Rapid tranquillisation guidelines – New BAP and NAPICU joint guidelines on the clinical management of acute disturbance
The British Association of Psychopharmacology (BAP) and the National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU) issued their joint guidance on the clinical management of acute disturbance in June 2018(1).
One problem in this area has been collecting reliable evidence to guide treatment choice, since obtaining service user consent and co-operation makes producing a well-designed randomised controlled trial (RTC) almost impossible. Since NICE guidelines rely on RCTs as the backbone of their recommendations, their 2015 guideline(2) was lacking in substantial recommendations around the use of medication.
What does this guideline examine?
This guideline examines the evidence base for pharmacological and non-pharmacological management of acute disturbance but uses a wider range of evidence sources to guide recommendations. In many cases this highlights how little we know about the relative effectiveness of different treatments, but even with the small amount of data available, there is useful information given about different treatments.
The guideline treats rapid tranquillisation as only applying to injectable medication, with oral medication treated as ‘pre-RT’. For this indication, the recommended drugs are broadly in line with previous recommendations made in the Maudsley Prescribing Guidelines summarised in Table 1.
The recommendations for rapid tranquilisation are presented in a staged manner, with intramuscular monotherapy followed by intramuscular combinations followed by intravenous monotherapy, as shown in Table 2.
Of particular interest is the inclusion of droperidol, which was withdrawn from use as a psychiatric drug in the UK in 2001 due to concerns over QT prolongation (although it has remained available for use in palliative care). This is based on several studies, particularly from Australia, showing the effectiveness of droperidol, as well as a Cochrane review(3).
A few drugs are discussed by the guideline but not recommended. The most widely used of these is probably levomepromazine which the authors conclude lacks evidence of effectiveness by the oral route, and that intramuscularly has evidence for effectiveness but “this has to be weighed against the risk of cardiovascular adverse effects, especially hypotension”. IM ketamine, oral valproate and oral barbiturates are also not recommended as options.
The authors recommend that patients should have physical monitoring carried out using the National Early Warning Score (NEWS) monitoring schedule, as well as psychiatric observations after pre-RT or RT. The frequency and intensity of the recommended monitoring is adjusted based on the route medication is given by, and the risk factors of the patient. Alternatively, Ashtons can provide a Rapid Tranquillisation Monitoring Form which has been specially developed for this purpose and this can be ordered online.
Overall, this guideline has summarised the existing evidence for managing acute disturbance and has made recommendations that give options for service users who do not respond to, or are not able to tolerate, the two options recommended by NICE.
- Patel M, Sethi F et al. (2018) Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation. Journal of Psychopharmacology: 32(6) 601-640.
- NICE Guideline NG10. (2015) Violence and aggression: short-term management in mental health, health and community settings. National Institute of Care and Health Excellence.
- Khokhar MA, Rathbone J. (2016)Droperidol for psychosis-induced aggression or agitation. Cochrane Collaboration.