Haloperidol plus promethazine for psychosis-induced aggression

Area of Science:

• Psychiatry
• Clinical Pharmacology
• Emergency Medicine

Background:

• Agitation and violence are common in emergency psychiatric services, affecting approximately 10% of patients.
• Effective pharmacological interventions are crucial for rapid and safe patient management.

Purpose of the Study:

• To evaluate the efficacy of haloperidol combined with promethazine for treating aggression induced by psychosis.

Main Methods:

• Systematic review of randomized controlled trials (RCTs) identified through comprehensive database searches.
• Data extraction and analysis included risk ratios and mean differences with 95% confidence intervals, using a fixed-effect model.
• Risk of bias and GRADE assessments were performed for included studies.

Main Results:

• Haloperidol plus promethazine was more effective than haloperidol alone in tranquilizing patients (high-quality evidence).
• Compared to olanzapine and ziprasidone, the combination showed comparable or potentially better outcomes regarding sedation and aggression recurrence, though statistical significance varied.
• Against midazolam, haloperidol plus promethazine demonstrated a lower risk of excessive sedation and reduced need for restraints, while midazolam offered faster initial tranquilization.
• The combination was more effective than lorazepam in achieving sedation within 30 minutes, with similar rates of restraint use.

Conclusions:

• Haloperidol plus promethazine is an effective and safe treatment for psychosis-induced aggression, supported by robust evidence.
• While benzodiazepines like midazolam offer rapid sedation, they carry risks of respiratory depression; haloperidol alone is difficult to justify due to adverse effects.
• Other options like olanzapine and ziprasidone are viable, but haloperidol plus promethazine may offer advantages in managing aggression recurrence.