Report: Protective effects of rice bran oil in haloperidol-induced tardive dyskinesia and serotonergic responses in rats

Effect of administration of Rice bran oil (RBO) was evaluated on haloperidol elicited tardive dyskinesia in rats. Albino Wistar rats treated with haloperidol in drinking water at a dose of 0.2mg/kg/day and RBO by oral tubes at a dose of 0.4 mL/day for 5 weeks. Motor coordination, VCMs and 8-hydroxy-2-(di-n-propylamino) tetraline)[8-OH-DPAT] _syndrome were monitored. Striatal serotonin (5-hydroxytryptamine; 5-HT) and 5-hydroxyindolacetic acid (5-HIAA) levels were determined by high performance liquid chromatography (HPLC-EC). Rats treated with haloperidol orally at a dose of for a period of 5 weeks developed VCMs, which increased progressively as the treatment continued for 5 weeks. Motor coordination impairment started after the 1st week and was maximally impaired after 3 weeks and gradually returned to the 1st week value. Co-administration of RBO prevented haloperidol_induced VCMs as well impairment of motor coordination. The intensity of 8-OH-DPAT_induced syndrome and decreased 5-HT metabolism were greater in water + haloperidol treated animals than RBO + haloperidol treated animals. The present study suggested that involvement of free radical in the development of TD and point to RBO as a possible therapeutic option to treat this hyperkinetic motor disorder.

Antipsychotic Dose Mediates the Association between Polypharmacy and Corrected QT Interval

Antipsychotic (AP) drugs have the potential to cause prolongation of the QT interval corrected for heart rate (QTc). As this risk is dose-dependent, it may be associated with the number of AP drugs concurrently prescribed, which is known to be associated with increased cumulative equivalent AP dosage. This study analysed whether AP dose mediates the relationship between polypharmacy and QTc interval. We used data from a cross-sectional survey that investigated the prevalence of QTc lengthening among people with psychiatric illnesses in Italy. AP polypharmacy was tested for evidence of association with AP dose and QTc interval using the Baron and Kenny mediational model. A total of 725 patients were included in this analysis. Of these, 186 (26%) were treated with two or more AP drugs (AP polypharmacy). The mean cumulative AP dose was significantly higher in those receiving AP polypharmacy (prescribed daily dose/defined daily dose = 2.93, standard deviation 1.31) than monotherapy (prescribed daily dose/defined daily dose = 0.82, standard deviation 0.77) (z = -12.62, p < 0.001). Similarly, the mean QTc interval was significantly longer in those receiving AP polypharmacy (mean = 420.86 milliseconds, standard deviation 27.16) than monotherapy (mean = 413.42 milliseconds, standard deviation 31.54) (z = -2.70, p = 0.006). The Baron and Kenny mediational analysis showed that, after adjustment for confounding variables, AP dose mediates the association between polypharmacy and QTc interval. The present study found that AP polypharmacy is associated with QTc interval, and this effect is mediated by AP dose. Given the high prevalence of AP polypharmacy in real-world clinical practice, clinicians should consider not only the myriad risk factors for QTc prolongation in their patients, but also that adding a second AP drug may further increase risk as compared with monotherapy.

Antipsychotic-induced akathisia in delirium: A systematic review

OBJECTIVE

Akathisia is a neuropsychiatric syndrome characterized by subjective and objective restlessness. It is a common side effect in patients taking antipsychotics and other psychotropics. Patients with delirium are frequently treated with antipsychotic medications that are well known to induce akathisia as a side effect. However, the prevalence, phenomenology, and management of akathisia in patients with delirium remain largely unknown. The purpose of this review was to examine the medical literature in order to establish the current state of knowledge regarding the prevalence of antipsychotic-induced akathisia in patients with delirium.

METHOD

A systematic review of the literature was conducted using the EMBASE, MEDLINE, PsycINFO, and CINAHL databases. Ten studies addressing the incidence of akathisia in patients taking antipsychotic medication for delirium were identified and included in our review.

RESULTS

The included studies reported a variable prevalence of antipsychotic-induced akathisia. A higher prevalence was found in patients taking haloperidol. Among atypical antipsychotics, paliperidone and ziprasidone were associated with a higher risk of akathisia. The risk for akathisia appeared to be a dose-related phenomenon.

SIGNIFICANCE OF RESULTS

Studies using specific scales for evaluation of akathisia in delirium are lacking. Some populations, such as patients with cancer or terminally ill patients in palliative care settings taking antipsychotics for the treatment of delirium, could be at higher risk for development of akathisia as a side effect.

A Cost-effectiveness Analysis of Antipsychotics for Treatment of Schizophrenia in Uganda

BACKGROUND

Reductions in prices following the expiry of patents on second-generation antipsychotics means that they could be made available to patients with schizophrenia in low-income countries. In this study we examine the cost effectiveness of antipsychotics for schizophrenia in Uganda.

METHODS

We developed a decision-analytic 10-state Markov model to represent the clinical and treatment course of schizophrenia and the experience of the average patient within the Uganda healthcare system. The model was run for a base population of 25-years-old patients attending Butabika National Referral Mental Hospital, in annual cycles over a lifetime horizon. Parameters were derived from a primary chart abstraction study, a local community pharmacy survey, published literature, and expert opinion where necessary. We computed mean disability-adjusted life-years (DALYs) and costs (in US$ 2012) for each antipsychotic, incremental cost, and DALYs averted as well as incremental cost-effectiveness ratios (ICERs).

