Alternative Delivery Systems for Agents to Treat Acute Agitation: Progress to Date

Abstract

Psychomotor agitation is often associated with aggression. It is important to identify agitation early and achieve results quickly in order to prevent aggressive behavior. Strategies may include verbal de-escalation techniques, reduced stimulation, medications, or a combination of approaches. Historically, pharmacological treatments for agitation have been delivered using oral and intramuscular formulations. Although the types of medication available have not changed dramatically, different formulations have been developed recently to aid in treating this difficult condition. This paper will detail some of the newer, more novel formulations used to deliver medications to treat agitation. Formulations to be described include orally disintegrating tablets, sublingual, buccal and intranasal forms, as well as an inhalation form. Each form has a unique purpose and will aid in treatment of different populations at different levels of agitation. Of note, of the medication formulations to be discussed, only inhaled loxapine is FDA approved for acute agitation in schizophrenia and bipolar disorder and no medications are approved for 'agitation' outside of a specific disease state. The orally disintegrating tablets of olanzapine, risperidone, and aripiprazole are swallowed and enter the circulation via the portal system. They do not have a more rapid onset of action than the standard oral tablets but are useful for patients that might otherwise divert the medication. The sublingual, buccal and intranasal formulations include asenapine and midazolam. Absorption by this route is more rapid and avoids first-pass metabolism. Finally, inhaled loxapine enters the alveoli and appears quickly in the arterial circulation. All of these novel formulations require at least some cooperation but have the potential to prevent escalation and improve the experience of patients and could be considered when negotiation is possible.

Recognition and Management of Agitation in Acute Mental Health Services: A Qualitative Evaluation of Staff Perceptions

“…The participating nurses in this study believed that engaging patients to share their experience of agitation effectively reduced the frequency and severity of agitation. This perception is consistent with previous research showing that patient engagement and the early recognition of an impending episode can prevent aggressive behaviours [26,27,28,29].…”

Approach To Agitated Patient

“…Yutma güçlüğü olan hastalarda dilaltı, ağız içinde dağılan ilaç formları uygun bir tercih olabilir. Yine kas içi uygulamalara göre daha invaziv olan intranasal midazolam uygulaması ile hızlı yanıt alınabilir (Nordstrom ve Allen, 2013). Şizofreni tanılı olguların akut ajitasyonunda kas içi (aripiprazol, olanzapin, ziprasidon) ve bipolar mani tanılı olgularda ise (olanzapin, aripiprazol) uygulaması Amerika Birleşik Devletleri Sağlık Bakanlığı'na bağlı; gıda, diyet eklentileri, ilaç bürosu (The Food and Drug Administration) (FDA) tarafından onaylanmıştır (Zeller ve Citrome, 2016).…”

Beyond the pill: new medication delivery options for ADHD

“…Alternative oral dosage forms, such as chewable tablets, liquid solutions, sublingual tablets, and ODTs have been developed for the treatment of psychiatric disorders. 44,45 Aside from obviating swallowing difficulties, each oral dosage form provides unique benefits. 3,40,44,46 Liquid agents can be accurately split into a flexible dose, enabling gradual dose adjustment.…”