HWN Suggests

Droperidol: Magic bullet or toxic tincture?

When someone mentions droperidol (Inapsine®), the drug seems to incite very different reactions. Some seem to remember it fondly as an effective drug for rapidly sedating severely agitated patients or as a powerful antiemetic. Others murmur about the potential for the drug to induce torsades de pointes (TdP)...

Since droperidol has reappeared as quickly as it left us several years ago, many younger providers with little or no experience with the drug have asked how it can be such a jack of all trades. A lot of it comes down to its mechanism of action. Droperidol, a butyrophenone similar to haloperidol, was approved in the US in the 1970s for postoperative nausea and vomiting (PONV),…

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 Droperidol Is Back (and Here’s What You Need to Know)

In 2001, when we had agitated patients in the emergency department, we’d give them intramuscular droperidol and everything would be fantastic. It also worked well for nausea and vomiting, and was a useful adjunct for headache treatment. But then because of concerns related to prolongation of the QT interval on ECG, the threat of torsades de pointes, and persistent shortages of the drug, the U.S. Food and Drug Administration (FDA) published a widely criticized warning that recommended a screening ECG prior to dosing, telemetry for two to three hours following administration, and a contraindication for patients with a long QTc (with a cutoff at >440 ms for males, >450 ms for females).1 In short order, droperidol disappeared from hospitals in the United States, the United Kingdom, and many other places, despite the fact that other medications like haloperidol had the same theoretical risks and remained widely available.

 Droperidol Reigns Supreme

Droperidol was more effective than lorazepam or either dose of ziprasidone for the treatment of acute agitation in the ED and caused fewer episodes of respiratory depression.

 Droperidol Use in the Emergency Department – What’s Old is New Again

Sounds like a great drug….. where’s it been the last two decades? Great question. This is slowly becoming a story lost to the previous generation. However, there are important points to be learned from the droperidol story that should be remembered as we develop an evidence-based practice.

 ​Stop the Madness, and Bring Back Droperidol

Droperidol was originally approved in the 1970s by the Food & Drug Administration for nausea, vomiting, anxiety, and sedation, but a controversial black box warning damned the drug as essentially untouchable in 2001. Sales fell 90 percent almost immediately. Production of the drug resumed in early 2019, and it has quickly become the talk of emergency medicine. But myths still surround droperidol, and you really should not associate it with a higher risk of torsades when compared with similar agents.

Articles of Interest

Droperidol coming back to an ED near you

If you’re not familiar with its use, don’t let the black box warning completely dissuade you. Subsequent studies looking at emergency department droperidol use have shown it to be safe, and that complications related to QT prolongation are rare in typical doses. As a rule of thumb, the dose of droperidol is about half of the dose of haloperidol for a given indication.

Droperidol for Agitation in Older Adults in the Emergency Department

The study authors recommend starting with 5 mg and repeating, if necessary, rather than initially using a dose of 10 mg.

Droperidol for Agitation in the ED - No Danger to the Dangerous?

Droperidol is a versatile medication with a number of potential uses for patients in the Emergency Department. It is also a medication surrounded in some degree of mystique because of the decision by the FDA in 2001 to issue a black box warning for its use in response to reports of QT prolongation and torsades de pointes. Many at the time (and since) have argued that, despite these case reports, droperidol is a safe and effective medication that can be used for the treatment of agitation, nausea and vomiting, and migraine.

Droperidol for the Management of Agitation in the ED

While there is no overwhelming evidence that droperidol is superior to haloperidol for management of acute agitation in the ED, there is some suggestion that it may work a few minutes faster and may require less rescue sedation. More importantly, the previous safety concerns appear to be unfounded, as the incidence of prolonged QT was around 0.6% with no reported cases of TdP in any study.

Droperidol Gets Dropped

Droperidol has been used successfully in the emergency department (ED) and operating room (OR) for over 40 years. It has been employed with success for the treatment of headache, nausea, agitation, pain in opiate-tolerance and even the dreaded multidrug-resistant abdominal pain (MDRAP). Unfortunately, in 2001 the FDA issued a black box warning indicating there was a significant risk of cardiac arrhythmias with droperidol. At the time of the black box warning, droperidol held more than 30% of the market share for antiemetics. After the black box warning was issued, many institutions put restrictions on the use of droperidol or completely removed it

Droperidol Use in the Emergency Department: A Clinical Review

Droperidol seems to be effective and safe, despite the boxed warning issued by the FDA. Droperidol is a powerful antiemetic, sedative, anxiolytic, antimigraine, and adjuvant to opioid analgesia and does not require routine screening with electrocardiography when used in low doses in otherwise healthy patients before administration in the emergency department.

Droperidol: Making a Comeback!!!

Our findings suggest droperidol’s effectiveness and safety when used as an analgesic, antiemetic and/or sedative.

I Can't fight this Med Any Longer – Droperidol for Acute Agitation

Consider Droperidol as a therapeutic option for agitated patients requiring parenteral sedation.

POTD: Droperidol

Overwhelming evidence after the FDA black box warning was issued has showed that droperidol is both safe and effective, especially when used at typical dosing for agitation... Typical dosing ranges between 5mg -10mg for agitation, and can be administered IM or IV. Uses:

The Edge: The Overstated Dangers of Droperidol

So, we have a drug that effectively became unavailable after decades of safe use because of poor-quality case reports of adverse events. Since the FDA black box warning, literature has again confirmed the very low incidence of QT prolongation and the more clinically relevant torsades. This would strongly suggest using droperidol at the doses typically used in the U.S. is safe and effective.

The Return of Droperidol...

Droperidol has evidence for efficacy in the treatment of nausea and vomiting, benign headache and migraine, and for the control of acute agitation in the Emergency Department. Its main side effects are sedation, extrapyramidal effects (primarily akathisia), hypotension (especially orthostatic), and prolongation of the QT interval (dose dependent). A black box warning for torsade de pointes was issued in 2001 for IVP doses >2.5 mg.