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Three Part Question

In [patients suffering from agitation with a psychiatric cause] is [olanzapine given intra-muscularly or orally] more effective at [reducing psychiatric agitation]?

Clinical Scenario

An aggressive and/or hostile patient in the Accident and Emergency department requires a dose of olanzapine as a sedative measure. You wonder whether administering the drug orally or intra-muscularly is the best option to bring about safe and effective sedation.

Search Strategy

MEDLINE 1950 to June week 2 2010 using the OVID interface, EMBASE 1980 to week 24 2010 using the OVID interface, psycINFO 1806 to June week 3 2010 using the OVID interface

[exp antipsychotic agents/ OR "olanzapine".mp/ OR "atypical antipsychotics".mp] AND [exp psychomotor agitation/ OR "agitation".mp] AND [exp administration, oral/ OR "oral$".mp] AND [exp injections, intramuscular/ OR "intramuscular".mp]

Search Outcome

190 papers were found, of which none were relevant

Comment(s)

Obviously there needs to be clinical investigation into this area. Olanzapine IM formulations have been shown to be at least as effective as other typical IM antipsychotic agents, while simultaneously producing fewer extrapyramidal side effects in the patient. As a result the patient requires fewer anticholinergic interventions and fewer additional doses of antipsychotics or benzodiazepines. However, the most effective route of administration of olanzapine is at present undetermined. Efforts should be made to produce reliable double blinded randomised controlled trials comparing the widely available routes of administration for the drug in a psychiatric emergency clinical setting. The choice between intravenous, intramuscular, standard oral tablet or Velotab quick dissolving tablet presents the emergency physician with a confusing range of treatments. More research is needed.

Clinical Bottom Line

further research is needed