RESULTS

In the base-case analysis, mean DALYs were highest with chlorpromazine (27.608), followed by haloperidol (27.563), while olanzapine (27.552) and risperidone had the lowest DALYs (27.557). Expected costs were highest with quetiapine (US$4943), and lowest with risperidone (US$4424). Compared to chlorpromazine, haloperidol was a dominant option (i.e. it was less costly and more effective); and risperidone was dominant over both haloperidol and quetiapine. The ICER comparing olanzapine to risperidone was US$5868 per DALY averted.

CONCLUSION

When choosing between first-generation antipsychotics, clinicians should consider haloperidol as the first-line agent for schizophrenia. However, overall, risperidone is a cost-saving strategy; policymakers should consider its addition to essential medicines lists for treatment of schizophrenia in Uganda.

Long-Term Haloperidol Treatment Prolongs QT Interval and Increases Expression of Sigma 1 and IP3 Receptors in Guinea Pig Hearts

Haloperidol is a neuroleptic drug used for a medication of various psychoses and deliria. Its administration is frequently accompanied by cardiovascular side effects, expressed as QT interval prolongation and occurrence of even lethal arrhythmias. Despite these side effects, haloperidol is still prescribed in Europe in clinical practice. Haloperidol binds to sigma receptors that are coupled with inositol 1,4,5-trisphosphate (IP3) receptors. Sigma receptors are expressed in various tissues, including heart muscle, and they modulate potassium channels. Together with IP3 receptors, sigma receptors are also involved in calcium handling in various tissues. Therefore, the present work aimed to study the effects of long-term haloperidol administration on the cardiac function. Haloperidol (2 mg/kg once a day) or vehiculum was administered by intraperitoneal injection to guinea pigs for 21 consecutive days. We measured the responsiveness of the hearts isolated from the haloperidol-treated animals to additional application of haloperidol. Expression of the sigma 1 receptor and IP3 receptors was studied by real time-PCR and immunohistochemical analyses. Haloperidol treatment caused the significant decrease in the relative heart rate and the prolongation of QT interval of the isolated hearts from the haloperidol-treated animals, compared to the hearts isolated from control animals. The expression of sigma 1 and IP3 type 1 and type 2 receptors was increased in both atria of the haloperidol-treated animals but not in ventricles. The modulation of sigma 1 and IP3 receptors may lead to altered calcium handling in cardiomyocytes and thus contribute to changed sensitivity of cardiac cells to arrhythmias.

Relating Spontaneously Reported Extrapyramidal Adverse Events to Movement Disorder Rating Scales

BACKGROUND

While antipsychotic-induced extrapyramidal symptoms (EPS) and akathisia remain important concerns in the treatment of patients with schizophrenia, the relationship between movement disorder rating scales and spontaneously reported EPS-related adverse events (EPS-AEs) remains unexplored.

METHODS

Data from four randomized, placebo- and haloperidol-controlled ziprasidone trials were analyzed to examine the relationship between spontaneously reported EPS-AEs with the Simpson Angus Scale (SAS) and Barnes Akathisia Rating Scale (BARS). Categorical summaries were created for each treatment group to show the frequencies of subjects with EPS-AEs in each of the SAS and BARS categories at weeks 1, 3, and 6, and agreement between ratings was quantified by means of weighted kappa (κ).

RESULTS

In general, we found greater frequencies of EPS-AEs with increasing severity of the SAS and BARS scores. The EPS-AEs reported with a "none" SAS score ranged from 0 to 22.2%, with a "mild" SAS score from 3.3 to 29.0%, and with a "moderate" SAS score from 0 to 100%. No subjects in any treatment group reported "severe" SAS scores or corresponding EPS-AEs. Agreement between SAS scores and EPS-AEs was poor for ziprasidone and placebo (κ < 0.2) and only slightly better for haloperidol. The EPS-AEs reported with "non questionable" BARS scores ranged from 1.9 to 9.8%, with "mild moderate" BARS scores from 12.8 to 54.6%, and with "marked severe" scores from 0 to 100%. Agreement was modest for ziprasidone and placebo (κ < 0.4) and moderate for haloperidol (κ < 0.6).

CONCLUSIONS

These findings may reflect either underreporting of AEs by investigators and subjects or erroneous rating scale evaluations.

[NON-RESPIRATORY FUNCTION OF THE LUNGS IN THE NIGROSTRIATAL DOPAMINERGIC SYSTEM DYSFUNCTION]

The study presents a comprehensive of the metabolism and the fractional composition of li- pids surfactant, water balance, hemostatic activity of the lungs in neyrodegeneration substantia nigra of the brain induced by stereotaxic microinjection of 6--hydroxydopamine and systemic administration of haloperidol. It is shown that a breach of dopaminergic neurotransmission leads to deterioration of surface-active properties of the alveolar lining of the complex against a decrea- se of phospholipids, cholesterol, phosphatidylcholine and lysophospholipids enhance the pulmo- nary surfactant in the activation of phospholipase hydrolysis and lipid peroxidation. Intranigral introduction neurotoxin accompanied by increased blood supply to the lungs and the blood coagu- lation potential of the pulmonary circulation, the blockade D2-receptors--hyporhydration lung tissue. The results obtained indicate the formation of dysregulation pneumopathy dysfunction nigrostriatal dopaminergic system.

