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Kim DH, Lee SB, Park CM, Levin R, Metzger E, Bateman BT, Ely EW, Pandharipande PP, Pisani MA, Jones RN, Marcantonio ER, Inouye SK. Comparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery : A Nationwide Cohort Study. Ann Intern Med 2023; 176:1153-1162. [PMID: 37665998 PMCID: PMC10625498 DOI: 10.7326/m22-3021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Antipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time. OBJECTIVE To compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery. DESIGN Retrospective cohort study. SETTING U.S. hospitals in the Premier Healthcare Database. PATIENTS 17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018. INTERVENTIONS Haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg). MEASUREMENTS The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting. RESULTS The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group. LIMITATION Residual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment. CONCLUSION These results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA
| | - Eran Metzger
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - E. Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Pratik P. Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI
| | - Edward R. Marcantonio
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Martinez FE, Tee R, Poulter AL, Jordan L, Bell L, Balogh ZJ. Delirium Screening and Pharmacotherapy in the ICU: The Patients Are Not the Only Ones Confused. J Clin Med 2023; 12:5671. [PMID: 37685738 PMCID: PMC10488395 DOI: 10.3390/jcm12175671] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Background: Delirium is difficult to measure in the Intensive Care Unit (ICU). It is possible that by considering the rate of screening, incidence, and rate of treatment with antipsychotic medications (APMs) for suspected delirium, a clearer picture can emerge. Methods: A retrospective, observational study was conducted at two ICUs in Australia, between April and June of 2020. All adult ICU patients were screened; those who spoke English and did not have previous neurocognitive pathology or intracranial pathology were included in the analysis. Data were collected from the hospitals' electronic medical records. The primary outcome was incidence of delirium based on the use of the Confusion Assessment Method for ICU (CAM-ICU). Secondary outcomes included measures of screening for delirium, treatment of suspected delirium with APMs, and identifying clinical factors associated with both delirium and the use of APMs. Results: From 736 patients that were screened, 665 were included in the analysis. The incidence of delirium was 11.3% (75/665); on average, the Richmond Agitation and Sedation Scale (RASS) was performed every 2.9 h and CAM-ICU every 40 h. RASS was not performed in 8.4% (56/665) of patients and CAM-ICU was not performed in 40.6% (270/665) of patients. A total of 17% (113/665) of patients were prescribed an APM, with quetiapine being the most used. ICU length of stay (LOS), APACHE-III score, and the use of alpha-2 agonists were associated with the presence of delirium, while ICU LOS, the use of alpha-2 agonists, and the presence of delirium were associated with patients receiving APMs. Conclusions: The incidence of delirium was lower than previously reported, at 11.3%. The rate of screening for delirium was low, while the use of APMs for delirium was higher than the incidence of delirium. It is possible that the true incidence is higher than what was measured. Critical prospective assessment is required to optimize APM indications in the ICU.
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Affiliation(s)
- F. Eduardo Martinez
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Rebecca Tee
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Amber-Louise Poulter
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Leah Jordan
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Liam Bell
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Zsolt J. Balogh
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
- Department of Traumatology, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW 2305, Australia
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Zhang Y, Wilkins JM, Bessette LG, York C, Wong V, Lin KJ. Antipsychotic Medication Use Among Older Adults Following Infection-Related Hospitalization. JAMA Netw Open 2023; 6:e230063. [PMID: 36800180 PMCID: PMC9938426 DOI: 10.1001/jamanetworkopen.2023.0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023] Open
Abstract
Importance There are limited data on discontinuation rates of antipsychotic medications (APMs) used to treat delirium due to acute hospitalization in the routine care of older adults. Objective To investigate discontinuation rates and patient characteristics of APMs used to treat delirium following infection-related hospitalization among older US adults. Design, Setting, and Participants This retrospective cohort study was conducted using US claims data (Optum's deidentified Clinformatics Data Mart database) for January 1, 2004, to May 31, 2022. Patients were aged 65 years or older without prior psychiatric disorders and had newly initiated an APM prescription within 30 days of an infection-related hospitalization. Statistical analysis was performed on December 15, 2022. Exposures New use (no prior use any time before cohort entry) of oral haloperidol and atypical APMs (aripiprazole, olanzapine, quetiapine, risperidone, etc). Main Outcomes and Measures The primary outcome was APM discontinuation, defined as a gap of more than 15 days following the end of an APM dispensing. Survival analyses and Kaplan-Meier analyses were used. Results Our study population included 5835 patients. Of these individuals, 790 (13.5%) were new haloperidol users (mean [SD] age, 81.5 [6.7] years; 422 women [53.4%]) and 5045 (86.5%) were new atypical APM users (mean [SD] age, 79.8 [7.0] years; 2636 women [52.2%]). The cumulative incidence of discontinuation by 30 days after initiation was 11.4% (95% CI, 10.4%-12.3%) among atypical APM users and 52.1% (95% CI, 48.2%-55.7%) among haloperidol users (P < .001 for difference between haloperidol vs atypical APMs). We observed an increasing trend in discontinuation rates from 2004 to 2022 (5% increase [95% CI, 3%-7%] per year) for haloperidol users (adjusted hazard ratio, 1.05 [1.03-1.07]; P < .001) but not for atypical APM users (1.00 [0.99-1.01]; P = .67). Prolonged hospitalization and dementia were inversely associated with the discontinuation of haloperidol and atypical APMs. Conclusions and Relevance The findings of this cohort study suggest that the discontinuation rate of newly initiated APMs for delirium following infection-related hospitalization was lower in atypical APM users than in haloperidol users, with prolonged hospitalization and dementia as major associated variables. The discontinuation rate was substantially higher in recent years for haloperidol but not for atypical APMs.
