Abstract
I welcomed the comments of Josh Geffen [1] on my article recently published in the Journal [2]. I would like to take the opportunity to both correct an apparent misunderstanding of my article and add support to some of the comments of Dr Geffen. The misunderstanding relates to the presumption that I am endorsing parenteral haloperidol as the drug of choice for brief periods of sedation. I did not mean for this to be implied in the article. I am firmly of the opinion that haloperidol is a poor choice for the sedation of psychotic patients, as stated by Geffen, due to its lack of intrinsic sedative properties and the high incidence of adverse events experienced by patients who receive it by parenteral form.
I would agree that the best forms of sedation available in Australia are the oral and parenteral benzodiazepines although we are limited by the failure of the pharmaceutical industry to have parenteral lorazepam made available here. In my experience, the majority of disturbed patients may be managed with either midazolam or diazepam in its various forms. Parenteral antipsychotics may be necessary, for example in patients with a history of heavy substance abuse and liver enzyme induction. These cases are uncommon, however, and when they occur there remain better alternatives to haloperidol, for example droperidol which is intrinsically more sedating.
Unfortunately, the literature surrounding the use of all of these agents in acutely disturbed patients is quite lacking. This is unlikely to change in the near future due to the practical and ethical difficulties involved in conducting adequate trials in the patient group. In this context we are required to base decisions on a combination of the limited data, inferences drawn from other research designs, clinical experience and wisdom. We must be careful, however, to critically question this clinical wisdom, as the rise of ‘myths’ around the use of haloperidol as a sedative agent have demonstrated.