Lorazepam, Haloperidol, and Delirium

JAMA Internal Medicinehas published a double-blind,randomized, placebo-controlled trial of adding lorazepam to haloperidol in patients with advanced cancer and agitated delirium. (We had a heads up about this trial because it waspresented at ASCO earlier this year.) If there ever was a sort of consensus in HPM about how we should be treating delirium, my sense is that it ’s been shattered by the recentRCT of low-dose haloperidol vs risperidone for delirium in Australian palliative care unit patients, showing those drugsworsened delirium symptoms. So, it seems like we should all see what we can learn from this newly published investigation.The authors note that to be best of their knowledge there has never been a RCT involving a benzodiazepine compared with placebo for delirium. The one kind of famous (if you are a delirium geek) trial which looked at benzos, which was the trial I was directed to when I askedwhy not benzos for delirium when I was training, involving a3-way comparison of lorazepam, haloperidol, and chlorpromazine for delirium in hospitalized patients with AIDS, and registered 6 (!) patients in the delirium arm (lorazepam patients did worse). It had no placebo arm.In fact, there is a lack of high quality drug trials in the delirium world which involve genuine placebo arms, ie, an arm in which there was no active pharmacologic treatment. I have wondered if we ’ve made a huge mistake by doing trials which assumed haloperidol was the standard of care, without r...
Source: Pallimed: A Hospice and Palliative Medicine Blog - Category: Palliative Care Tags: antipsychotics delirium research issues rosielle Source Type: blogs