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EDITORIALS: Chittaranjan Andrade Rapid tranquillisation in emergency psychiatric settings BMJ 2007; 335: 835-836 [Full text]

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Need clinical trials of solo-promethazine for rapid tranquillization.

Bruce G Charlton   (29 October 2007)

Intramuscular Olanzepine rarely used in rapid tranquillisation

Sudip Sikdar   (19 November 2007)

Need clinical trials of solo-promethazine for rapid tranquillization. 29 October 2007
Bruce G Charlton, Reader in Evolutionary Psychiatry Newcastle University, NE1 7RU, UK. Send response to journal: Re: Need clinical trials of solo-promethazine for rapid tranquillization.	By highlighting the benefits of the sedative anti-histamine promethazine in rapid tranquillization, Andrade's thoughtful editorial adds to the hope that neuroleptic/ antipsychotic drugs may eventually be virtually discarded from medical practice, to be used only as a last resort [1]. It would be desirable to minimize usage of the antipsychotic drugs since 'neuroleptic' control of agitated behaviour is essentially achieved by iatrogenic induction of Parkinsonism (especially emotional blunting and demotivation) [2]. Used long-term they produce dependence [3], and trigger psychosis on withdrawal [4]. The more recent so-called ‘atypical’ agents are probably less neurotoxic, but some have serious metabolic toxicity manifested in massive weight gain and increased mortality [1, 2, 4]. By contrast, promethazine has an excellent safety profile, having been available without prescription for many decades. Clearly, the next step should be clinical trials of emergency tranquillization using promethazine without neuroleptics. If solo-promethazine proves effective, more patients can be spared exposure to dangerous and dysphoric antipsychotics. References 1. Charlton BG. Why are doctors still prescribing neuroleptics? QJM 2006; 99: 417-20. 2. Healy D. Psychiatric drugs explained. 4th edition. Churchill Livingstone: Edinburgh, 2004. 3. Healy D. The creation of psychopharmacology. Harvard University Press: Cambridge, MA, USA, 2002. 4. Whitaker R. The case against antipsychotic drugs: a 50 year record of doing more harm than good. Medical Hypotheses 2004; 62: 5-13. Competing interests: None declared
Intramuscular Olanzepine rarely used in rapid tranquillisation 19 November 2007
Sudip Sikdar, Consultant Psychogeriatrician Mersey Care NHS Trust, Liverpool, UK Send response to journal: Re: Intramuscular Olanzepine rarely used in rapid tranquillisation	Editor I read Andrade's editorial(1) with interest on this subject. He seems to be under the impression that im olanzepine is preferentially used over im haloperidol when the need to rapidly tranquilise an agitated, aggressive patient arises in the western world compared to the practice in developing countries such as India(2) or Brazil(3). Having had post grduate psychiatry training both in India and the UK and after 15 years of practising psychiatry in this country as well as being a medical member member of the drugs and therapeutic committee of my trust, I can confirm that the practise in the real world settings of inpatient psychiatry, medical or accident and emergency wards doesn't differ much except that lorazepam is frequently used in conjunction with haloperidol rather than promethazine. In real world of acute psychiatry, calmness and sedation frequently merge when the end point of tranquillisation is considered ( in contrast to NICE guidelines (4). Perhaps the other major difference arises when the patients considered for rapid tranquillisation is compared. While two thirds of the patients in the Indian study had a diagnosis of mania, rapid tranquillisation is more often considered for acutely psychotic patients (scizophrenics, substance induced psychotics, delirious etc)in the uk. Zuclopenthixol acetate (clopixol acuphase) is commonly used for rapid neuroleptisation though rarely gets inadvertently used for rapid tranquillisation especially in an acutely psychotic and violent and aggressive patient. References 1. Andrade C. Rapid tranquillisation in emergency settings. BMJ 2007;335:835(27 October) 2. Raveendran NS, Tharyan P, Alexander J, Adams CE and the TREC India II collaboration group. Rapid tranqillisation in psychitric emergency settings in India: pragmatic randomised controlled trialof intramuscular olanzepine and intramuscular haloperidol plus promethazine. BMJ 2007;335:865(27 October) 3. Huf G, Coutinho ESF, Admas CE TREC collabaorative group. Rapid tranqillisation of violent and agitated people in psychitric emergency settings: pragmatic randomised controlled trialof intramuscular haloperidol and intramuscular haloperidol plus promethazine. BMJ 2007;335:869(27 October) 4. National Institute for Health and Clinical Excellence. Violence: the short term management of disturbed/violent behaviour in inpatient psychiatric settings and emergency departments. 2005. www.nice.org.uk/pdfcg025niceguidelines.pdf Competing interests: None declared