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Medscape
13-08-2025
- Health
- Medscape
Lorazepam for Cancer Patients With Delirium? What to Know
Lorazepam and other benzodiazepines are typically avoided when managing end-of-life agitated delirium in patients with cancer because these drugs can precipitate, even worsen, delirium. But a new multicenter trial found that patients with advanced cancer and delirium experienced greater reductions in agitation and restlessness at the end-of-life when given lorazepam compared with the more frequently used haloperidol. 'Lorazepam-based regimens were found to be more efficacious than haloperidol alone or placebo in reducing agitation and restlessness in patients who were admitted to the palliative care unit with persistent agitated delirium,' said study lead author David Hui, MD, professor of palliative, rehabilitation and integrative medicine at the University of Texas MD Anderson Cancer Center, Houston. Delirium — a serious change in mental abilities that leads to confused thinking and a lack of awareness — affects more than 90% of patients in their last days or weeks of life, with up to 70% of these patients developing restlessness, agitation, or both. Although a common issue at the end-of-life, delirium often goes underrecognized and there are no guidelines for treating it. The current analysis found that patients with advanced cancer and delirium who received lorazepam or a combination of haloperidol and lorazepam had lower Richmond Agitation-Sedation Scale (RASS) scores than those given haloperidol alone and required rescue medications less frequently to control breakthrough restlessness or agitation. Although lorazepam-based regimens led to better symptom control in this patient population, the findings don't necessarily mean that all should receive a benzodiazepine, Hui told Medscape Medical News . Managing delirium requires achieving a delicate balance between lowering the symptoms and preserving patients' alertness. These final days are 'one of the most precious times for families to interact with the patients,' Hui explained, and these new data can help oncologists and families 'develop a personalized approach to the best management of delirium for a specific patient.' Treating End-of-Life Delirium: The Data Hui and his colleagues conducted the current study to better understand the risks and benefits of using neuroleptic or benzodiazepine agents to control restlessness and agitation intensity in patients with cancer and delirium receiving palliative care. The study included patients aged 18 years or older with an advanced cancer diagnosis who had been admitted to an acute palliative care unit in Taiwan or the US from July 2019 to June 2023. Patients had delirium, a history of hyperactivity, and were taking standard-dose haloperidol (< 8 mg/d) or required 4 mg/d or more of rescue haloperidol for agitation in the past 24 hours. Overall, 72 patients were randomized to one of four groups — scheduled haloperidol with dose escalation (12 mg/d), lorazepam alone, lorazepam plus haloperidol, and placebo on restlessness and agitation intensity in the advanced cancer patients. 'For ethical reasons,' the authors said, the placebo group received lorazepam as a rescue medication. The primary outcome was change in RASS score during the first 24 hours of treatment, though patients were followed for 30 days after medication administration. RASS scores spanned a 10-point scale, ranging from -5 to 4, with -5 representing deeply sedated or unarousable and 4 being combative. At enrollment, all patients started taking 2 mg of haloperidol intravenously every 6 hours and 2 mg intravenously every hour as needed. Patients were monitored until they reached an RASS score of at least 1, at which time researchers switched to the blinded phase in which patients were randomized to their scheduled medication every 4 hours, plus a rescue medication every hour as needed. RASS scores were initially similar in the four groups: 1.7 for haloperidol, 1.6 for lorazepam alone, 1.3 for lorazepam plus haloperidol, and 1.6 for placebo. Within the first hour, RASS scores decreased significantly in all four groups, with the lowest scores in the two lorazepam groups. The mean RASS change at 24 hours was -2.3 for the haloperidol alone group, -4.5 for the lorazepam group, -4.3 for the combination group, and -2.8 for the placebo group. Compared with patients in the haloperidol group, those in the lorazepam and combination group had significantly lower RASS scores, with a mean difference of about -2. The difference in RASS scores between the haloperidol and placebo groups was not significant (-0.5; 95% CI, -1.7 to 0.7), nor was the difference between the combination and lorazepam groups (0.2; 95% CI, -1.1 to 1.4). The combination and lorazepam groups needed significantly fewer rescue medications for breakthrough restlessness or agitation (32% and 37%, respectively) than the haloperidol and placebo groups (56% and 83%, respectively). Hiu and colleagues also noted no differences in survival or adverse events between the groups. 'Taken together, these study findings highlight three options with light (haloperidol), moderate (lorazepam), and heavy (combination) sedation for persistent restlessness and agitation in the end-of-life setting,' the authors wrote. Perspectives: Striking a Balance Thomas B. Strouse, MD, who was not involved in the study, explained that overall 'most practitioners would agree that combining a sedative-hypnotic like lorazepam or midazolam with an antipsychotic like haloperidol or olanzapine are reasonable strategies' for treating agitated delirium in the last days of life for someone with advanced cancer. Strouse, David Geffen School of Medicine, UCLA, explained that he and many colleagues often use antipsychotic agents other than haloperidol, such as olanzapine or quetiapine, which he said are more sedating with generally fewer side effects, particularly akathisia or motor restlessness that 'can sometimes be hard to distinguish from the agitated delirium one is trying to reduce.' In an invited commentary, palliative care experts Justin J. Sanders, MD, MSc, and James Downar, MDCM, MHSc, highlighted important questions raised by the trial. Notably, the goal of managing agitated delirium is not typically about lowering RASS as much as possible but rather about achieving a mid-range of 0 to -2 where patients are calm but not over-sedated. However, most patients in the lorazepam groups achieved a mean RASS score below that target, meaning these patients were more heavily sedated, Sanders, of McGill University, Montreal, Quebec, Canada, and Downar, of the University of Ottawa, Ottawa, Ontario, Canada, explained. When managing delirium, there is often a trade-off between managing the agitated delirium and keeping patients aware and conscious enough to continue communicating, Sanders explained in an interview with Medscape Medical News . Sanders discusses this trade-off with patients and families, telling them that 'we have medications that can treat the delirium, but it will come at the expense of alertness.' He then works with families to help make the best decisions based on their values. Overall, Sanders called this study 'an extraordinary trial in our field,' citing its level of complexity, including the contributions from patients and families. In a comment reacting to the study, Hiroyuki Otani, MD, of Kyushu Cancer Center in Fukuoka, Japan, agreed and elaborated on ambiguity of these end-of-life decisions. 'Deep sedation occupies a complex emotional and ethical space,' Otani wrote. 'While it may relieve visible distress, it may also preclude final opportunities for expression — a glance, a whispered farewell, a final touch.' The trial, Otani concluded, 'calls us to reimagine sedation not merely as symptom control but as a final act of care — where relief, reverence, and relational presence converge at the threshold of life's end.'
