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Emergency Psych Meds

Discussion in 'Psychiatry' started by Hurricane, Jul 25, 2006.

  1. Hurricane

    Hurricane Senior Member
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    So I'm in the psych ER and trying to get a feel for emergency antipsychotics, and it seems like every attending I work with has a different set of meds they like and dislike. For example, one attending has a major issue with PO Zyprexa in the ER because he says it takes 6 hours to reach its peak plasma concentration, whereas IM Zyprexa takes less than an hour and PO Risperdal around 2 hours. OTOH, other attendings give Zydis all the time and swear it works faster than regular PO Zyprexa (I tend to agree with the first attending.) And then some attendings give everyone 10-2-50 and then the next shift of attendings is grumpy because the patients are too sedated to assess and discharge. And I hardly ever see anyone using Geodon.

    So after a couple weeks in the ER, I've been mostly giving IM Haldol +/- Ativan with either Benadryl or Cogentin, (or sometimes Prolixin to the people who say they are "allergic" to Haldol) and PO Risperdal to those who will take it. And IM Zyprexa, but not a lot because I'm afraid I won't be able to give them Ativan, thanks to the new warnings. And like I said, not a lot of ziprasidone.

    So what are your favorite emergency psych meds and why?
     
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  3. prominence

    prominence Senior Member
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    i like geodon 20 mg IM q4h for psychosis, with a max dose of Geodon 80 mg IM per 24 hours.
     
  4. 50960

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    In an emergency situation zydis is the best option. I do 10 zydis/1 lorazepam, no anticholinergic needed.

    :cool:
     
  5. Doc Samson

    Doc Samson gamma irradiated
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    Haldol 5/Ativan 2/Cogentin 1... high efficacy, minimal adverse effects, low cost. You can never go wrong with Haldol, especially when delivered parenterally. For Haldol "allergy", substitute Thorazine 50.
     
  6. 50960

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    Fellow super-hero, why do you prefer Haldol...aside from cost...in an emergency situation? I am not questioning you, just curious and eager to learn. :cool:
     
  7. fiatslug

    fiatslug Senior Member
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    It seems like Geodon has done a good job of marketing itself as an emergency psych med to ED docs--in the (relatively rare) situation that they sedate someone (without Ativan) before I get there, the patient has often gotten Geodon IM. I've never used it myself; I tend to go with the old 5250 (Haldol 5, Ativan 2, Benadryl 50), but have also used Zyprexa 10 mg IM. Frankly, give 'em 10-20 minutes, and whatever antipsychotic you give (if a decent enough dose) will knock most people down, IMHO. I often have to resist the ED staff's desire to hit the pt with another round of IM meds when they haven't calmed down in 2 minutes... chill, people! That's what 4-pts and giant security guards are for! (I've never had a pt who had a really long, sustained "fight" against restraints--if so, would check CPK).

    The Zyprexa folks are pushing the IM in lieu of Haldol for emergency sedation, highlighting the risk of laryngeal paralysis with Haldol (which is apparently totally frightening, if you've ever seen it--I haven't--anyone else?).
     
  8. Anasazi23

    Anasazi23 Your Digital Ruler
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    In a true emergency, zydis is not an option. They won't take it. Atypicals are 'typically' not given with benzodiazepines. Geodon, for example, is rarely give with Ativan in my experience. They're not even allowed in the same syringe.

    It entirely depends on what you plan on starting the patient on the following day, and whether or not you're LOOKING for sedation (Geodon reportedly has less sedation compared to typicals).

    Haldol given with Ativan is virtually dystonia-free. Cogentin is rarely needed.

    Some patients should get thorazine, some haldol, some risperdal, others zyprexa or haldol, depending. It's easy to drop a Bellevue bomb (10/2-4/50) and be relatively sure that it'll work. Extensive sedation is of course, an issue...particulary if you're running a CPEP and want the patient out the following morning.
     
  9. 50960

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    That's why zydis Sazi, get it on a wet mucosa and it is gone. The ? was why haldol over zydis, and why not seroquel if you want sedation...aside from the PO limitation. Haldol in an emergency can be changed to olanz in long term if indicated?????

    :confused:
     
  10. Anasazi23

    Anasazi23 Your Digital Ruler
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    Still doesn't make much sense to me. I can't imagine having security hold a guy down while forcing open a guy's mouth to get zydis in that he'll try to spit in your face, while risking your finger getting bit off.

    Think it doesn't happen? Come to NYC residency with me.