Divergent long-term consequences of chronic treatment with haloperidol, risperidone, and bromocriptine on traumatic brain injury-induced cognitive deficits

Antipsychotic drugs (APDs) are provided in the clinic to manage traumatic brain injury (TBI)-induced agitation and aggression. Experimental TBI studies consistently show that daily administration of the APDs, haloperidol (HAL) and risperidone (RISP), hinder recovery. However, it is unknown how long the adverse effects remain after cessation of treatment. To elucidate this clinically relevant issue, anesthetized male rats were randomly assigned to four TBI (controlled cortical impact) and four sham groups administered HAL (0.5 mg/kg), RISP (0.45 mg/kg), bromocriptine (BRO; 5.0 mg/kg, included as a control for D2 receptor action), or vehicle (VEH; 1 mL/kg) 24 h after surgery and once-daily for 19 days. Motor and cognitive recovery was assessed on days 1-5 and 14-19, respectively, and again at 1 and 3 months after drug withdrawal. No overall group differences were observed for motor function among the TBI groups, although the HAL group showed a greater beam-walk deficit on day 5 versus the VEH and BRO groups. Cognitive recovery was significantly impaired in the HAL and RISP groups during the treatment phase versus VEH and BRO. Further, BRO was superior to VEH (p=0.0042). At 1 month, both groups that received APDs continued to exhibit significant cognitive impairment versus VEH and BRO; at 3 months, only the HAL group was impaired. Moreover, the HAL, RISP, and VEH groups continued to be cognitively deficient versus BRO, which also reduced cortical damage. These data replicate previous reports that HAL and RISP impede cognitive recovery after TBI and expand the literature by revealing that the deleterious effects persist for 3 months after drug discontinuation. BRO conferred cognitive benefits when administered concomitantly with behavioral testing, thus replicating previous findings, and also after cessation demonstrating enduring efficacy.

Risk of ischemic stroke associated with the use of antipsychotic drugs in elderly patients: a retrospective cohort study in Korea

Objective

Strong concerns have been raised about whether the risk of ischemic stroke differs between conventional antipsychotics (CAPs) and atypical antipsychotics (AAPs). This study compared the risk of ischemic stroke in elderly patients taking CAPs and AAPs.

Method

We conducted a retrospective cohort study of 71,584 elderly patients who were newly prescribed the CAPs (haloperidol or chlorpromazine) and those prescribed the AAPs (risperidone, quetiapine, or olanzapine). We used the National Claims Database from the Health Insurance Review and Assessment Service (HIRA) from January 1, 2006 to December 31, 2009. Incident cases for ischemic stroke (ICD-10, I63) were identified. The hazard ratios (HR) for AAPs, CAPs, and for each antipsychotic were calculated using multivariable Cox regression models, with risperidone as a reference.

Results

Among a total of 71,584 patients, 24,668 patients were on risperidone, 15,860 patients on quetiapine, 3,888 patients on olanzapine, 19,564 patients on haloperidol, and 7,604 patients on chlorpromazine. A substantially higher risk was observed with chlorpromazine (HR = 3.47, 95% CI, 1.97–5.38), which was followed by haloperidol (HR = 2.43, 95% CI, 1.18–3.14), quetiapine (HR = 1.23, 95% CI, 0.78–2.12), and olanzapine (HR = 1.12, 95% CI, 0.59–2.75). Patients who were prescribed chlorpromazine for longer than 150 days showed a higher risk (HR = 3.60, 95% CI, 1.83–6.02) than those who took it for a shorter period of time.

Conclusions

A much greater risk of ischemic stroke was observed in patients who used chlorpromazine and haloperidol compared to risperidone. The evidence suggested that there is a strong need to exercise caution while prescribing these agents to the elderly in light of severe adverse events with atypical antipsychotics.

Haloperidol versus first-generation antipsychotics for the treatment of schizophrenia and other psychotic disorders

BACKGROUND

Haloperidol is worldwide one of the most frequently used antipsychotic drugs with a very high market share. Previous narrative, unsystematic reviews found no differences in terms of efficacy between the various first-generation ("conventional", "typical") antipsychotic agents. This established the unproven psychopharmacological assumption of a comparable efficacy between the first-generation antipsychotic compounds codified in textbooks and treatment guidelines. Because this assumption contrasts with the clinical impression, a high-quality systematic review appeared highly necessary.

OBJECTIVES

To compare the efficacy, acceptability, and tolerability of haloperidol with other first-generation antipsychotics in schizophrenia and schizophrenia-like psychosis.

SEARCH METHODS

In October 2011 and July 2012, we searched the Cochrane Schizophrenia Group's Trials Register, which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. To identify further relevant publications, we screened the references of all included studies and contacted the manufacturers of haloperidol for further relevant trials and missing information on identified studies. Furthermore, we contacted the corresponding authors of all included trials for missing data.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared oral haloperidol with another oral first-generation antipsychotic drug (with the exception of the low-potency antipsychotics chlorpromazine, chlorprothixene, levopromazine, mesoridazine, perazine, prochlorpromazine, and thioridazine) in schizophrenia and schizophrenia-like psychosis. Clinically important response to treatment was defined as the primary outcome. Secondary outcomes were global state, mental state, behaviour, overall acceptability (measured by the number of participants leaving the study early due to any reason), overall efficacy (attrition due to inefficacy of treatment), overall tolerability (attrition due to adverse events), and specific adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data from the included trials. The methodological quality of the included studies was assessed using The Cochrane Collaboration`s 'Risk of bias' tool.We analysed dichotomous outcomes with risk ratios (RR) and continuous outcomes with mean differences (MD), both with the associated 95% confidence intervals (CI). All analyses were based on a random-effects model and we preferably used data on an intention-to-treat basis where possible.