Economic Times
21-06-2025
- Health
- Economic Times
Hong Kong medical expert recommends annual Covid-19 and flu vaccinations for high-risk groups
Professor David Hui urges annual Covid-19 and influenza vaccinations for Hong Kong's high-risk groups, citing the cyclical nature of outbreaks and the need for preventive healthcare David Hui Shu-cheong, professor of respiratory medicine at the Chinese University of Hong Kong, has urged that vulnerable groups in Hong Kong receive Covid-19 vaccinations annually. Speaking on Saturday, June 21, Hui noted that outbreaks are expected to recur every six to nine months due to declining antibody levels in the population.'The current outbreak started in April, peaked at the end of May and is now beginning to subside,' Hui said during a radio interview. He estimated that the present wave may end by July or August. Also read: The pandemic isn't over: New COVID cases are on the rise in Hong Kong, Singapore, Thailand, and other Sout Hui emphasized that high-risk groups, including individuals with chronic illnesses, children, the elderly, and immunocompromised individuals, face greater risks of severe complications, such as pneumonia, respiratory failure, or even death, if infected. Authorities have confirmed six severe pediatric Covid-19 cases so far in 2025, with no fatalities reported. Two of the children had pre-existing conditions, and four had not received Covid-19 vaccinations. 'As a new outbreak will come back every year, I would advise the high-risk groups to get jabbed at least once every year against the infections,' Hui said. He added that because Covid-19 symptoms often resemble those of seasonal influenza, individuals showing respiratory symptoms should use rapid antigen tests immediately. Early detection allows for timely treatment, which can help prevent complications. In addition to Covid-19 vaccines, Hui recommended annual influenza vaccinations for high-risk individuals. He referenced a recent cluster of influenza A cases at a primary school in Sham Shui Po, involving 46 people, 41 male students aged 7 to 10 and five staff members. Also read: What international travellers should know amidst rising Covid-19 cases Of the infected, 41 sought medical care and three required hospitalization. All cases were mild. Hui attributed the cluster to poor ventilation and inadequate sanitation of shared classroom items.'Influenza vaccines have been used for many years with extremely low side effects, mainly minor redness and swelling at the injection site,' he said. 'Parents should arrange for their young children to receive the flu vaccines to reduce infection risks.'He warned that Hong Kong's summer flu season typically spans half the summer, usually from July to August. The vaccination rate among children aged six months to two years remains low, with only 27 per cent vaccinated. Professor David Hui of the Chinese University of Hong Kong recommends annual Covid-19 and influenza vaccinations for vulnerable populations, citing recurring outbreaks every six to nine months. He warns that chronically ill individuals, children, and the elderly remain at risk of serious complications without regular immunization and timely testing and treatment Hong Kong medical expert recommends annual Covid-19 and flu vaccinations for high-risk groups Hui concluded by stressing the importance of immunization for reducing public health risks amid ongoing viral transmission cycles.
South China Morning Post
21-06-2025
- Health
- South China Morning Post
Vulnerable groups in Hong Kong should get Covid-19 vaccinations: medical expert
Hong Kong's vulnerable groups should get vaccinated against Covid-19 infections once a year as new outbreaks will occur every six to nine months, a medical expert has urged. David Hui Shu-cheong, a professor of respiratory medicine at the Chinese University of Hong Kong, made the appeal on Saturday while pointing out that the current wave of Covid-19 infections had been declining since late last month and could end in July or August. 'The current outbreak started in April, peaked at the end of May and is now beginning to subside,' he told a radio programme. 'High-risk groups such as the chronically ill, children, the elderly and those with weakened immunity, can easily develop complications such as pneumonia, respiratory failure or even fatalities once infected with the Covid-19 virus.' Authorities have reported six severe paediatric Covid cases so far this year, none of which have been fatal. Two had underlying illnesses and four were unvaccinated. Hui said as Covid-19 antibodies were not long-lasting, there would be periodic decreases in overall community immunity and new outbreaks occurring in cycles – about once every six to nine months.
