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

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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.

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Acknowledgments

Drs. Nordstrom and Allen were supported in part by the VISN 19 Mental Illness Research, Education and Clinical Center. This work does not necessarily represent the views of the Department of Veterans Affairs or the United States Government. Dr. Nordstrom has participated in an advisory board for Alexza Pharmaceuticals. Dr. Allen had or has relationships with: Alexza Pharmaceuticals, Sunovion Pharmaceuticals, Dainippon Sumitomo Pharma Japan, inVentiv Health, and Bracket.

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  1. Psychiatric Emergency Service, Denver Health Medical Center, 777 Bannock St, Denver, CO, 80204, USA

    Kimberly Nordstrom

  2. University of Colorado School of Medicine, Denver, CO, USA

    Kimberly Nordstrom & Michael H. Allen

  3. Colorado Depression Center, Denver, CO, USA

    Michael H. Allen

  4. VISN 19 Mental Illness Research Educational and Clinical Center, Denver, CO, USA

    Michael H. Allen

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  1. Kimberly Nordstrom
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Correspondence to Kimberly Nordstrom.

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Nordstrom, K., Allen, M.H. Alternative Delivery Systems for Agents to Treat Acute Agitation: Progress to Date. Drugs 73, 1783–1792 (2013). https://doi.org/10.1007/s40265-013-0130-3

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