MAIN RESULTS

The systematic review currently includes 63 randomised trials with 3675 participants. Bromperidol (n = 9), loxapine (n = 7), and trifluoperazine (n = 6) were the most frequently administered antipsychotics comparator to haloperidol. The included studies were published between 1962 and 1993, were characterised by small sample sizes (mean: 58 participants, range from 18 to 206) and the predefined outcomes were often incompletely reported. All results for the main outcomes were based on very low or low quality data. In many trials the mechanism of randomisation, allocation, and blinding was frequently not reported. In short-term studies (up to 12 weeks), there was no clear evidence of a difference between haloperidol and the pooled group of the other first-generation antipsychotic agents in terms of the primary outcome "clinically important response to treatment" (40 RCTs, n = 2132, RR 0.93 CI 0.87 to 1.00). In the medium-term trials, haloperidol may be less effective than the other first-generation antipsychotic group but this evidence is based on only one trial (1 RCT, n = 80, RR 0.51 CI 0.37 to 0.69).Based on limited evidence, haloperidol alleviated more positive symptoms of schizophrenia than the other antipsychotic drugs. There were no statistically significant between-group differences in global state, other mental state outcomes, behaviour, leaving the study early due to any reason, due to inefficacy, as well as due to adverse effects. The only statistically significant difference in specific side effects was that haloperidol produced less akathisia in the medium term.

AUTHORS' CONCLUSIONS

The findings of the meta-analytic calculations support the statements of previous narrative, unsystematic reviews suggesting comparable efficacy of first-generation antipsychotics. In efficacy-related outcomes, there was no clear evidence of a difference between the prototypal drug haloperidol and other, mainly high-potency first-generation antipsychotics. Additionally, we demonstrated that haloperidol is characterised by a similar risk profile compared to the other first-generation antipsychotic compounds. The only statistically significant difference in specific side effects was that haloperidol produced less akathisia in the medium term. The results were limited by the low methodological quality in many of the included original studies. Data for the main results were low or very low quality. Therefore, future clinical trials with high methodological quality are required.

Comparative analysis of the treatment of chronic antipsychotic drugs on epileptic susceptibility in genetically epilepsy-prone rats

Antipsychotic drugs (APs) are of great benefit in several psychiatric disorders, but they can be associated with various adverse effects, including seizures. To investigate the effects of chronic antipsychotic treatment on seizure susceptibility in genetically epilepsy-prone rats, some APs were administered for 7 weeks, and seizure susceptibility (audiogenic seizures) was evaluated once a week during treatment and for 5 weeks after drug withdrawal. Furthermore, acute and subchronic (5-day treatment) effects were also measured. Rats received haloperidol (0.2-1.0 mg/kg), clozapine (1-5 mg/kg), risperidone (0.03-0.50 mg/kg), quetiapine (2-10 mg/kg), aripriprazole (0.2-1.0 mg/kg), and olanzapine (0.13-0.66 mg/kg), and tested according to treatment duration. Acute administration of APs had no effect on seizures, whereas, after regular treatment, aripiprazole reduced seizure severity; haloperidol had no effects and all other APs increased seizure severity. In chronically treated rats, clozapine showed the most marked proconvulsant effects, followed by risperidone and olanzapine. Quetiapine and haloperidol had only modest effects, and aripiprazole was anticonvulsant. Finally, the proconvulsant effects lasted at least 2-3 weeks after treatment suspension; for aripiprazole, a proconvulsant rebound effect was observed. Taken together, these results indicate and confirm that APs might have the potential to increase the severity of audiogenic seizures but that aripiprazole may exert anticonvulsant effects. The use of APs in patients, particularly in patients with epilepsy, should be monitored for seizure occurrence, including during the time after cessation of therapy. Further studies will determine whether aripiprazole really has a potential as an anticonvulsant drug and might also be clinically relevant for epileptic patients with psychiatric comorbidities.

[Comparison of sedation with dexmedetomidine and haloperidol in patients with delirium after femoral neck fractures]

Delirium seriously complicates the recovery period after surgery, injury and increases mortality in elderly patients with femoral fractures.

PATIENTS AND METHODS

We examined 80 geriatric patients admitted to the Institute of Traumatology and Orthopedics in Astana in the period from September 2012 to June 2014. We evaluated the efficacy of dexmedetomidine and haloperidol sedation according to RASS, communication ability and level of tolerance of procedures. The effect of dexmedetomidine was better and was expressed 30.3% decreasing of the duration of delirium in comparison with haloperidol (p < 0.05). Overall assessment of the ability of patients to the interaction, cooperation and tolerance of procedures evaluated by nurses, was higher in the dexmedetomidine group compared with haloperidol, as well as evaluating the effectiveness of individual communication and cooperation (8.3 ± 2.3 points vs 4.5 ± 1.9 points, p < 0.05). Despite the development of bradycardia in a small number of patients, as well as headaches and nausea after stopping the infusion, dexmedetomidine provided a more controlled and safe sedation compared with haloperidol.

