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Khalid J, Aparasu RR. Adverse effects associated with antipsychotic use in older adults. Expert Opin Drug Saf 2024:1-15. [PMID: 39076106 DOI: 10.1080/14740338.2024.2386377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 06/17/2024] [Accepted: 07/16/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION Antipsychotic (AP) medications are extensively utilized for diverse psychiatric and non-psychiatric conditions, but they are associated with significant adverse effects in older adults. This expert opinion review provides an updated profile of adverse effects associated with AP medications in older adults. AREAS COVERED This review specifically examines real-world evidence for adverse events associated with AP use, including all-cause mortality, falls and fractures, diabetes, cardiovascular and cerebrovascular events, acute kidney injury, venous thromboembolism/pulmonary embolism, extrapyramidal symptoms, and infections based on real-world evidence. EXPERT OPINION This comprehensive safety review of AP revealed multiple adverse events in older adults. All-cause mortality, more associated with typical APs than atypicals, underscores a dose-dependent risk, urging cautious prescribing practices and avoidance of typical APs. Falls/fractures associated with atypical APs highlight the importance of judicious dosing and -close monitoring, especially after initiation. Cardiovascular risks, particularly stroke, with AP use emphasize the need for vigilant monitoring. Extrapyramidal symptoms, more linked to typical APs, also pose a significant risk in older adults. Pneumonia and pulmonary embolism/venous thromboembolism demand cautious consideration of APs, prompting the need for additional real-world studies to inform clinical practice. Conflicting evidence on diabetes and acute kidney injury necessitates ongoing studies and further research in older adults.
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Affiliation(s)
- Javeria Khalid
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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Perreault S, Boivin Proulx LA, Brouillette J, Jarry S, Dorais M. Antipsychotics and Risks of Cardiovascular and Cerebrovascular Diseases and Mortality in Dwelling Community Older Adults. Pharmaceuticals (Basel) 2024; 17:178. [PMID: 38399393 PMCID: PMC10892683 DOI: 10.3390/ph17020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
This study aims to investigate the effect of antipsychotic agents on cardiovascular and cerebrovascular diseases (CVD/CEV) and mortality risks in the older population living in a community. A cohort of 42,650 new users of antipsychotic agents was built using Quebec healthcare databases (1998-2011). The outcomes were CVD/CEV and mortality incidence in 5 years of follow-up in the total cohort, sub-cohort of patients with no schizophrenia/dementia, sub-cohort with schizophrenia, and sub-cohort with dementia. Comparisons were made between the new users who continued the treatment (adherent level ≥ 60%) vs. those ceasing treatment (adherence level < 60%) using inverse probability of treatment weighting and Cox models. Comparing high adherence vs. low levels, CVD/CEV risk was increased by 36% in the sub-cohort with schizophrenia for atypical antipsychotic users and by 25% in the sub-cohort with dementia for typical antipsychotic users. An increasing mortality risk of 2- to 3-fold was linked with the typical antipsychotic use in all cohorts except the sub-cohort with schizophrenia; in addition, mortality risk is linked with the use of high vs. low doses. Antipsychotics were not linked with CVD/CEV risk, except for atypical antipsychotics in patients with schizophrenia and typical antipsychotics in patients with dementia. The mortality risk was linked with the use of typical antipsychotics and the dose used.
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Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3C 3J7, Canada
- Centre de Recherche en Santé Publique (CReSP), Partenaire CIUSSS du Centre-Sud-de-l’Île-de-Montréal et l’Université de Montréal, Montreal, QC H3L 1M3, Canada
| | - Laurie-Anne Boivin Proulx
- Department of Cardiology, Faculty of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Judith Brouillette
- Department of Psychiatry and Addictology, Université de Montréal, Montreal, QC H3L 1M3, Canada;
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC H3L 1M3, Canada;
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l’Île-Perrot, QC H3L 1M3, Canada;
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Crisafulli S, Khan Z, Karatas Y, Tuccori M, Trifirò G. An overview of methodological flaws of real-world studies investigating drug safety in the post-marketing setting. Expert Opin Drug Saf 2023; 22:373-380. [PMID: 37243676 DOI: 10.1080/14740338.2023.2219892] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/07/2023] [Accepted: 05/26/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION The evaluation of the post-marketing safety profile of drugs is a continuous monitoring process for approved and marketed medicines and it is crucial for detecting new adverse drug reactions. As such, real-world studies are essential to complement pre-marketing evidence with information concerning drug risk-benefit profile and use in wider patient populations and they have a great potential to support post-marketing drug safety evaluations. AREAS COVERED A detailed description of the main limitations of real-world data sources (i.e. claims databases, electronic healthcare records, drug/disease registers and spontaneous reporting system databases) and of the main methodological challenges of real-world studies in generating real-world evidence is provided. EXPERT OPINION Real-world evidence biases can be ascribed to both the methodological approach and the specific limitations of the different real-world data sources used to carry out the study. As such, it is crucial to characterize the quality of real-world data, by establishing guidelines and best practices for the assessment of data fitness for purpose. On the other hand, it is important that real-world studies are conducted using a rigorous methodology, aimed at minimizing the risk of bias.
