Intravenous olanzapine for acute agitation in the emergency department

Background: Despite the lack of supporting evidence, olanzapine intramuscular (IM) injection continues to be used via the unapproved intravenous (IV) route for the management of acute agitation in the emergency setting. Aim: To report the management of acute agitation using IV olanzapine via 4 representative cases in the emergency department (ED). Clinical details and outcome: IV olanzapine was used in 4 adult patients. Hospital security alerts were called in each case, mobilising security and ED staff. De-escalation strategies were employed and chemical restraints were administered as a last resort. IV olanzapine was used as the initial, second or last drug to chemically manage the agitation. Olanzapine was used alone or in combination with benzodiazepines and/or other antipsychotics. No adverse events were observed and vital signs remained within normal ranges. Sedation was noted from 30 minutes post olanzapine administration. There were relapses of agitation which required further sedation. No clinical trials have reported on the safety of IV olanzapine for the management of acute agitation specifically in the ED. Conclusion: There is little evidence of efficacy or safety to support the use of IV olanzapine in the ED.