A randomized trial of the effectiveness of topical "ABH Gel" (Ativan(®), Benadryl(®), Haldol(®)) vs. placebo in cancer patients with nausea

CONTEXT

The topical gel known as "ABH gel," comprising lorazepam (Ativan(®)), diphenhydramine (Benadryl(®)), and haloperidol (Haldol(®)), is frequently used to treat nausea because of its perceived efficacy, relatively low cost, and ease of use in the home setting. There are limited scientific data on this medication, however. Recent pilot studies showed no absorption of the active ingredients of the gel, prompting further prospective studies into the cause of the perceived efficacy in the clinical setting.

OBJECTIVES

To determine any difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea.

METHODS

A randomized, double-blind, placebo-controlled, crossover, noninferiority clinical trial was developed to test the hypothesis that there is no difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. The primary outcome was the difference in nausea score (on a 0-10 scale) at baseline and at 60 minutes in each treatment group. The difference in the ABH gel-treated group compared with placebo was evaluated for noninferiority. Secondary outcomes included the number of vomiting episodes and side effects over time.

RESULTS

The mean change in nausea score from baseline to 60 minutes after treatment in the ABH gel group was 1.7 ± 2.05 and 0.9 ± 2.45 for the placebo group (P = 0.42). The placebo group was found to be noninferior to the ABH gel group in reducing the nausea score. ABH gel also did not decrease vomiting events better than placebo (P = 0.34). Only one patient reported any side effects from the treatments in either arm of the study.

CONCLUSION

ABH gel in its current formulation should not be used in cancer patients experiencing nausea.

Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development

CONTEXT

Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context.

OBJECTIVES

To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development.

METHODS

We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium.

RESULTS

The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo.

CONCLUSION

Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.

Treatment of methamphetamine-induced psychosis: a double-blind randomized controlled trial comparing haloperidol and quetiapine

RATIONALE

To our knowledge, only a few double-blind randomized controlled trials with antipsychotic drugs have been conducted to examine the treatment of methamphetamine-induced psychosis (MAP).

OBJECTIVES

The aims of this study are to compare the antipsychotic and adverse events of quetiapine, an atypical antipsychotic drug, to haloperidol, a standard treatment for primary psychotic disorder, in individuals with MAP.

METHODS

Eighty individuals with MAP were randomly assigned into two groups, i.e. treatment with quetiapine (n = 36) and haloperidol (n = 44). Sixty-eight patients (85 %) completed the study protocol, i.e. treatment with quetiapine at least 100 mg per day or haloperidol at least 2 mg per day orally once a day for 4 weeks. The doses were increased every 5 days until no psychotic symptom was observed from the Positive and Negative Syndrome Scale (PANSS). Data were analysed by survival analysis with Cox's proportional regression analysis, general estimating equations and log-rank tests.

RESULTS

Thirty-two (89 %) subjects from the quetiapine group and 37 subjects (84 %) from the haloperidol group met the remission criteria at the end of the study. Baseline PANSS total scores of quetiapine and haloperidol groups were 82.4 ± 16.6 and 90.0 ± 18.4, respectively (mean ± SD; p = 0.06). The change-from-baseline scores were -47.8 for the quetiapine group and -53.2 for the haloperidol group. There were no significant differences between the antipsychotic effects (coefficient value = -2.6, p = 0.32, 95%CI = -7.6, 2.5) and the adverse effects of quetiapine and haloperidol.

CONCLUSIONS

Quetiapine may be used as an antipsychotic treatment for MAP with comparable therapeutic effects and adverse events to treatment with classical antipsychotic drugs.

Haloperidol versus low-potency first-generation antipsychotic drugs for schizophrenia

BACKGROUND

Antipsychotic drugs are the core treatment for schizophrenia. Treatment guidelines state that there is no difference in efficacy between antipsychotic compounds, however, low-potency antipsychotic drugs are often clinically perceived as less efficacious than high-potency compounds, and they also seem to differ in their side-effects.

OBJECTIVES

To review the effects in clinical response of haloperidol and low-potency antipsychotics for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (July 2010).

SELECTION CRITERIA

We included all randomised trials comparing haloperidol with first-generation low-potency antipsychotic drugs for people with schizophrenia or schizophrenia-like psychosis.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data, we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD), again based on a random-effects model.

MAIN RESULTS

The review currently includes 17 randomised trials and 877 participants. The size of the included studies was between 16 and 109 participants. All studies were short-term with a study length between two and 12 weeks. Overall, sequence generation, allocation procedures and blinding were poorly reported. We found no clear evidence that haloperidol was superior to low-potency antipsychotic drugs in terms of clinical response (haloperidol 40%, low-potency drug 36%, 14 RCTs, n = 574, RR 1.11, CI 0.86 to 1.44 lowquality evidence). There was also no clear evidence of benefit for either group in acceptability of treatment with equivocal difference in the number of participants leaving the studies early due to any reason (haloperidol 13%, low-potency antipsychotics 17%, 11 RCTs, n = 408, RR 0.82, CI 0.38 to 1.77, low quality evidence). Similar equivocal results were found between groups for experiencing at least one adverse effect (haloperidol 70%, low-potency antipsychotics 35%, 5 RCTs n = 158, RR 1.97, CI 0.69 to 5.66, very low quality evidence ). More participants from the low-potency drug group experienced sedation (haloperidol 14%, low-potency antipsychotics 41%, 2 RCTs, n = 44, RR 0.30, CI 0.11 to 0.82, moderate quality evidence), orthostasis problems (haloperidol 25%, low-potency antipsychotics 71%, 1 RCT, n = 41, RR 0.35, CI 0.16 to 0.78) and weight gain (haloperidol 5%, low-potency antipsychotics 29%, 3 RCTs, n = 88, RR 0.22, CI 0.06 to 0.81). In contrast, the outcome 'at least one movement disorder' was more frequent in the haloperidol group (haloperidol 72%, low-potency antipsychotics 41%, 5 RCTs, n = 170, RR 1.64, CI 1.22 to 2.21, low quality evidence). No data were available for death or quality of life. The results of the primary outcome were robust in several subgroup and sensitivity analyses.

