Palliative use of psychotropic drugs in response to the COVID-19 outbreak: an Italian experience

Abstract

The outbreak of the COVID-19 infection in Italy was challenging and demanding. Emergency Departments and Intensive Care Units were overloaded and the death rate was huge and impacting for professionals and the general population. Lockdown was necessary, especially to protect elders, but evoked emotional distress.
The highest number of deaths and the highest Case Fatality Rate (CFR) were found among those older than 60 years old (95%, CFR 89.5%) ¹. Older people are more often affected by comorbidities and take several medications, showing a lower capability to react to infections in general and to the COVID-19.
Those with the most severe symptoms of the COVID-19 infection often show delirium as an expression of worsening conditions ¹. 
Delirium, especially the hyperactive form, is an emergency and, together with the treatment of organic precipitating factors, it needs specific management using psychotropic drugs.
Hyperactive delirium or agitation are common in compromised patients affected by COVID-19 and, consequently, their management became routine. 
The COVID-19 emergency allows the possibility of learning from several specialties aiming at an active cooperation to face the crisis. An ordinary procedure used in palliative medicine demonstrated efficacy in handling patients who show COVID related agitation.
Psychiatrists are often involved in the management of psychotropic drugs used to treat delirium but are not used to palliative treatments.
Palliative therapy is sometimes wrongly understand as euthanasia or medical assisted suicide. On the contrary, it is a procedure aimed at controlling unbearable sufferance due to untreatable symptoms and its goal is not death; therefore palliative sedation is empirically and ethically different from Euthanasia or Medical Assisted Suicide and it cannot be used as alternative to euthanasia and medical assisted suicide ^1,2.
Haldol is one of the best options, offering acute tranquilization without risky side effects. Along with habitual ways of administration (oral or intramuscular), a subcutaneous intake shows many advantages.
First of all, it has less extrapyramidal effects compared to oral and it is less sedative with fewer cardiac side effects than parenteral administration ³.
Furthermore, while the bioavailability of oral Haloperidol is about 60-70%, that of subcutaneous administration is nearly 100% 
Several guidelines report the use of subcutaneous Haloperidol in the management of delirium and palliative care but the daily maximum dosage varies from 5 mg ⁴ to 20 mg ⁵.
Italian guidelines of the Italian Society for Palliative Care (SICP) recommend the use of Haloperidol as a first choice in hyperactive delirium with an initial dosage of 2-5 mg sc and continuous subcutaneous infusion of 5-100 mg/daily ².
Adverse side effects are limited to cutaneous reactions in injection sites, but they are limited and without dangerous connotations. Moreover, parenteral administration shows less adverse effects compared to oral and subcutaneous is the safer way among parenteral because it is associated with lower infection risk than endovenous and prevents patients from receiving repetitive intramuscular injections ³. 
A special gain is offered by the fact that most of the patients affected by COVID-19 are usually treated with anticoagulants to prevent blood clotting. Avoiding several injections may thus be safer to them for their coagulation status.

Article

The outbreak of the COVID-19 infection in Italy was challenging and demanding. Emergency Departments and Intensive Care Units were overloaded and the death rate was huge and impacting for professionals and the general population. Lockdown was necessary, especially to protect elders, but evoked emotional distress.

The highest number of deaths and the highest Case Fatality Rate (CFR) were found among those older than 60 years old (95%, CFR 89.5%) ¹. Older people are more often affected by comorbidities and take several medications, showing a lower capability to react to infections in general and to the COVID-19.

Those with the most severe symptoms of the COVID-19 infection often show delirium as an expression of worsening conditions ¹.

Delirium, especially the hyperactive form, is an emergency and, together with the treatment of organic precipitating factors, it needs specific management using psychotropic drugs.

Hyperactive delirium or agitation are common in compromised patients affected by COVID-19 and, consequently, their management became routine.

The COVID-19 emergency allows the possibility of learning from several specialties aiming at an active cooperation to face the crisis. An ordinary procedure used in palliative medicine demonstrated efficacy in handling patients who show COVID related agitation.

Psychiatrists are often involved in the management of psychotropic drugs used to treat delirium but are not used to palliative treatments.

Palliative therapy is sometimes wrongly understand as euthanasia or medical assisted suicide. On the contrary, it is a procedure aimed at controlling unbearable sufferance due to untreatable symptoms and its goal is not death; therefore palliative sedation is empirically and ethically different from Euthanasia or Medical Assisted Suicide and it cannot be used as alternative to euthanasia and medical assisted suicide ^1,2.

Haldol is one of the best options, offering acute tranquilization without risky side effects. Along with habitual ways of administration (oral or intramuscular), a subcutaneous intake shows many advantages.

First of all, it has less extrapyramidal effects compared to oral and it is less sedative with fewer cardiac side effects than parenteral administration ³.

Furthermore, while the bioavailability of oral Haloperidol is about 60-70%, that of subcutaneous administration is nearly 100%

Several guidelines report the use of subcutaneous Haloperidol in the management of delirium and palliative care but the daily maximum dosage varies from 5 mg ⁴ to 20 mg ⁵.

Italian guidelines of the Italian Society for Palliative Care (SICP) recommend the use of Haloperidol as a first choice in hyperactive delirium with an initial dosage of 2-5 mg sc and continuous subcutaneous infusion of 5-100 mg/daily ².

Adverse side effects are limited to cutaneous reactions in injection sites, but they are limited and without dangerous connotations. Moreover, parenteral administration shows less adverse effects compared to oral and subcutaneous is the safer way among parenteral because it is associated with lower infection risk than endovenous and prevents patients from receiving repetitive intramuscular injections ³.

A special gain is offered by the fact that most of the patients affected by COVID-19 are usually treated with anticoagulants to prevent blood clotting. Avoiding several injections may thus be safer to them for their coagulation status.