Management of Delirium and Symptom Control

First-line Antipsychotics

• The American Society of Clinical Oncology recommends haloperidol 0.5-1 mg PO or SC stat, with PRN dosing of 0.5-1 mg every 1 hour as needed, for delirium management in patients with cancer 1, 2
• Lower doses (0.25-0.5 mg) of haloperidol should be used in older or frail patients to minimize the risk of extrapyramidal symptoms (EPS) and QTc prolongation 1

Second-line Antipsychotics

• Olanzapine 2.5-5 mg PO or SC stat is recommended as a second-line antipsychotic for delirium management in patients with cancer 1, 2
• Quetiapine 25 mg (immediate release) PO stat and risperidone 0.5 mg PO stat are also recommended as second-line antipsychotics for delirium management in patients with cancer 1

Management of Severe Agitation

• Lorazepam 1 mg SC or IV stat (up to 2 mg maximum) is recommended for severe agitation in patients with cancer, with lower doses (0.25-0.5 mg) used in older or frail patients or those with COPD 1, 3
• Lorazepam may be combined with haloperidol for refractory agitation in patients with cancer 4

Management of Nausea and Vomiting

• The National Comprehensive Cancer Network recommends considering appropriate routes of administration (rectal, transdermal, subcutaneous, or intravenous) for nausea and vomiting management in palliative care 4
• Antiemetics should be selected based on the underlying cause of nausea and vomiting, and octreotide may be considered early due to its high efficacy and tolerability (starting at 150 mcg SC twice daily) 4

Important Considerations for Parenteral Administration

• Benzodiazepines should be used with caution in patients with severe pulmonary insufficiency, severe liver disease, or myasthenia gravis 1
• Fatalities have been reported with concurrent use of benzodiazepines with high-dose olanzapine, and therefore this combination should be avoided 1

Patient-Specific Considerations

• Benzodiazepines are the treatment of choice as monotherapy for patients with alcohol or benzodiazepine withdrawal 1, 2
• Haloperidol should be avoided in patients with Parkinson's disease or Lewy body dementia due to the risk of extrapyramidal symptoms 1
• Older patients should receive lower doses of all medications and titrate gradually to minimize the risk of adverse effects 1, 2