Until this decade, only typical antipsychotics were available for IM use, which is often needed in the uncooperative patient,² thus, a lack of familiarity with newer IM atypicals may have limited physician use. In addition, lack of rapid ED availability (Pyxis®, Omnicell®) and higher drug costs could play a role. AmerisourceBergen®, a large pharmaceutical distributor, lists a wide range of institutional acquisition prices. For example, IM haloperidol lists at $0.82 per vial, while IM olanzapine lists at $28.69 per vial.5 Increased acquisition costs may be directly related to drug availability in the ED. At the author’s home institution, a large urban ED in Chicago, droperidol, quetiapine, ziprasidone, and aripiprazole are not available in any of the hospital pharmaceutical distribution machines.

Droperidol was routinely used in the ED for rapid tranquilization until 2001. Compared with haloperidol, droperidol has a faster onset of action, shorter duration of action, more consistent effects, and comparable side effects, even in severely intoxicated patients.^1,3,6 Droperidol remained the ideal drug for the combative ED patient who needed rapid re-assessment until 2001, when the FDA instituted a black box warning for prolonged QT syndrome and fatal arrhythmia.⁷ Since the FDA warning, use in many EDs declined secondary to both medico-legal and safety concerns. Data underlying the FDA’s decision was based on post marketing surveillance, not on peer reviewed medical literature.⁸ For example, haloperidol at doses greater than 50 mg IV has been shown to cause QT prolongation to the same degree as droperidol, though it has no FDA black box warning and continues to be used in the ED with great frequency. Since the FDA warning, several large retrospective reviews have shown no increase in morbidity or mortality between droperidol and haloperidol.^9,10 A large Australian prospective ED trial described no difference in QT prolongation or other adverse effects in head to head trials between droperidol and midazolam.¹¹ Many ED’s have removed the drug from formulary use, and until the FDA revisits safety data, it is unlikely that droperidol will regain common use.¹