Favorite IM antipsychotic and why...

[9point75]

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I like aripiprazole. A nice tranquilizing effect without much sedation. I find it helps the patient better manage his or her own symptoms so that they can learn to have mastery of their bodies. Now you go.

 

[9point75]

Let's see if those LCSW's can derail this one, eh Wallstreet?

 

[firedoor]

Haldol.

Please tell me more about your experience with Abilify 9.75 mg IM.

 

[9point75]

I like good old haldol (preferably with benzo>anticholinergic). Minimal sedation with good tranquilization.

Please tell me more about your experience with Abilify 9.75 mg IM.

I'm enthusiastic about the purportedly up and comng the aripiprazole long-acting depot.

I just find the learning aspect of "if I act in a violent nature, then I get a good night's sleep", completely backwards. I believe that a person needs to be calm and in control under their own auspices. It might be labor intensive, but worth it. Just making sure that somebody ends up on the Glasgow Coma Scale is lazy medicine. That being said, there are situations where for safety's sake where a GCS score of 3 are appropriate.

 

[billypilgrim37]

There are lots of reasons to use each of the available IMs based on diagnosis, pt tolerance, past experience, acute dangerousness, etc. Abilify is probably the only one I haven't used, and I haven't really found a clinical scenario yet where I wouldn't prefer to use Haldol or Geodon (and the latter is just because at point I had an attending who really liked it for nonspecific reasons, so I just got used to it). And 85% of the time Haldol just makes sense for the same reason you said you liked Abilify: good tranquilizer, minimum sedation. The decision of benzos or not seems more important than which of the 3 minimally sedating IMs you'd pick.

I've only talked to people who have either thought Abilify was by far the best one, or people who have thought it was useless. I imagine it works just fine, but I've never talked with anybody who had a nuanced opinion about it.

 

[BobA]

Personally, I like IM Zyprexa because there's less risk for acute dystonic reaction and it's sedating (Which is what I want in an IM!)

 

[whopper]

I don't think there should be a favorite. Each med has it's pros and cons and depending on the situation, you should capitalize the best based on the benefit/ratio profile.

But here's how I usually go about it.

If the person just needs to be taken down-Thorazine. E.g. an antisocial guy who's trying to grab a nurse's butt and he's not psychotic or manic and not responding to verbal redirection.

If the person is dangerous, is psychotic and/or manic, Haldol or Zyprexa. Why? Haldol-lots of D2 blockage. If the guy is dangerous, that likely means a lot of positive sx of psychosis, and that's where the D2 blockage comes in handy. Zyprexa because it did very well in CATIE for psychosis.

Abilify: you don't want the guy knocked out. There are times where someone is in need of an IM med and knocking the patient out could cause problems. E.g. the guy hasn't drank anything for several hours, he's already got a high sodium level, and you want him to drink some water.

Geodon: this one I tend to avoid. Why? While I believe all the QT stuff has been dispelled by CATIE, the product warnings are still there and there is also mention to not mix it with other types of antipsychotics such as phenothiazines. Sometimes you give Geodon IM, and it doesn't work, and then if you truly try to follow the product warnings, you now won't want to give some other antipsychotics, some which may have to eventually be used. I often told residents and medstudents that I compared Geodon IM to an effective gun, but if you use it, it's the only one you can bring, and you only have 1 bullet. Haldol, you can shoot that thing almost as many times as you want, and if it doesn't do the job, you can use a different one.

 

[393656]

First off if it comes to the point of needing an IM medicine than its not "lazy medicine" to want to sedate someone, its probably the reason you are giving the IM in the first place. Sedate means to slow him down and eliminate the aggression displayed or unsafe behavior. Sedating is the purpose. I do agree that giving them a happy buzz is not good and I never use benzo's in this respect.

Thorazine IMO is the best by far. Acts real fast, super sedating, no EPS at all and literally disables them from standing up too fast and acting aggressive. Obviously falls is one concern but most I see learn to stay down or are sleeping. You can also mix it with ativan if you so choose or benadryl, not that you would need to.

Zyprexa is by far the worst choice in today's day with ativan being given out like crazy and people on so many meds. Too much risk and a warning to not give with benzo's. I would not want the liability. Especially if you did want to use a benzo or something else sedating on top of it they do not play nicely. It also is MUCH slower acting IM than anything except abilify which is even slower. Time to clinical onset of zyprexa IM is 45 min and cmaz is 1.5 hours.

Also dosing is useless with zyprexa. Typically 20mg is a good dose but then that leaves you only with 10mg left to use in 24 h per their 30mg per day limit by FDA.

Abilify is the worst as its not sedating and IMO is bad, time to action is 1-2h with cmax in 2 h. If you are using it urgently this is too long.

Haldol has peak cmax in 30mins and onset in 15mins of IM dosing and is favored as reasons mentioned above.

Geodon is pretty good with cmax within 45 mins and onset within 30mins as well as nice dosing limit of 40mg means you get two good doses of 20mg twice per day and no limits on using benzos with this, although cannot literally do it in same syringe.

In the end Haldol 5/benadryl 50 for agitation in non delirious/dementia patients.

If its someone court ordered who you are doing daily then obviously a different strategy is in order with a different choice.

 

[Manicsleep]

Depends on what you are trying to do.

I am using the IM thorazine/benadryl or cogentin combo again in agitated patients and found it to be just as effective as zyprexa for example or the 5150 (haldol 5, ativan 1, benadryl 50). Sometimes you really want that sedation and you want a cheaper option without giving ativan to a drug addict. Thorazine gives you a very high upper limit of how much you can give but there is a caveat that only 50mg can be given per shot so you sometimes end up giving in different locations especially if you are giving with benadryl. 150mg of thorazine/50mg of benadryl is 4 shots...at that point it may be better to go with zyprexa.

In the end, it really depends on what you are attempting to accomplish.
Zyprexa, Geodon, Abilify and possibly benadryl
Thorazine, Haldol with benadryl and possibly ativan. IM preparations are available for other typicals as well but I don't really use them and I rarely see them.

There are also the prolixin, haldol, risperdal, invega preps of the depot formulations. The invega is very effective in that it often allows discharge from hospital faster.

 

[393656]

Not sure where you are practicing but 100-150 of thorazine per shot is given frequently. Also absolutely no need for benadryl or especially cogentin with thorazine. THorazine is a more potent anti-muscaric than both benadryl and cogentin, which cogentin is not sedating and with thorazine as mentioned has more than adequate anticholinergic effects

 

[Manicsleep]

Not sure where you are practicing but 100-150 of thorazine per shot is given frequently. Also absolutely no need for benadryl or especially cogentin with thorazine. THorazine is a more potent anti-muscaric than both benadryl and cogentin, which cogentin is not sedating and with thorazine as mentioned has more than adequate anticholinergic effects

We never give it because the ampule is only 2ml or 50mg so each ampule is given separately. Benadryl helps with sedation as opposed to just giving more thorazine.