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Midazolam for rapid tranquillisation: its place in practice

Published online by Cambridge University Press:  11 February 2014

Caroline Parker
Caroline Parker*
Affiliation:
Consultant Pharmacist, Adult Mental Health, Central and North West London NHS Foundation Trust
*
Correspondence to: Dr Caroline Parker, CNWL NHS Foundation Trust, Pharmacy, St Charles Mental Health Unit, Exmoor St, London, W10 6DZ. E-mail: caroline.parker@nhs.net
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Abstract

Benzodiazepines are mainstay medicines in rapid tranquillisation. Midazolam is a short acting benzodiazepine. It is not available for oral administration as this route of administration leads to poor bioavailability. It has recently become available in a new formulation specifically designed for buccal administration, and is also available as a solution for injection.

The absorption of intramuscular midazolam is erratic and it has an unpredictable propensity for causing profound oversedation. Healthcare providers who include IM midazolam in their rapid tranquillisation guidelines or policies need to ensure that clinicians using it have the necessary knowledge, skills and competencies surrounding its use including clinical sequelae and the use of the ‘antidote’ flumazenil.

This brief review describes midazolam's potential role in rapid tranquillisation via these routes, and discusses the risks and benefits of these options in order to help readers consider their places in regular clinical practice, particularly in light of the shortage of lorazepam injection.

Keywords

Rapid tranquillisationmidazolambuccalintramuscular
Type
Review Articles
Information
Journal of Psychiatric Intensive Care , Volume 11 , Issue 1 , April 2015 , pp. 66 - 72
Copyright
Copyright © NAPICU 2014 

