POEMs

Patient-Oriented Evidence That Matters

Lorazepam Added to Haloperidol Effective for Agitated Delirium in End-of-Life Cancer Patients

 

Am Fam Physician. 2018 Feb 15;97(4):online.

Clinical Question

Does adding lorazepam (Ativan) to haloperidol improve symptoms of agitation in patients with advanced cancer and acute delirium?

Bottom Line

Using a single dose of lorazepam in combination with haloperidol decreases agitation in end-of-life patients with cancer who had persistent agitated delirium despite scheduled haloperidol. A recent POEM (https://www.aafp.org/afp/2017/0315/od3.html) reported that haloperidol increases symptoms of distress in patients with cancer and acute delirium who are receiving palliative care. The findings from the current study suggest that lorazepam alone may provide relief, although this can be fully answered only with a trial that includes a benzodiazepine-only arm. Further, the patients in the current study had an average age of 65 years, so the findings may not apply to an older population. (Level of Evidence = 1b)

Synopsis

These investigators enrolled patients from an acute palliative care unit with a history of advanced cancer and a diagnosis of delirium with agitation. The Richmond Agitation-Sedation Scale (RASS) score was used to identify agitation (range: −5 to 4, where −5 = unarousable and 4 = combative). After enrollment in the study, all patients received open-label haloperidol, 2 mg intravenously every four hours, with 2 mg every hour as needed for agitation. Once patients had a RASS score of 2 or more and required a rescue medication, they received a single dose of lorazepam, 3 mg intravenously, or an identical placebo based on their randomization group, followed by 2 mg of haloperidol. All patients also received standardized care for delirium including treatment for potentially reversible causes, nonpharmacologic delirium prevention measures, and symptom management.

Patients in the two groups were similar at baseline, with a mean age of 65 years, a mean RASS score of 1.6, and a median survival of 73 hours. Out of the 90 patients who were randomized in this study, 29 patients in each group received the study medication

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of POEMs published in AFP is available at http://www.aafp.org/afp/poems.

 

 

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