    Seroquel has it's purposes as a PRN, but is rarely indicated for emergency room psychosis. I guess it depends on the degree of agitation, the age of the patient, and what you're trying to achieve. When people tell me "emergency situation," I'm thinking a true, difficult-to-manage emergency. Perhaps the OP means someone mildly agitated, which might change my management.

    Yes, you could change haldol in an emergency setting to olanzapine in the longer term, as well as the other atypicals.

    Geodon does work reasonably well, but some pharmacies will max the dosing at 3 doses of 20mg. Know the conversion of IM ziprasidone to PO, and you'll see that you can max out quickly. You can dose Geodon 10mg Q2h, 20mg Q4h. However, it maxes on the books at 40mg. So, two 20mg IM shots and you're done. People like Geodon in the ER since you can easily switch them to the oral prep the following day. Haldol, on the other hand, has literature reports of up to 1000mg IV QD.
     
  11. Psyclops

    Psyclops 1K Member
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    I have, and I agree, it is freaky. But, not to be too calous, it tends to scare patients straight too. You know the kind of patient that is acting out just for the sake of it, not the true psychotic. In the case of the true psychotic it really only contributes to their paranoia and distrust of doctors and can be very sad.
     
  12. Doc Samson

    Doc Samson gamma irradiated
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    Cost is no small issue - last time I checked Haldol 5 mg IM cost ~$0.39 with an equivalent dose of Zyprexa or Geodon IM in the $60-$70 range.

    Aside from that though, Haldol works, works quickly, and has the most data of any neuroleptic for control of the agitated pt. Atypicals were developed for treatment of the negative symptoms of schizophrenia, they block some dopamine, but a good deal of their action is serotonergic. In an emergency, I don't care about serotonin or negative symptoms, I want rapid, clean control of the patient. Also, with an agitated pt in the ED, I don't necessarily know if I'm dealing with delirium or psychosis. I don't like the relative anticholinergicity of atypicals in delirium, so Haldol is a safer choice there too.
     
  13. Hurricane

    Hurricane Senior Member
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    Both I guess. In our ER we have patients ranging from 1) the truly agitaged who yell and spit and go straight to seclusion after the police bring them in then bang on the seclusion room door until the meds take effect, to 2) the mildly agitated who are pacing around the day room scaring the other patients and will probably go off unless they get some meds soon but are still redirectable to the 3) non-agitated pyschotic patients who need some meds to treat their psychosis. We admit to about a half-dozen different psych hospitals and thus we often have no idea what they'll be started on, so that's not much of an issue for us when choosing an emergency med.

    For the type 1 patients, I've ususally given Haldol and Ativan, and maybe some Benadryl too if they need extra sedation. The Haldol has worked every time, however, sometimes the patients stay sedated for a very long time, which makes it difficult for the next shift to asses them for discharge/admission, so they lay around the ER longer than is perhaps necessary. I gave Zyprexa to a patient like this once, and after 2 IM doses of 10 mg spaced 3 hours apart, he was still walking around naked in the seclusion room responding to internal stimuli. After another couple hours we gave him some Haldol and Benadryl and he went right down. So based on that limited experience, Zyprexa's not exactly my favorite, although I have seen it work well for the less agitated patients. But I don't like that you can't give Ativan after you use it.

    For the type 3 patient, I usually give Ripserdal PO, because it works quickly (reaches peak plasma concentration within an hour) and is not as sedating. We rarely give Seroquel PO in the ER because we don't want to deal with the orthostatic hypotension issue if it arises, and usually the people who are willing to take PO don't need a whole lot of sedating.

    The type 2 patient I'm not sure what to do with. This is the person we debate over what to give - IM atypicals, etc. And this is usually when someone suggests Zydis. But I tend to agree with my attending who says it's not an emergency psych med because it takes so long to work. But other attendings swear that Zydis is fast acting. So I went to lily's site and the prescribing information says this:

    Which makes it sound like Zydis and regular PO Zyprexa are exactly the same and the only benefit of the Zydis is that the patient's can't cheek it or spit it out. But as a naive beginning intern, maybe I'm missing something, so I'm not exactly eager to whip out the prescribing info and try to correct an attending with years of experience.

    So anyway, after three weeks in the psych ER I mostly give people Haldol, Ativan, or Risperdal 90% of the time, and I'm wondering if I'm being too simple-minded and should branch out more into the atypicals...
     
  14. sdn1977

    sdn1977 Senior Member
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    I'll give you a pharmacy perspective for what its worth:


    The reason Zyprexa & Zyprexa Zydis are bioequivalent is because the clinical effect is due to the parent drug level in the brain, which is the rate limiting step. Buccal or sublingual dosage forms do bypass the first pass effect of rapid abosorption into the portal circulation which then starts the liver conjugation process. However, if you have rapid blood absorption from buccal administration, the speed at which the drug is presented to the liver then processed is still faster than the speed at which the drug crosses the blood brain barrier. The Zydis form was orginially designed for children & adults who couldn't swallow a tablet, however, it can & is used in situations as you folks describe. The kinetic differences are not like oral NTG & sl NTG.

