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IM Droperidol versus Olanzapine for the Agitated Patient – Which to Choose?

September 23, 2021

Written by Rebecca White

Spoon Feed
There was no difference between IM droperidol and IM olanzapine in time to adequate sedation for the acutely agitated ED patient. Droperidol carried a slightly higher risk of extrapyramidal effects. 

Why does this matter?
Agitation is a common ED presentation. Given risk of injury to patients and staff, quick and effective management is vital. Verbal de-escalation and oral medications are often unsuccessful, and IV access is not always present. Intramuscular administration is useful; however, there is no consensus on the ideal first-line agent. When faced with an agitated patient, which drug do we choose?

You are getting very sleeeeepy…
This single-center, prospective, observational study compared IM droperidol (n = 538) and IM olanzapine (n = 719) for acute agitation. Treating physicians determined medication choice and dosage (median dose: droperidol 5mg, olanzapine 10mg), though there was a shortage of each drug at different times during the study.

Using Altered Mental Status Scale ≤ 0 as an indicator of adequate sedation, time to sedation was 16 minutes for droperidol and 17.5 minutes for olanzapine (AD –0.7 minutes; 95%CI –2.1 to 0.5 minutes). Patients receiving olanzapine were more likely to require additional medication for sedation (24% vs 17%; AD –8% [95%CI –12% to –3%]). Extrapyramidal effects were more common with droperidol (n=6; 1% versus n=1; 0.1%), though there was otherwise no difference in adverse events. Patients who received olanzapine spent more time in the ED (500 vs 444 minutes; median difference –59 minutes [95% CI –78 to –40 minutes]). 

While this study was limited by lack of randomization and blinding, drug shortages during the study theoretically mitigate selection bias. In my practice, I’ll continue to consider both drugs viable options for agitation, though I will reach for droperidol more often given its association with shorter ED stay and lower likelihood that additional medications will be required.

Another Spoonful
Droperidol has previously shown to be more effective than ziprasidone or lorazepam, and also works well in combination with midazolam for IV administration.

A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med. 2021 Aug;78(2):274-286. doi: 10.1016/j.annemergmed.2021.01.005. Epub 2021 Apr 9.

What are your thoughts?