treatment of acute exacerbation or recurrence of schizophrenia

Last reviewed 01/2018

Requires specialist advice.

Parenteral medication may occasionally be needed to restrain a violent, psychotic patient when talking, distraction, seclusion and measured physical restraint have failed.

  • choice of antipsychotic between chlorpromazine (25-50 mg i.m.) and haloperidol (2-10 mg i.m. repeated hourly if necessary to a maximum of 60 mg over 24 hours)
    • acute dystonia is probably least likely with chlorpromazine, but it may cause hypotension and arrhythmias
      • preferred antipsychotic agent is often haloperidol; procyclidine (5-10 mg i.m.) can be given prophylactically to prevent dystonic reactions
    • use of a benzodiazepine e.g. lorazepam, may rapidly produce drowsiness and reduce anxiety but may depress respiration and so should not be given to a patient with respiratory impairment.

NICE suggest (1):

  • oral antipsychotic medication
    • offer oral antipsychotic medication to people with an acute exacerbation or recurrence of schizophrenia
      • when choosing a drug
        • when using antipsychotic medication then consider treatment with antipsychotic medication as an individual therapeutic trial:
          • record the indications, expected benefits and risks, and expected time for a change in symptoms and for side effects to occur
          • start with a dose at the lower end of the licensed range and titrate upwards slowly within the dose range in the British National Formulary (BNF) or SPC
          • justify and record reasons for dosages outside the range specified in the BNF or SPC
          • monitor and record the following regularly and systematically throughout treatment, but especially during titration:
            • efficacy, including changes in symptoms and behaviour
            • side effects of treatment, taking into account overlap with some of the clinical features of schizophrenia
            • adherence
            • physical health
          • the rationale for continuing, changing or stopping medication and the effects of such changes should be recorded
          • gake into account the clinical response and side effects of previous and current medication
  • consider rapid tranquillisation for people who pose an immediate threat to themselves or others during an acute episode (2):
    • oral medication should be offered before parenteral medication as far as possible
      • when the behavioural disturbance occurs in a non-psychotic context it is preferable to initially use oral lorazepam alone, or intramuscularly if necessary
      • when the behavioural disturbance occurs in the context of psychosis, to achieve early onset of calming/sedation, or to achieve a lower dose of antipsychotic, an oral antipsychotic in combination with oral lorazepam, should be considered in the first instance
    • where rapid tranquillisation through oral therapy is refused, is not indicated by previous clinical response, is not a proportionate response, or is ineffective, a combination of an intramuscular antipsychotic and an intramuscular benzodiazepine (i/m haloperidol and i/m lorazepam) is recommended
    • in the event of moderate disturbance in service users with psychosis, i/m olanzapine may be considered
      • intramuscular lorazepam should not be given within 1 hour of i/m olanzapine. Oral lorazepam should be used with caution
    • the following medications are not recommended for rapid tranquillisation:
      • intramuscular or oral chlorpromazine or oral (a local irritant if given intramuscularly; risk of cardiovascular complications; causes hypotension due to alpha-adrenergic receptor blocking effects, especially in the doses required for rapid tranquillisation; is erratically absorbed; its effect on QTc intervals suggests that it is unsuitable for use in rapid tranquillisation)
      • intramuscular diazepam
      • thioridazine
      • intramuscular depot antipsychotics
      • olanzapine or risperidone should not be used for the management of disturbed/violent behaviour in service users with dementia

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