Let’s Replace: Droperidol; With: Olanzapine

The U.S. has been suffering acute droperidol-emia for quite some time, now.  Around the time ondansetron was exclusively on-patent, the FDA “coincidentally” published a “black box” for this otherwise universally beloved medication.  This led to restrictions in use at many institutions.  Then, recently, it’s simply no longer available from any local manufacturer.  It is a sad world, indeed.

At times, I have replaced its use with haloperidol.   Droperidol and haloperidol are, of course, both typical butyrophenone antipsychotics – but the complex metabolism of haloperidol leads to some unpredictability in sedation and effect.  Despite being approved only for oral and intramuscular use, I have occasionally used olanzapine intravenously for headache in the Emergency Department – and, now, the fine folks at Hennepin County have published their robust experience.

This is simply a retrospective review of its use at their institution, with an eye towards safety events, not effectiveness.  Six months of data, comprising 713 patients, were manually reviewed by two co-authors.  The most common usages for olanzapine were agitation (34.4%), abdominal pain (23.1%), headache (17.0%), nausea & vomiting (15.0%), and non-specific pain (8.4%).  Many patients reviewed also received co-administration of olanzapine with other sedating medications, including opiates, benzodiazepines, and ketamine.

Unfortunately, this study ultimately does not provide terribly insightful data regarding olanzapine use.  Only 20 patients had an EKG before and after administration, and median increase in QTc was 12ms.  Four patients suffered akasthisia “likely” or “possibly” related to olanzapine.  About 10% of patients required supplemental oxygen for respiratory depression and hypoxia.  Then, seven patients required intubation and two patients died during their subsequent hospitalizations.  Each of these serious adverse outcomes was multifactorial.

So, there is no simple answer regarding olanzapine.  Just like the case series behind the black box for droperidol, olanzapine was used in many patients with significant comorbid physiology or pharmacology.  Without a control or comparator group, this study cannot address the comparative efficacy and safety of any potential alternative agents.  It is probably reasonable to consider olanzapine as an option in situations where droperidol was previously used, but its effectiveness and true safety remains unknown.

“A Large Retrospective Cohort of Patients Receiving Intravenous Olanzapine in the Emergency Department”
http://www.ncbi.nlm.nih.gov/pubmed/26720055