    From my perspective as a pharmacist....so much depends on what your P&T committee has decided with respect to pt population, needs, price, contracts, etc...Those of you who have a higher indigent population will probably be encouraged from our end to use the lower cost alternatives. My facility does have a locked mental health unit with a moderate to low indigent population, however, no house staff so the ER physicians only sometimes deal with these pts as you describe. Having said that - neither Geodon nor Zyprexa is available in their pyxis (which is their 24 hr source of drugs). However, all dosage forms are available in the mental health unit pyxis for those decompensations. If an ER guy wants to order the drug for an ER pt - he'd have to get one of the MH unit nurses to sign it out - not likely. So...they use the combination Doc Sampson described (which is in their pyxis) to get them calmed enough to get them to the mh unit. Then psych takes over.....
     
  15. 50960

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    Granted, your emergencies are more severe that mine.....not a doubt. So you mainly stick to IM stuff?
     
  16. Anasazi23

    Anasazi23 Your Digital Ruler
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    I feel that Geodon IM should be available to ER docs should they need it. There are cases where you'd try to avoid giving a typical in certain situations. Though, they may not be entirely privy to these reasons.

    For the reasons described above, Zydis is not my first choice for agitation.

    As Doc Samson importantly points out, haldol has the largest and longest efficacy record. This, combined with cost and rapid onset is key.

    However, the most important thing, at least to me, is that I feel entirely comfortable with most anything that goes wrong with the administration of the drug. I can't say the same for thorazine, for example. If you make a mistake with a drug, or there's an unforseen bad reaction, we're responsible for that too.
     
  17. fiatslug

    fiatslug Senior Member
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    Hiya SDN1977--I had have a question for you. The reps for olanzapine told us there's no significant buccal absorption of the Zydis form, that it must be swallowed to have clinical effect. Got a call one night about an elderly, combative, delirious man on medicine--neurology had apparently (though they did not give a reason) told the poor med interns managing the case that Haldol was forbidden (don't know what this pt's med dx was, other than delirium/dementia), and they had been throwing Zydis into his mouth with no effect. I was thinking maybe it was because he didn't swallow it, and possibly drooled it all out!
     
  18. Hurricane

    Hurricane Senior Member
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    Thanks, I always love hearing from the PharmDs - you guys are great :love:

    But I'm a little unclear - are you saying Zydis does or does not cross the BBB faster than oral Zyprexa? And FWIW, I ran into the Zyprexa rep a couple hours ago, and he told me that in some people, Zydis starts working in as little as 5 minutes, which I find a little hard to believe. And what about the Risperdal M-tab - is that faster than PO Risperdal?


    Such as? history of dystonia?
     
  19. Anasazi23

    Anasazi23 Your Digital Ruler
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    Agitated patient with strong TD, history of severe dystonia (young + muscular patient), so-called "allergy" to haldol (truly rare, but does exist), and most importantly, agitation secondary to akithesia.
     
  20. sdn1977

    sdn1977 Senior Member
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    Yes - the rep is correct (he should be!!!). The Zydis formulation was designed to be rapidly disintegrating. It interacts fast with salivary contents to dissolve then, hopefully, the normal physiologic mechanism of swallowing saliva will take over & the pt swallows & it becomes just like Zyprexa.

    I hope I have time to post all the factors - my power is on a rolling blackout, so I don't know how long I have....sorry if I get interrupted!

    There are a few barriers to absorption. If its a tablet formulation, depending on the coating, the pH of the stomach (if your pt hasn't eaten in days the pH changes - can be a benefit or otherwise) & the transit time into the small bowel. Most drug absorption goes on in the small bowel (not all - there are exceptions). Most drug dissolution goes on in the stomach.

    So...if you have a pt who seems to have erratic drug response to a tablet, but better to something like an orally disintegrating product or a liquid - likely they aren't able to break the tablet down sufficiently for absorption.

    If something remains in the mouth long enough....there will be buccal absorption - this happens with babies. However, most adults will not be able to just keep saliva in their mouth (also - the presence of something - can be anything - generates saliva)...so they drool it, spit it or swallow it. But...this buccal absorption of olanzapine is not enough to provide sufficient blood levels which will then provide sufficient brain levels. It was never designed for that purpose.

