Drug | Dose | Mechanism | Adverse effect | Our experience | Special points |
---|---|---|---|---|---|
Opioids | 2–8 mg (IV morphine) 10–30 mcg/hr (fentanyl patch) | Reducing pain response, blunting sympathetic activity | Respiratory depression, constipation, ileus hypotension over-sedation | Most effective in preventing PSH event | Need adequate dose titration |
Bromocriptine | 1.25 mg/bid/day (PO) | D2 agonist | Confusion, dyskinesia, hypotension | Not used | Titrate up to 10–40 mg/day |
Baclofen | 5 mg/tid/day (PO) | GABAB agonist | Muscle weakness, sedation, liver enzyme elevation, bronchial hyperactivity | Not effective | PO agent is not effective |
Propranolol | 20–60 mg/qid/day (PO) | Nonselective β-blocker | Negative inotropic effect, bronchospasm, hypoglycemia | Effective in decreasing BP and HR during PSH attack | Contraindication in COPD, AV block, Heart failure |
Benzodiazepines | Midazolam 1–2 mg IV Lorazepam 2–4 mg IV Diazepam 5–10 mg IV | GABAA agonist | Respiratory depression, hypotension, over-sedation | Not effective | Diazepam may be preferred in PSH |
Dantrolene | 0.25–2 mg/kg/bid/Day (IV) | Muscle excitation–contraction dissociation by blocking Ca2 + release from sarcoplasmic reticulum | Fatal hepatotoxicity, respiratory depression | Not used | Effective for amelioration of dystonic posturing |
Gabapentin | 300–900 mg/day (PO) | Block α2δ subunit of voltage-gated Ca2 + channel, inhibiting neurotransmitter release in CNS | Sedation, lethargy | Not used | Titrate up to 3600–4800 mg/day |