AUTHORS' CONCLUSIONS

The results do not clearly show a superiority in efficacy of haloperidol compared with low-potency antipsychotics. Differences in adverse events were found for movement disorders, which were more frequent in the haloperidol group, and orthostatic problems, sedation and weight gain, which were more frequent in the low-potency antipsychotic group. The quality of studies was low, and the quality of evidence for the main outcomes of interest varied from moderate to very low, so more newer studies would be needed in order to draw a definite conclusion about whether or not haloperidol is superior or inferior to low-potency antipsychotics.

Effectiveness of paliperidone palmitate vs haloperidol decanoate for maintenance treatment of schizophrenia: a randomized clinical trial

IMPORTANCE

Long-acting injectable antipsychotics are used to reduce medication nonadherence and relapse in schizophrenia-spectrum disorders. The relative effectiveness of long-acting injectable versions of second-generation and older antipsychotics has not been assessed.

OBJECTIVE

To compare the effectiveness of the second-generation long-acting injectable antipsychotic paliperidone palmitate with the older long-acting injectable antipsychotic haloperidol decanoate.

DESIGN, SETTING, AND PARTICIPANTS

Multisite, double-blind, randomized clinical trial conducted from March 2011 to July 2013 at 22 US clinical research sites. Randomized patients (n = 311) were adults diagnosed with schizophrenia or schizoaffective disorder who were clinically assessed to be at risk of relapse and likely to benefit from a long-acting injectable antipsychotic.

INTERVENTIONS

Intramuscular injections of haloperidol decanoate 25 to 200 mg or paliperidone palmitate 39 to 234 mg every month for as long as 24 months.

MAIN OUTCOME MEASURES

Efficacy failure, defined as a psychiatric hospitalization, a need for crisis stabilization, a substantial increase in frequency of outpatient visits, a clinician's decision that oral antipsychotic could not be discontinued within 8 weeks after starting the long-acting injectable antipsychotics, or a clinician's decision to discontinue the assigned long-acting injectable due to inadequate therapeutic benefit. Key secondary outcomes were common adverse effects of antipsychotic medications.

RESULTS

There was no statistically significant difference in the rate of efficacy failure for paliperidone palmitate compared with haloperidol decanoate (adjusted hazard ratio, 0.98; 95% CI, 0.65-1.47). The number of participants who experienced efficacy failure was 49 (33.8%) in the paliperidone palmitate group and 47 (32.4%) in the haloperidol decanoate group. On average, participants in the paliperidone palmitate group gained weight and those in the haloperidol decanoate group lost weight; after 6 months, the least-squares mean weight change for those taking paliperidone palmitate was increased by 2.17 kg (95% CI, 1.25-3.09) and was decreased for those taking haloperidol decanoate (-0.96 kg; 95% CI, -1.88 to -0.04). Patients taking paliperidone palmitate had significantly higher maximum mean levels of serum prolactin (men, 34.56 µg/L [95% CI, 29.75-39.37] vs 15.41 µg/L [95% CI, 10.73-20.08]; P <.001, and for women, 75.19 [95% CI, 63.03-87.36] vs 26.84 [95% CI, 13.29-40.40]; P<.001). Patients taking haloperidol decanoate had significantly larger increases in global ratings of akathisia (0.73 [95% CI, 0.59-0.87] vs 0.45 [95% CI, 0.31-0.59]; P=.006).

CONCLUSIONS AND RELEVANCE

In adults with schizophrenia or schizoaffective disorder, use of paliperidone palmitate vs haloperidol decanoate did not result in a statistically significant difference in efficacy failure, but was associated with more weight gain and greater increases in serum prolactin, whereas haloperidol decanoate was associated with more akathisia. However, the CIs do not rule out the possibility of a clinically meaningful advantage with paliperidone palmitate.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01136772.

[Treatment of delirium in the early postoperative period after cardiac surgery]

OBJECTIVE

To assess efficacy and safety of dexmedetomidine for treatment of delirium in cardiac surgery.

METHODS

We performed an open, prospective comparative study in 60 patients, who received surgery on the heart or major vessels under general anaesthesia. In the early postoperative period, all patients suffered from delirium. All patients were divided into two groups. The patients in group-I (30 patients) received dexmedetomidine (0.2-1.4 mcg/kg/ hour), 20 of them received dexmedetomidine only and 10 received a combination of dexmedetomidine with haloperidol and midazolam. Patients in group-2 received haloperidol 5 mg 3 times a day intramuscularly and 0.1 mg/kg intravenously separately and in combination with benzodiazepines (midazolam, relanium). All patients received analgesia with ketoprofen 100 mg each 12 hours and trimeperidin 20 mg intramuscularly.