    Other drugs have the same design - Tylenol Meltaways, Claritin-Reditabs - all designed for the pt who can't or won't swallow a solid formulation. None of these act faster - they just dissolve without the use of the stomach.
     
  21. sdn1977

    sdn1977 Senior Member
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    Again - I'll try to respond fast before my power goes....

    No Zyprexa Zydis does not cross the blood brain barrier faster than Zyprexa. The bioavailability is the same. However, if for reasons I mentioned to the other poster, if your pt cannot for physiologic reasons break down a Zyprexa tablet, then the zydis formulation will get to the major absorptive area (the small intestine) more efficiently. However, if left in the mouth long enough....there might be some buccal absorption due to the large surface area & capillary presence, however, the chemical is large & will not easily diffuse into the capillaries. Not enough to demonstrate any difference in studies. Large drug studies even out individual variability, so this doesn't mean you won't have a pt who might respond faster - there are always outliers in any study. So.....it might be more rapid in some folks, but that might be because of their physiologic inability to break down a tablet formulation - something probably not of prime importance to know when needing Zyprexa fast I'm guessing.

    The rate limiting step in how much olanzapine crosses the blood brain barrier is how much drug gets presented to it. If you have a reliable pt with an unreliable gut - you may get less drug presented to the brain. If you have an unreliable pt who gets Zydis, but who will reliably swallow, you'll get more drug presented to the brain. If you get the previous poster's pt with an unreliable pt who won't reliably swallow - you get very little presented to the brain.

    Risperdal M & Risperdal have the same pharmacokinetics. Similar to Zyprexa - Risperdal M was designed to be orally disintegrating. Not to be faster....just to be easier for some people to take.
     
  22. fiatslug

    fiatslug Senior Member
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    thanks for all the pharm info! It does seem like the zydis form would cross the BBB faster since it doesn't have the wait time of tablet dissolution in the stomach...
     
  23. 50960

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    Yes, it may get there faster, but transport across the BBB is the same.
     
  24. Anuwolf

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    Why dont you guys just give your patients a high dose of Ativan? It certainly worked for me when I was there :)
     
  25. Psyclops

    Psyclops 1K Member
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  26. 50960

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    Ativan... a sure way to have a pt return!! Anuwolf...there are many reasons, this med is a benzo, thus addictive, not treating anything but agitation which will get worse when it wears off. Do your research...
     
  27. Poety

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    I'm with DS on this, i also don't mind snowing a psychotic patient thats about to be put in handcuffs and admitted involuntarily via the police, its probably better they don't remember that anyway. I also like that I can repeat the dose in an hour if it doesn't work.

    Remember, these are one timers no long term, you won't harm the patient by snowing them when they're psychotic and violent, plus, it keeps them, the staff and everyone safer and more secure.

    I don't like physical restraints anyway, i think they're cruel. Especially for hte children, which I like to sedate to minimize the trauma of whats going to happen.
     
  28. Hurricane

    Hurricane Senior Member
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    Why? Does ativan have enough anticholinergic properties to substitute for cogentin or benadryl?
     
  29. 50960

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  30. Anasazi23

    Anasazi23 Your Digital Ruler
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    To partially answer your question, remember what the original purposes of benzodiazepines were...seizure disorders and muscle spasm.
     
  31. Hurricane

    Hurricane Senior Member
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    that's why I was confused - I didn't think that ativan had anticholinergic properties. So what is the mechanism of its protective effect against EPS then? Just neuronal inhibition in general?
     
  32. psychRNlisa

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    So other night had psych.pt. and attending ordered zydis 10mg po. patient took that. no effect. 2+ hour later increasing agitation.psychosis. Now attending ordered Ativan 2mg PO. Patient took that. no effect. (well didnt have time to). cont. agitation,escalation. attempt to elope. police called/attending now ordered geodon 40mg IM with Benadryl 50mg IM.

    Question is..Is 40mg Geodon too much at one time. Was given in two seperate syringes and diff. muscle and of course benadryl in its own syringe....someone told me geodon 40 is too much to give at one time and doc made mistake? and i should have called him on this and not gave? pt. is fine just slept ALLLLLL day and night mostly
     
  33. Fastball32

    Fastball32 Fastball
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    The B-52 Bombs (Benadryl 50, 2 Ativan, bomb=antipsychotic of choice) will work.
    If I want to limit polypharmacy, I like the antihistaminergic antipsychotics for the sedative properties - Thorazine IM, Olanzapine IM, Seroquel PO.

    Geodon 40 IM in one dose sounds excessive. Remember that NMS is a risk, given agitated patients in the ER aren't hydrating themselves and may be getting multiple different dopamine blockade, both of which are big risk factors for NMS.