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Affiliation(s)
| | - Zakir Khan
- Faculty of Medicines, Department of Medical Pharmacology Çukurova University, Sarıçam, Adana, Türkiye
| | - Yusuf Karatas
- Faculty of Medicines, Department of Medical Pharmacology Çukurova University, Sarıçam, Adana, Türkiye
- Pharmacovigilance Specialist, Faculty of Medicines, Balcali Hospital, Sarıçam, Adana, Türkiye
| | - Marco Tuccori
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Unit of Adverse Drug Reaction Monitoring, University Hospital of Pisa, Pisa, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Luo Y, Jiang Y, Xu H, Lyu H, Zhang L, Yin P, Tang P. Risk of post-operative cardiovascular event in elderly patients with pre-existing cardiovascular disease who are undergoing hip fracture surgery. INTERNATIONAL ORTHOPAEDICS 2021; 45:3045-3053. [PMID: 34643797 PMCID: PMC8626362 DOI: 10.1007/s00264-021-05227-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/23/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the association between pre-existing cardiovascular disease (CVD) and the risk of developing post-operative cardiovascular event among elderly patients who underwent hip fracture surgery. METHODS We performed an observational study among patients with acute hip fracture aged at least 65 years and who received surgical intervention. Hip fracture patients with pre-existing CVD were matched for age, gender, fracture type, and year of admission with patients without pre-existing CVD. The primary endpoint was post-operative cardiovascular events, and patients were followed until discharge from hospital. Conditional logistic regression was used to determine the association between pre-existing CVD and post-operative cardiovascular event after adjusting for potential confounders including age, body mass index, time from fracture to surgery, pre-existing comorbidities, and the Charlson Comorbidity Index (CCI). RESULTS The study matched 858 pairs of patients with and without pre-existing CVD. Post-operative cardiovascular events developed in 40 and 14 patients with and without pre-existing CVD (44.6 versus 16.3 per 1000 persons), respectively. Compared to patients without pre-existing CVD, patients with any pre-existing CVD were more likely to develop post-operative cardiovascular events, with a crude odds ratio (OR) of 2.857 [95% confidence interval (CI), 1.554 to 5.251] and multivariable adjusted OR of 2.850 (95% CI, 1.318 to 7.139), respectively. CONCLUSION In elderly patients who received hip fracture surgery, patients with pre-existing CVD are at a higher risk of developing post-operative cardiovascular events. Appropriate screening for this vulnerable population is recommended to prevent the risk of post-operative complications.
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Affiliation(s)
- Yan Luo
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
- National Clinical Research Centre for Orthopaedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Yu Jiang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
| | - Hongli Xu
- Medical Big Data Research Centre, Chinese PLA General Hospital, Beijing, China
| | - Houchen Lyu
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
| | - Pengbin Yin
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China.
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, China
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Mueller C, John C, Perera G, Aarsland D, Ballard C, Stewart R. Antipsychotic use in dementia: the relationship between neuropsychiatric symptom profiles and adverse outcomes. Eur J Epidemiol 2021; 36:89-101. [PMID: 32415541 PMCID: PMC7847435 DOI: 10.1007/s10654-020-00643-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/02/2020] [Indexed: 12/29/2022]
Abstract
Antipsychotic treatments are associated with safety concerns in people with dementia. The authors aimed to investigate whether risk of adverse outcomes related to antipsychotic prescribing differed according to major neuropsychiatric syndromes-specifically psychosis, agitation, or a combination. A cohort of 10,106 patients with a diagnosis of dementia was assembled from a large dementia care database in South East London. Neuropsychiatric symptoms closest to first dementia diagnosis were determined according to the Health of the Nation Outcome Scales' mental and behavioural problem scores and the sample was divided into four groups: 'agitation and psychosis', 'agitation, but no psychosis', 'psychosis, but no agitation', and 'neither psychosis nor agitation'. Antipsychotic prescription in a one-year window around first dementia diagnosis was ascertained as exposure variable through natural language processing from free text. Cox regression models were used to analyse associations of antipsychotic prescription with all-cause and stroke-specific mortality, emergency hospitalisation and hospitalised stroke adjusting for sixteen potential confounders including demographics, cognition, functioning, as well as physical and mental health. Only in the group 'psychosis, but no agitation' (n = 579), 30% of whom were prescribed an antipsychotic, a significant antipsychotic-associated increased risk of hospitalised stroke was present after adjustment (adjusted hazard ratio (HR) 2.16; 95% confidence interval (CI) 1.09-4.25). An increased antipsychotic-related all-cause (adjusted HR 1.14; 95% CI 1.04-1.24) and stroke-specific mortality risk (adjusted HR 1.28; 95% CI 1.01-1.63) was detected in the whole sample, but no interaction between the strata and antipsychotic-related mortality. In conclusion, the adverse effects of antipsychotics in dementia are complex. Stroke risk may be highest when used in patients presenting with psychosis without agitation, indicating the need for novel interventions for this group.
