Unsafe Use of Intravenous Haloperidol Pervasive in Hospitalized Elderly
University of Colorado Hospital and University of Colorado Denver at Anschutz Medical Campus, Aurora, Colorado
Delirium is present in 11-24% of elderly patients on hospital
556 patients received IV haloperidol during the study period.
admission while another 6-56% will develop it during their
Median size of the first dose of haloperidol given is 2 mg (range
Only the first haloperidol doses were recorded so events
associated with prolonged or cumulative doses of haloperidol
Off-label intravenous (IV) administration of haloperidol is often
20% received ≥ 5 mg of haloperidol for their first dose.
may be missed which may underestimate unsafe use.
used due to its rapid onset and ease of administration.4
80% had an ECG within 7 days of their first dose. (Measure 1)
We did not account for transient factors (i.e. electrolyte
Numerous case reports of QT prolongation, Torsades de Pointes
16% received IV haloperidol despite having a baseline QTc ≥ 500
disturbances) that may have affected QTc.
(TdP), and sudden death is associated with IV haloperidol.
In 2007, FDA issued a black box warning for IV haloperidol due
Only 21% of patients with a baseline QTc ≥ 450 ms had a repeat
the risk of adverse outcomes from QT prolongation.5
ECG measured within 24 hrs after the first dose. (Measure 3)
Conclusion Table 1: Characteristics of Study Population
Off-label IV haloperidol use is common among hospitalized
58% of patients in this analysis did not receive care concordant
To determine whether hospitalized elderly patients who are
prescribed IV haloperidol receive expert recommendation-concordant
More than 1 in 10 elderly patients received IV haloperidol despite
care to minimize adverse events related to QT prolongation.
a QTc ≥ 500 ms even after the FDA black box warning was
An adverse outcome in a patient receiving IV haloperidol with
known prolonged QTc may have significant medico legal
Retrospective study of patients ≥ 65 years who received ≥ 1 dose
Interventions to improve physician prescribing and assure proper
of IV haloperidol at the University of Colorado Hospital (UCH)
monitoring for this medication should be implemented.
Concomittant QT Prolonging Drugs - no. (%)
Patient demographics, co-morbid conditions, and QTc from
electrocardiogram (ECG) were collected from electronic medical
Inouye SK. Delirium in older persons. NEJM 2006; 354(11):1156-65.
Date of first dose of haloperidol administered, amount given, and
Saxena S, Lawley D. Delirium in the elderly: a clinical review. Postgrad Med
concomitant QT prolonging drugs were obtained from electronic
Expert Recommendation Non-Adherence
Fong TG, Tulebae SR, Inouye SK. Delirium in elderly adults: diagnosis,
prevention, and treatment. Nat Rev Neurol 2009;5:210-20.
Adherence to expert recommendations defined as meeting the
Haloperidol Injection USP (for immediate release) Package Insert. Bedford,
Information for Healthcare Professionals: Haloperidol. Available at:
ECG performed within 7 days before administration of
IV haloperidol administration avoided if QTc ≥ 500 ms
Crouch MA, Limon L, Cassano AT. Clinical relevance and management of
ECG performed to reevaluate QTc within 24 hours after
drug-related QT interval prolongation. Pharmacotherapy 2003;23(7):881-908.
first dose of haloperidol if prior QTc ≥ 450 ms
Li EC, Esterly JS, Pohl S, et al. Drug-induced QT-interval prolongation:
considerations for the clinicians. Pharmacotherapy 2010;30(7):684-701.
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