    Geodon 10-20mg IM is usually want I give, plus or minus ativan.
    anyone use abilify IM as first line?
     
  34. TexasPhysician

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    I start with Geodon 20 if I give IM.

    Abilify IM medically makes little sense to me so I haven't tried it. The thing to most likely irritate a violent person is akathisia in my opinion. Abilify is also the most activating - is that what you want?

    Usually I want sedation when someone is becoming violent. If in the ER and psych has not evaluated yet, I prefer them to use Geodon. Just my thoughts.
     
  35. HooahDOc

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    IM Haldol 5 / IM Ativan 2. Don't need an anticholinergic.

    Zydis is stupid to give emergently; it is NOT absorbed in the mucosa and only has a slightly faster onset of action due to becoming a solution instead of a solid. It's still absorbed in the GI tract.

    I don't like geodon because of the QTc stuff and you almost never have a recent EKG in these situations.

    Watch the countertransference of ED docs. I once had an ED doc sedate a psych patient who tried to assault him with haldol 10 and versed. The patient ended up having to be brought to a resus room and emergently intubated and bought an overnight stay in the ICU. I had to explain to the ICU attending that I most certainly did NOT recommend versed.
     
  36. Fastball32

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    http://www.ncbi.nlm.nih.gov/pubmed/11431240
    Eli Lilly funded study, but Haldol IM had EPS.

    Even in emergencies, agitated patients often agree to take a pill, thus a sedating atypical like olanzapine would not be out of the question. So are you saying Zydis over Zyprexa is stupid or anything other than an IM is stupid?
    From what I remember, QTc prolongation is not associated with Geodon IM, only the PO version, thus ECG is unnecessary.
    There's literature supporting Versed for agitation in non-psychiatric journals, so some ED docs are comfortable with it, but I wouldn't use it either.
     
  37. Fastball32

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    I've only used Abilify IM a couple times, usually to a Borderline who has reported allergies to numerous meds, or if someone is on non-max dosages of Abilify as an outpt to limit different types of medications, which is a risk factor for NMS.
    Abilify does carry the FDA approval for agitation in Bipolars and Schizophrenics, so it is an option. Although Abilify is stimulating at low dosages, Abilify is supposed to be sedating at higher dosages, but not sure if 9.75 IM would be considered high or if it has higher concentrations as an IM compared to PO. Akathisia definitely detracts it in my book.
     
    #36 Fastball32, Nov 28, 2012
    Last edited: Nov 28, 2012
  38. HooahDOc

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    I don't characterize someone who is agitated but not violent an, "emergency". An, "emergency" is, at least to me, someone who requires immediate restraint. In these cases, I would not even bother to offer an oral medication.
     
  39. xlithiumx

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    Oftentimes we will offer an oral medication to avoid what you'd characterize as an emergency requiring forced injection of medication. Use of least restrictive measures is an important ethical principle. I would counter that even in the case of someone who requires restraint, an oral medication must be offered. I think it is not uncommon that hospital staff feel compelled to give an injection as a means of discharging their negative countertransference and "winning" over the patient. I have observed cases where seclusions/restraint/injection has been averted by alternative means of de-escalation and staff have seemed disappointed by that outcome, which is troubling.

    With respect to your previous characterization of use of Zydis in emergencies as "stupid," I will counter that because it is orally dissolveable, it is less likely to be able to be cheeked or spit out and does have some utility. Also, because it dissolves orally, it will be more rapidly absorbed by the gastric/proximal small bowel mucosa than a conventional tablet that has to dissolve in the stomach.
     
  40. VMSmith

    7+ Year Member

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    But, there are cases where using an injectable that will have an effect within 20 minutes as opposed to an oral medication which could take 2 hours is the least restrictive measure. If you are reasonably certain that a patient will continue escalating without medication on-board and offer the option of oral vs injectable, you are in a bind if the patient selects the oral med. Because then you have several hours of waiting for it to kick in as you watch the patient escalate - and then when the dust clears, he or she will have received an oral medication, an injection, and restraints.
     
  41. xlithiumx

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    I'm not sure why you believe that the time to onset of sedative effect of oral olanzapine is 2+ hours. In my experience, most patients having received 10 mg of oral olanzapine are feeling quite sedate within about 30 minutes.

    That said, if a person does end up needing to be restrained and secluded, there is nothing to say that they must receive an injection. That is what usually happens, but it does not follow that it must always be the case, and certainly it shouldn't be the case if they are willing to take an oral medication.

    Again, I think that the shot is oftentimes staff's way of getting back at the patient.
     

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