-potencies better on account of their greater sedation?
 
Doc Samson said:
It's the agent o' choice for delirium b/c of strong D2 blockade, almost no anticholinergic action, and very little toxicity when administered IV even in gram amounts. Personally, I rarely use it for schizophrenia.
Click to expand...

Thanks, I don't know enough about delirium. Hadn't considered the anticholinergic angle for delirium, yeah Haldol would seem better here.

What do you use for schizophrenia? Mostly atypicals? Or do have a favorite non-Haldol typical?

What about my original question--would mid-potencies be better (or at least okay) in acute agitation?
 
Other than mentioned above, its very clean compared to other typicals. I don't know if its the cleanest, but definitely up there.

But what about acute agitation? Are mid-potencies better on account of their greater sedation?
Click to expand...

No upper limit on how much can be used has ever been established. Definitely something to consider when you've got someone and you keep hitting them with ativan, & some other antipsychotic and they're not going down.

I have heard there's a study claiming that the effect of treating the acute agitation tops off at 30mg from an attending I worked with (& she knew her stuff) but I haven't found any study yet that backed this.
 
Chrismander said:
Thanks, I don't know enough about delirium. Hadn't considered the anticholinergic angle for delirium, yeah Haldol would seem better here.

What do you use for schizophrenia? Mostly atypicals? Or do have a favorite non-Haldol typical?

What about my original question--would mid-potencies be better (or at least okay) in acute agitation?
Click to expand...

Problem is, in the ED you often don't know what the underlying etiology of the pt's agitation is. Haldol plays it safe on the delirium front. The other benefit is that you might want to tranquilize, not sedate (i.e., keep 'em awake enough to interview so that you can figure out dispo) - again haldol trumps the other typicals here too.

For long-term treatment of schizophrenia, my first-line tends to be risperdal (which drifts somewhere between typicals and atypicals.
 
Benefits of Haldol over other typicals i.e perphenazine, chlorpromazine to my understanding is that haldol has more studies,is least anticholinergic,least likely to cause orthostasis, and comparatively low likelyhood of effecting QTC interval. the perphenazine, chropromazine has low cardiax safety profle i.e qtc especially in Delririum at medical floor where pt's might not be in their best of cardiac status.this risk might lead to cardiac arrythmias .also haldol can be administered in im/iv/oral/dec forms.
 
Hey guys. Related to this thread, and also in light of some of my clinical experiences, I thought it was time for me to study PsychoPharm in more detail than I have previously.

I'm looking for a Pharm Book that would be best for me, not sure which one to get.
I went to the bookstore today & saw the Stahl's "essentials" of Psychopharm, it looked like maybe it still wasn't detailed enough?

They had a BIG GIANT book from APPI but it was shrink-wrapped so I couldn't get a look at it. (Anyone have experience with that book?)

(For studying general pharmacology I used the Lange book (author is Katzung) and liked it pretty well - but it doesn't seem to be quite detailed enough in the "PsychoPharm" chapters.)

(I left a post about this before in the "Psychiatry Books" sticky, but got no replies, so I guess that wasn't the place to leave my post.) I'll cut-and-paste that post here:

Still Kickin said:
I need to get a Psychopharm text to get myself up to speed. I have a very basic / general sense of most of the drugs but hadn't even HEARD of the kind of details like those mentioned in this thread: ("What's so great about Haldol?")
http://forums.studentdoctor.net/showthread.php?t=555050
(ie - "clean", "no cholingeric effects", etc.)

And for depression, I hadn't even heard of SNRIs, ?DNRIs? etc. before a recent psych rotation.
(My "classification scheme" had been: "SSRIs, Tricyclics, MAOs, and 'Wellbutrin' ")
(I HAD heard of the SNRI, ?DNRI? drugs individually, by name; I knew they were antidepressants - but I hadn't heard of those drug classes & didn't know which drugs belonged to which class.)

Will the Stahl books provide the info I need? Do I need the "extended" version or will the "essentials" have this info?
Click to expand...
 
Still Kickin said:
They had a BIG GIANT book from APPI but it was shrink-wrapped so I couldn't get a look at it. (Anyone have experience with that book?)


(I left a post about this before in the "Psychiatry Books" sticky, but got no replies, so I guess that wasn't the place to leave my post.) I'll cut-and-paste that post here:
Click to expand...

That's basically the one you want.
http://www.appi.org/book.cfm?id=62060

They also make an essentials version, I think, that's smaller and cheaper.
 
Thanks for the info!

(Yeah, I recognize the cover from the bookstore. I remembered it was expensive but guess I didn't QUITE remember just HOW expensive...)

Again, thanks!
 
it's available for IM injection, along with all the other mentioned benefits.

Some of the atypicals now have IM formulations. And zyprexa (olanzapine) has an orally dissolving tablet. We have used zydis at the hospital for acute agitation, but to my knowledge are not using IM atypicals...
 
Doc Samson said:
It's the agent o' choice for delirium b/c of strong D2 blockade, almost no anticholinergic action, and very little toxicity when administered IV even in gram amounts. Personally, I rarely use it for schizophrenia.
Click to expand...

Doc Samson, do you find it necessary to monitor QTC when giving haldol IV at high doses?
 
I think it is important to monitor the patient's cardiac status with IV haldol
 
Sleepygator said:
I think it is important to monitor the patient's cardiac status with IV haldol
Click to expand...

But there are of course plenty of QT prolonging medications we give without batting an eye. I love how on the floor where I work right now, macrolide use abounds, but IV Haldol? Ooh, apparently I'm trying to KILL the patient. PO amio is fine too. And methadone, which (correct me, godfathers, if need be) is quite a bit more dangerous than IV haldol. I had a resident go to pieces when I signed out what I thought was a near homeopathic 0.5mg PO TID prn haldol order on a guy.

Seriously, nurses on this floor shrap their pants when I mention IV haldol. Which makes them love me on call when I refuse to get their gomers drunk on IV ativan like those nice medicine interns will.

Btw, qtdrugs.org. Very useful.
 
michaelrack said:
Doc Samson, do you find it necessary to monitor QTC when giving haldol IV at high doses?
Click to expand...

I'm not Doc Samson, but that's one of many things you should be doing...if you can find an ICU that will even allow that nowadays.
 
Yes. Whenever I recommend a neuroleptic for delirium, I also recommend close monitoring of the QTc (listing the last recorded QTc in my note), potassium, and magnesium (with hypokalemia and hypomagnesemia being readily correctable risks for TDP). I also include my boilerplate text of the risk/benefit calculus involving the potential risk of QTc prolongation being outweighed by the immediate and real danger to patient and staff due to agitation, aggression, and interference with medical care. I also take care to comment on other QTc prolonging agents that the primary might want to think about changing (Ca channel blockers, methadone, fluoroquinolones, etc.).
 
Doc Samson said:
I also take care to comment on other QTc prolonging agents that the primary might want to think about changing (Ca channel blockers, methadone, fluoroquinolones, etc.).
Click to expand...
The thought of the primary team reading this part of the note gives me some sick pleasure...
 
billypilgrim37 said:
The thought of the primary team reading this part of the note gives me some sick pleasure...
Click to expand...

When they squeal in protest I also like to point out that I know I'm using the agent with the lowest per-dose average QTc prolongation for the condition I'm being asked to treat, but that I'm not sure if Cipro is more or less likely to prolong QTc than Levaquin and perhaps they should go find a reference on it.
 
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