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Affiliation(s)
- Christoph Mueller
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - Christeena John
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
| | - Gayan Perera
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
| | - Dag Aarsland
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
- Stavanger University Hospital, Centre for Age-Related Disease, Stavanger, Norway
| | - Clive Ballard
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
- University of Exeter Medical School, Exeter, UK
| | - Robert Stewart
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Antidepressants and the Risk of Cardiovascular Events in Elderly Affected by Cardiovascular Disease: A Real-Life Investigation From Italy. J Clin Psychopharmacol 2020; 40:112-121. [PMID: 32134848 DOI: 10.1097/jcp.0000000000001189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to assess the possible relation between use of antidepressant (AD) drugs, that is, tricyclic ADs, selective serotonin reuptake inhibitors (SSRIs), and atypical ADs (AAs), and the risk of hospitalization for cardiovascular (CV) events among older patients with previous CV diseases. METHODS A nested case-control study was carried out among patients aged 65 years and older from 5 Italian health care territorial units who were discharged for CV disease during 2008 to 2010. The cohort was composed by 344,747 individuals, and of these, 97,739 (28%) experienced hospital admission for CV events (myocardial infarction, arrhythmia, stroke, heart failure) during follow-up (until 2014) and were included as cases. Up to 5 controls were randomly selected and matched to each. A conditional logistic regression was fitted to estimate the risk of CV events associated with ADs past or current use. A within-patient comparison was performed by the case-crossover design to account the effect of depression. FINDINGS Current users of SSRIs and AAs were at increased risk of CV events with odds ratios of 1.25 (95% confidence interval, 1.21-1.29) and 1.31 (1.25-1.37), respectively. An increased risk of arrhythmia and stroke was associated with current use of SSRIs and AAs, whereas an increased risk of heart failure was detected with current use of any ADs. The results were confirmed by the case-crossover approach. IMPLICATIONS Evidence that AD use is associated with an increased risk of CV events in accordance with specific mechanisms of action among older people with CV disease was added by this study.
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Gini R, Sturkenboom MCJ, Sultana J, Cave A, Landi A, Pacurariu A, Roberto G, Schink T, Candore G, Slattery J, Trifirò G. Different Strategies to Execute Multi-Database Studies for Medicines Surveillance in Real-World Setting: A Reflection on the European Model. Clin Pharmacol Ther 2020; 108:228-235. [PMID: 32243569 PMCID: PMC7484985 DOI: 10.1002/cpt.1833] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/13/2020] [Indexed: 12/18/2022]
Abstract
Although postmarketing studies conducted in population-based databases often contain information on patients in the order of millions, they can still be underpowered if outcomes or exposure of interest is rare, or the interest is in subgroup effects. Combining several databases might provide the statistical power needed. A multi-database study (MDS) uses at least two healthcare databases, which are not linked with each other at an individual person level, with analyses carried out in parallel across each database applying a common study protocol. Although many MDSs have been performed in Europe in the past 10 years, there is a lack of clarity on the peculiarities and implications of the existing strategies to conduct them. In this review, we identify four strategies to execute MDSs, classified according to specific choices in the execution: (A) local analyses, where data are extracted and analyzed locally, with programs developed by each site; (B) sharing of raw data, where raw data are locally extracted and transferred without analysis to a central partner, where all the data are pooled and analyzed; (C) use of a common data model with study-specific data, where study-specific data are locally extracted, loaded into a common data model, and processed locally with centrally developed programs; and (D) use of general common data model, where all local data are extracted and loaded into a common data model, prior to and independent of any study protocol, and protocols are incorporated in centrally developed programs that run locally. We illustrate differences between strategies and analyze potential implications.
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Affiliation(s)
- Rona Gini
- Agenzia regionale di sanità della ToscanaFlorenceItaly
| | | | | | - Alison Cave
- European Medicines AgencyAmsterdamThe Netherlands
| | - Annalisa Landi
- Fondazione per la Ricerca Farmacologica Gianni Benzi OnlusValenzanoItaly
- Teddy European Network of Excellence for Paediatric Clinical ResearchPaviaItaly
| | | | | | - Tania Schink
- Leibniz Institute for Prevention Research and EpidemiologyBremenGermany
| | | | - Jim Slattery
- European Medicines AgencyAmsterdamThe Netherlands
| | - Gianluca Trifirò
- Department of Biomedical and Dental Sciences and Morphofunctional ImagingUniversità di MessinaMessinaItaly
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