RESULTS

In 67% of all patients the symptoms of delirium occurred on the 1st or 2nd day after surgery. A hyperactive type of delirium dominated (> 77%). The average lasting time of delirium was 26.5 hours in group-I and 36.3 hours in group-2 (p = 0.001). Spontaneous breathing occurred in 26 patients (87%) out of group-I and in 18 patients (60%) out of group-2 (p = 0.04). The duration of stay in the ICU was 2.73 days in group-I and 3.5 days in group-2 (p = 0.04). Dexmedetomidine provided an average target level of sedation better according to RASS-scale (p = 0.001). 10 patients (33%) of group-I and 12 patients (40%) of group-2 received opioids (p = 0.8). Bradycardia as a side effect predominated in group-I (p = 0.01). Respiratory depression predominated in group-I (p = 0.005).

CONCLUSIONS

Dexmedetomidine provides an average target level of sedation, decreases duration of delirium and duration of stay in the ICU. Dexmedetomidine does not cause depression of respiration which allows keeping a verbal contact with patients and improving a diagnostics of pain syndrome. The most common side effect of the dexmedetomidine use is a dose-depending bradycardia.

Short- and long-term mortality risk associated with the use of antipsychotics among 26,940 dementia outpatients: a population-based study

OBJECTIVE

To investigate short- and long-term mortality risk associated with the use of antipsychotics in dementia outpatients, assessing the risk over specific time frames and quantifying the risk by the individual antipsychotics.

METHODS

This population-based study used data from the Norwegian Prescription Database. The study sample included 26,940 dementia outpatients aged 65 years or older prescribed antidementia drugs and psychotropics from Norwegian pharmacies between 2004 and 2010.

RESULTS

Cox survival analyses, adjusted for age, gender, mean daily defined dose, and severe medical conditions, showed that antipsychotic use compared with other psychotropics involved approximately twice the mortality risk in outpatients with dementia. Furthermore, these results are consistent for all investigated time points after first dispensing the drugs (hazard ratio [HR]30 days = 2.1 [95% confidence interval {CI}: 1.6-2.9] to HR 730-2,400 days = 1.7 [95% CI: 1.6-1.9]). Haloperidol was associated with higher mortality risk (HR 30 days = 1.7 [95% CI: 1.0-3.0] to HR 730-2,400 days = 1.4 [95% CI: 1.0-1.9]) than risperidone.

CONCLUSION

This first study to observe antipsychotic use and mortality in dementia outpatients over more than 6 years clearly shows that antipsychotics involve increased short- and long-term mortality risk. Physicians may justly consider antipsychotics to be the best option for some dementia patients among available nonpharmacologic and pharmacologic treatments. However, although causal conclusions are precluded due to limited adjustments in the analyses, the findings support the current treatment recommendations that antipsychotics should be avoided or used with great caution.

[QTc prolongation induced by intravenous sedation with Haloperidol, Prothipendyl and Lorazepam]

OBJECTIVE

Specific sedation of acute psychotic patients with iv Haloperidol has been repeatedly criticized due to its cardiac risk on the basis of QTc prolongation, cumulating in the fact that iv application is no longer recommended according to the producer. Since Haloperidol still provides the only iv formulation of a high potency neuroleptic medication, and iv application offers some crucial advantages over other forms of application, we wanted to objectify QTc prolongation of Haloperidol iv as well as QTc prolongation of Prothipendyl iv, a low potency neuroleptic medication for unspecific sedation.

METHODS

In our department all treatments with Haloperidol and Prothipendyl iv are ECG monitored and documented following an appointed guideline. Over 3 years all treatments according to this scheme and additionally treatments with Lorazepam iv have been analyzed regarding QTc prolongation. Non-parametric tests have been applied due to missing normal distribution of the data.

RESULTS

99 patients have been included in the survey. According to the iv medication applied patients have been divided into different subgroups. A significant QTc prolongation compared to the Lorazepam control group could be seen in the Haloperidol/Prothipendyl combination group as well as in the Prothipendyl monotherapy group, but not in the haloperidol monotherapy group. When patients were included, who additionally had received Lorazepam, results did not differ essentially with the exception that the Haloperidol/Prothipendyl combination had a significant greater prolongation than the Haloperidol group.

CONCLUSIONS

Our data proves the well known fact that Haloperidol iv causes a pronounced QTc prolongation. However QTc prolongation by iv Prothipendyl is still more pronounced according to our data. Most potent in producing a QTc prolongation proved a combination of Prothipendyl and Haloperidol, a fact that most likely depicts a dose effect. Since we assume, that there will be continuing need for iv medication with Haloperidol and Prothipendyl in the future, due to lack of arguable alternatives, we recommend safety measures like ECG monitoring not only for Haloperidol, but too for unspecific sedation with iv Prothipendyl.

Medication fall risk in old hospitalized patients: a retrospective study

BACKGROUND

While the causes of falls in old hospitalized patients are multifactorial, medication has been considered as one of the most significant factors. Given the large impact that this phenomenon has on the lives of the elderly and organizations, it is important to explore such phenomenon in greater depth.

OBJECTIVE

The objective of this study was to explore the association between medication and falls and the recurrent falls (n≥2), and identify medication related risk for fall in hospitalized patients, in a large acute hospital.

DESIGN

Retrospective and quantitative study from June 2008 to December 2010.

SETTING

The study was conducted in a private hospital for acute patients in Lisbon, Portugal.

