Medication Use for Acute Behavioural Disturbance in COVID-19 infections

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Guidance

NHS GGC guidance on Intramuscular Medication for Acutely Disturbed Patients should be followed1 but with additional consideration to potential physical complications in patients with diagnosed or suspected COVID-19 infection.

  • Consider current personal protection equipment (PPE) guidance as part of the risk assessment when making clinical decisions about the management of acute behavioural disturbance.
  • Exclude delirium which may be a symptom of COVID-19 infection. Refer to management of delirium guidelines (general and COVID- specific guidance).2,3
  • Oral medication should always be considered first line as parenteral (IM) medications are more likely to cause dose-related adverse effects such as respiratory depression, QTc prolongation, postural hypotension and extrapyramidal side effects. (Refer to section on oral medication)
  • If a patient has suspected or diagnosed COVID-19 and there are no signs of respiratory compromise (decreased or increased respiratory rate), cardiovascular disease or decreased level of consciousness, then management of acute behavioural disturbance should follow current NHS GGC guidance with caution and adequate safeguards for monitoring. Consider that the patient’s physical health may deteriorate rapidly.4
  • Respiratory depression is a known adverse effect of benzodiazepines. COVID-19 is known to affect the respiratory function of patients. Therefore benzodiazepines should not be used where there is evidence of respiratory compromise.
  • If benzodiazepines are used, this should be the lowest possible dose for the shortest period of time. Consider benzodiazepines with shorter half-lives (e.g. oral or IM lorazepam, IM midazolam). Avoid longer acting benzodiazepines e.g. diazepam.
  • Flumazenil will reverse the effects of benzodiazepines, but not if respiratory depression is due to COVID-19.
  • NHS GGC guidance regarding haloperidol should be followed and should not be used if there is evidence of cardiovascular disease (including QTc prolongation), any contraindications to treatment or if there is no recent ECG.5 Where haloperidol use is contraindicated, IM olanzapine or IM aripiprazole would be more appropriate antipsychotics. Consider the increased sedative potential of olanzapine.
  • Promethazine should be used with caution in patients with COVID-19-related respiratory insufficiency due to the potential to thicken or dry lung secretions and impair expectoration.
  • Ensure physical health monitoring is done in line with current guidance especially with regards to respiratory rate and level of consciousness.
Oral medication

Oral medication should always be considered before intramuscular medication. Doses should be given at least 60 minutes apart. If single agent is ineffective combinations of lorazepam and antipsychotic should be considered.

It should be noted that the doses for lorazepam given below exceed the recommended doses for the treatment of anxiety.

Administration of oral ‘when required’ psychotropics in ADULTS:

  • lorazepam 1-2mg (max 8mg/24hrs) or
  • olanzapine 5-10mg (max 20mg oral or IM/24hrs) or
  • quetiapine 50-150mg (max 750mg/24hrs) or
  • risperidone 2mg (max 16mg/24hrs)* or
  • in patients with a confirmed history of significant antipsychotic exposure: haloperidol 5-10mg (max 20mg oral or IM/24hrs)**

Administration of oral ‘when required’ psychotropics in OLDER ADULTS (excluding behavioural disturbance due to dementia):

  • lorazepam 0.5-1mg (max 4mg/24hrs) or
  • olanzapine 2.5-5mg (max 20mg oral or IM/24hrs) or
  • quetiapine 25-75mg (max 750mg/24hrs) or
  • risperidone 0.5-1mg (max 4mg/24hrs) or
  • in patients with a confirmed history of significant antipsychotic exposure: haloperidol 0.5-5mg (max 10mg oral or IM/24hrs)**. This should not be given if suspected dementia with Lewy bodies
  • Beware of contraindication to some antipsychotics with co-existing dementia

Administration of oral ‘when required’ psychotropics in ADOLESCENTS:

  • lorazepam 0.5-2mg (max 4-8mg/24hrs) or
  • olanzapine 2.5-5mg (max 20mg oral or IM/24hrs) or
  • quetiapine 25-50mg (max 750mg/24hrs) or
  • risperidone 0.5-2mg (max 16mg/24hrs)* or
  • Adolescents have developing brains and are vulnerable to side effects e.g. disinhibition due to the use of benzodiazepine medication.
  • It is NEVER appropriate to use haloperidol in adolescents

*Doses above 10 mg/day have not demonstrated superior efficacy to lower doses and may cause increased incidence of extrapyramidal symptoms. Safety of doses above 16 mg/day has not been evaluated, and is therefore not recommended.

** NHS GGC guidance regarding haloperidol & QTc prolongation should be followed

References
  1. NHS GGC Guideline for Intramuscular Medication for Acute Behavioural Disturbance October 2018. 
  2. Scottish Intercollegiate Guidelines Network (SIGN). Risk reduction and management of delirium. (SIGN publication no. 157). March 2019. https://www.sign.ac.uk/assets/sign157.pdf
  3. British Geriatric Society. Coronavirus: Managing delirium in confirmed and suspected cases. Mar 2020. https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases
  1. The National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU) Managing acute disturbance in the context of COVID-19; 30th March 2020. https://napicu.org.uk/
  2. NHS GGC Guideline for Haloperidol and QTc Interval Prolongation. April 2020. 
Editorial Information

Last reviewed: 14 April 2020

Next review: 01 April 2021

Author(s): Mental Health Pharmacy Services

Version: 1

Approved By: Mental Health Pharmacy Services

Reviewer Name(s): Andrew Walker, Suzanne Burke