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References

Baldacara, L., Sanches, M., Cordeiro, D.C., Jackoswski, A.P. (2011) Rapid tranquilization for agitated patients in emergency psychiatric rooms: a randomized trial of olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol alone. Revista Brasileira de Psiquiatria. 33: 30–39.CrossRefGoogle Scholar
Benazzi, F., Mazzoli, M., Rossi, E. (1992) Benzodiazepines and acute psychotic agitation. Canadian Journal of Psychiatry. 37(10): 732–733.Google Scholar
Care Quality Commission (2011) CQC Mental Health Operations Newsletter. Issue 18.Google Scholar
Choudhury, R., Dewsbury, M., Williams, K., Hovery, N. (2011) Audit of the rapid tranquillisation policy in the together NHS foundation trust. Journal of Psychiatric Intensive Care. 7(1): 55–61. DOI:10.1017/S1742646410000142 CrossRefGoogle Scholar
European Medicines Agency (2013) Adasuve (loxapine). EMEA/H/C/002400Google Scholar
Gillies, D., Sampson, S., Beck, A., Rathbone, J. (2013) Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database of Systematic Reviews. 2013(9): CD003079. DOI:10.1002/14651858.CD003079.pub4 Google Scholar
Huf, G., Coutinho, E.S.F., Adams, C.E. and TREC Collaborative Group (2007) Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomized controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine. British Medical Journal. 335(7625): 869–875.CrossRefGoogle ScholarPubMed
Innes, J., Iyeke, L. (2012) A review of the practice and position of monitoring in today's rapid tranquillisation protocols. Journal of Psychiatric Intensive Care. 8(1): 15–24. DOI:10.1017/S1742646411000057 Google Scholar
Innes, J., Sethi, F. (2013) Current rapid tranquillisation documents in the UK: a review of the drugs recommended, their routes of administration and clinical parameters influencing their use. Journal of Psychiatric Intensive Care. 9(2): 110–118. DOI:10.1017/S174264641200026X CrossRefGoogle Scholar
Isbister, G.K., Calver, L.A., Page, C.B., Stokes, B., Bryant, J.L., Downes, M.A. (2010) Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioural disturbance: the DORM study. Annals of Emergency Medicine. 56: 392–401.CrossRefGoogle ScholarPubMed
Joint Formulary Committee (2013) British National Formulary, 65th edition. London: BMJ Group and Pharmaceutical Press.Google Scholar
Keating, G. (2013) Loxapine inhalation powder: a review of its use in the acute treatment of agitation in patients with bipolar disorder or schizophrenia. CNS Drugs. 27: 479–489.Google Scholar
Knott, J.C., Taylor, D. McD, Castle, D.J. (2006) Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patients in the emergency department. Annals of Emergency Medicine. 47: 61–67.CrossRefGoogle ScholarPubMed
Loynes, B., Innes, J., Dye, S. (2013) Assessment of physical health monitoring following rapid tranquillisation: a national survey. Journal of Psychiatric Intensive Care. 9(2): 85–90. DOI:10.1017/S1742646412000295 CrossRefGoogle Scholar
Martel, M., Sterzinger, A., Miner, J., Clinton, J., Biros, M. (2005) Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Academic Emergency Medicine. 12(12): 1167–1172.Google Scholar
National Institute for Clinical Excellence (2005) Violence—the short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. NICE, CG25. http://www.nice.org.uk/guidance/CG25 Google Scholar
National Institute for Health and Care Excellence (2012) Review consultation document. Review of Clinical Guideline (CG) – CG25 Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. http://guidance.nice.org.uk/CG25/ReviewProposal Google Scholar
National Institute for Health and Care Excellence (2013) Loxapine inhalation for treating acute agitation and disturbed behaviours associated with schizophrenia and bipolar disorder (terminated appraisal). NICE, TA286. http://guidance.nice.org.uk/TA286 Google Scholar
National Patient Safety Agency (2008) Reducing risk of overdose with midazolam injection in adults. Rapid Response Report NPSA/2008/RRR011. http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59896 Google Scholar
Nobay, F., Simon, B., Levitt, A., Dresden, G.M. (2004) A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Academic Emergency Medicine. 11: 744–749.Google Scholar
Parker, C., Khwaja, M., Cumming, I. (2013) Use of medication and ECT in the management of violence. In Khwaja, M., Beer, D. (eds) Prevention and management of violence: guidance for mental healthcare professionals. Royal College of Psychiatrists CR177, pp. 35–62.Google Scholar
Pereira, S., Paton, C., Walkert, L.M., Shaw, S., Gray, R., Wildgust, H. (2005) Treatment of acute behavioural disturbance: a UK national survey of rapid tranquillisation. Journal of Psychiatric Intensive Care. 1(2): 84–88.Google Scholar
Roche Products Ltd (2012) Hypnovel 10 mg/2 ml solution for injection. Summary of product characteristics, last updated 16 May 2012. http://www.medicines.org.uk Google Scholar
Roche Products Ltd. (2013) Rivotril 0.5 mg and 2 mg tablets. Summary of product characteristics, last updated 4 February 2013. http://www.medicines.org.uk Google Scholar
Schwagmeier, R., Alincic, S., Striebel, H.W. (1998) Midazolam pharmacokinetics following intravenous and buccal administration. British Journal of Clinical Pharmacology. 46(3): 203–206.Google Scholar
Sweetman (2011) Martindale: The Complete Drug Reference, 37th edition. Pharmaceutical Press. http://www.medicinescomplete.com/mc/martindale/current/ Google Scholar
Taylor, D., Okocha, C., Paton, C., Smith, S., Connolly, A. (2008) Buccal midazolam for agitation on psychiatric intensive care wards. International Journal of Psychiatry in Clinical Practice. 12(4): 309–311.CrossRefGoogle ScholarPubMed
Taylor, D., Paton, C., Kapur, S. (2012) The Maudsley Prescribing Guidelines in Psychiatry, 11th edition. London: Wiley-Blackwell.Google Scholar
TREC Collaborative Group (2003) Rapid tranquillisation for agitated patients in psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine. British Medical Journal. 327(7417): 708–711.Google Scholar
ViroPharma Ltd. (2013) Buccolam 10 mg oromucosal solution ▾. Summary of product characteristics, last updated 3 May 2013. http://www.medicines.org.uk Google Scholar
Windfuhr, K., Turnball, P., While, D., Mehta, H., Hadfield, K., Hiroeh, U., Watkinson, H., Dixon, C., Flynn, S., Thomas, S., Lewis, G., Ferrier, I.N., Amos, T., Skapinakis, P., Shaw, J., Kapur, N., Appleby, L. (2011) The incidence and associated risk factors for sudden unexplained death in psychiatric in-patients in England and Wales. Journal of Psychopharmacology. 25(11): 1533–1542.Google Scholar
Wockhardt UK Ltd (2008) Diazepam 5 mg/ml solution for injection. Summary of product characteristics, last updated 25 September 2013. http://www.medicines.org.uk Google Scholar