PARTICIPANTS

The study included a sample of 214 episodes of fall event notifications which occurred in 193 patients.

METHODS

The current study was conducted through the "face to face consensus" technique which emerged the treatment groups to investigate. Regarding the data analysis we used Student's t test, ANOVA and Odds Ratio. In the violation of the premises for the use of parametric statistics we used the Kruskal-Wallis test. To assess the fall risk, and the medication-related fall risk, we used the Morse Fall Risk Scale, and the Medication Fall Risk Score.

RESULTS

Patients who received drugs from the therapy group of "Central Nervous System", are 10 times more likely to have fall risk (OR 9. 90, 95% CI 1.6-60.63). Association was found between falls (OR 6.09, 95% CI 1.30-28.54) and its recurrence (OR 3.32, 95% CI 1.61-6.85), among patients receiving haloperidol and receiving tramadol for recurrent falls (OR 3.10, 95% CI 1.59-6.07). In 34% of the patients the medication fall risk score was 6 or higher.

CONCLUSIONS

This current study allowed identifying medication-related risk factors for falls, that nurses should consider when prescribing interventions to prevent falls and its recurrence, when patients are admitted to acute care hospitals.

Comparison of droperidol and haloperidol for use by paramedics: assessment of safety and effectiveness

BACKGROUND

Since the 2001 "black box" warning on droperidol, its use in the prehospital setting has decreased substantially in favor of haloperidol. There are no studies comparing the prehospital use of either drug. The goal of this study was to compare QTc prolongation, adverse events, and effectiveness of droperidol and haloperidol among a cohort of agitated patients in the prehospital setting.

METHODS

In this institutional review board-approved before and after study, we collected data on 532 patients receiving haloperidol (n = 314) or droperidol (n = 218) between 2007 and 2010. We reviewed emergency department (ED) electrocardiograms when available (haloperidol, n = 78, 25%; droperidol, n = 178, 76%) for QTc length (in milliseconds), medical records for clinically relevant adverse events (defined a priori as systolic blood pressure (SBP) <90 mmHg, seizure, administration of anti-dysrhythmic medications, cardioversion or defibrillation, bag-valve-mask ventilation, intubation, cardiopulmonary arrest, and prehospital or in-hospital death). We also compared effectiveness of the medications, using administration of additional sedating medications within 30 minutes of ED arrival as a proxy for effectiveness.

RESULTS

The mean haloperidol dose was 7.9 mg (median 10 mg, range 4-20 mg). The mean droperidol dose was 2.9 mg (median 2.5 mg, range 1.25-10 mg.) Haloperidol was given i.m. in 289 cases (92%), and droperidol was given i.m. in 132 cases (61%); in all other cases, the medication was given i.v.. There was no statistically significant difference in median QTc after medication administration (haloperidol 447 ms, 95% CI: 440-454 ms; droperidol 454 ms, 95% CI: 450-457). There were no statistically significant differences in adverse events in the droperidol group as compared to the haloperidol group. One patient in the droperidol group with a history of congenital heart disease suffered a cardiopulmonary arrest and was resuscitated with neurologically intact survival. There was no significant difference in the use of additional sedating medications within 30 minutes of ED arrival after receiving droperidol (2.9%, 95% CI: -2.5-8.4%).

CONCLUSIONS

In this cohort of agitated patients treated with haloperidol or droperidol in the prehospital setting, there was no significant difference found in QTc prolongation, adverse events, or need for repeat sedation between haloperidol and droperidol.

Genetics of adverse reactions to haloperidol in a mouse diallel: a drug-placebo experiment and Bayesian causal analysis

Haloperidol is an efficacious antipsychotic drug that has serious, unpredictable motor side effects that limit its utility and cause noncompliance in many patients. Using a drug-placebo diallel of the eight founder strains of the Collaborative Cross and their F1 hybrids, we characterized aggregate effects of genetics, sex, parent of origin, and their combinations on haloperidol response. Treating matched pairs of both sexes with drug or placebo, we measured changes in the following: open field activity, inclined screen rigidity, orofacial movements, prepulse inhibition of the acoustic startle response, plasma and brain drug level measurements, and body weight. To understand the genetic architecture of haloperidol response we introduce new statistical methodology linking heritable variation with causal effect of drug treatment. Our new estimators, "difference of models" and "multiple-impute matched pairs", are motivated by the Neyman-Rubin potential outcomes framework and extend our existing Bayesian hierarchical model for the diallel (Lenarcic et al. 2012). Drug-induced rigidity after chronic treatment was affected by mainly additive genetics and parent-of-origin effects (accounting for 28% and 14.8% of the variance), with NZO/HILtJ and 129S1/SvlmJ contributions tending to increase this side effect. Locomotor activity after acute treatment, by contrast, was more affected by strain-specific inbreeding (12.8%). In addition to drug response phenotypes, we examined diallel effects on behavior before treatment and found not only effects of additive genetics (10.2-53.2%) but also strong effects of epistasis (10.64-25.2%). In particular: prepulse inhibition showed additivity and epistasis in about equal proportions (26.1% and 23.7%); there was evidence of nonreciprocal epistasis in pretreatment activity and rigidity; and we estimated a range of effects on body weight that replicate those found in our previous work. Our results provide the first quantitative description of the genetic architecture of haloperidol response in mice and indicate that additive, dominance-like inbreeding and parent-of-origin effects contribute strongly to treatment effect heterogeneity for this drug.