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Affiliation(s)
- Yichi Zhang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily Gui Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cassandra York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vincent Wong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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Ueda N, Igarashi M, Okuyama K, Sano H, Takahashi K, P Qureshi Z, Tokita S, Ogawa A, Okumura Y, Okuda S. Demographic and clinical characteristics of patients with delirium: analysis of a nationwide Japanese medical database. BMJ Open 2022; 12:e060630. [PMID: 36104137 PMCID: PMC9476131 DOI: 10.1136/bmjopen-2021-060630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Delirium commonly occurs during hospitalisation and is associated with increased mortality, especially in elderly patients. This study aimed to determine the demographic and clinical characteristics of patients with delirium in the Japanese real-world clinical setting using a nationwide database comprising claims and discharge abstract data. DESIGN This was an observational, cross-sectional, retrospective study in hospitalised patients with an incident delirium identified by a diagnosis based on International Classification of Diseases, 10th Revision codes or initiating antipsychotics recommended for delirium treatment in Japan during their hospitalisation. SETTING Patients from the Medical Data Vision database including more than 400 acute care hospitals in Japan were evaluated from admission to discharge. PARTICIPANTS Of the 32 910 227 patients who were included in the database between April 2012 and September 2020, a total of 145 219 patients met the criteria for delirium. PRIMARY AND SECONDARY OUTCOME MEASURES Demographic and baseline characteristics, comorbidities, clinical profiles and pharmacological treatments were evaluated in patients with delirium. RESULTS The mean (SD) patient age was 76.5 (13.8) years. More than half of the patients (n=82 159; 56.6%) were male. The most frequent comorbidities were circulatory system diseases, observed in 81 954 (56.4%) patients. Potentially inappropriate medications (PIMs) with risk of delirium including benzodiazepines and opioids were prescribed to 76 798 (52.9%) patients. Approximately three-fourths of these patients (56 949; 74.2%) were prescribed ≥4 PIMs. The most prescribed treatment for delirium was injectable haloperidol (n=82 490; 56.8%). Mean (SD) length of hospitalisation was 16.0 (12.1) days. CONCLUSIONS The study results provide comprehensive details of the clinical characteristics of patients with delirium and treatment patterns with antipsychotics in the Japanese acute care setting. In this patient population, the prescription rate of injectable haloperidol and PIMs was high, suggesting the need for improved understanding among healthcare providers about the appropriate management of delirium, which may benefit patients.
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Affiliation(s)
| | | | | | | | | | - Zaina P Qureshi
- Center for Observational and Real-world Evidence (CORE), Merck & Co, Inc, Rahway, New Jersey, USA
| | | | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Chiba, Japan
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Ritchie C, Walters RW, Ramaswamy S, Alla VM. Impact of delirium on mortality in patients hospitalized for heart failure. Int J Psychiatry Med 2022; 57:212-225. [PMID: 34176306 DOI: 10.1177/00912174211028019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs. METHODS We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts. RESULTS Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51-1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45-1.51), and hospital costs (RR: 1.44, 95% CI: 1.41-1.48) were all statistically higher in the presence of delirium (all p < 0.001). CONCLUSION In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.
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Affiliation(s)
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, 12282Creighton University School of Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Sriram Ramaswamy
- Department of Psychiatry, Creighton University School of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata M Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
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Lai FTT, Guthrie B, Mercer SW, Smith DJ, Yip BHK, Chung GKK, Lee KP, Chung RY, Chau PYK, Wong ELY, Yeoh EK, Wong SYS. Association between antipsychotic use and acute ischemic heart disease in women but not in men: a retrospective cohort study of over one million primary care patients. BMC Med 2020; 18:289. [PMID: 33131494 PMCID: PMC7604971 DOI: 10.1186/s12916-020-01765-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Research comparing sex differences in the effects of antipsychotic medications on acute ischemic heart disease (IHD) is limited and the findings ambiguous. This study aimed to investigate these associations within a primary care setting. METHODS Hong Kong public general outpatient electronic records of patients aged 45+ during 2007-2010 were extracted, with the last consultation date as the baseline for a 4-year follow-up period to observe acute IHD hospitalizations (2011-2014). Antipsychotic use was defined as any prescription over the previous 12 months from a list of 16 antipsychotics, while acute IHD was defined by ICD-9: 410.00-411.89. Both sex-specific and sex-combined (both sexes) mixed-effects Cox models (random intercept across 74 clinics) were implemented to examine the association and test the interaction between antipsychotics and sex. RESULTS Among 1,043,236 included patients, 17,780 (1.7%) were prescribed antipsychotics, and 8342 (0.8%) developed IHD. In sex-specific analyses, antipsychotic prescription was associated with a 32% increased hazard rate of acute IHD among women (95% CI 1.05-1.67) but not among men. A likelihood ratio test comparing sex-combined models with and without the interaction between antipsychotic use and sex suggested significant interaction (χ2 = 4.72, P = 0.030). The association between antipsychotic use and IHD among women attenuated and became non-significant when haloperidol was omitted from the operationalization of antipsychotic use (HR = 1.23, 95% CI 0.95-1.60). CONCLUSION Our results suggest that antipsychotic prescription is moderately associated with an increased risk of acute IHD among women in primary care and this relationship may be explained by specific antipsychotics. Further research should observe and capture the potential intermediary mechanisms and the dose-response relationship of this association to provide more rigorous evidence to establish causality and inform clinical practices.
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Affiliation(s)
- Francisco T T Lai
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Bruce Guthrie
- Usher Institute, The University of Edinburgh, Scotland, UK
| | | | - Daniel J Smith
- Institute of Health & Wellbeing, The University of Glasgow, Scotland, UK
| | - Benjamin H K Yip
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Gary K K Chung
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Kam-Pui Lee
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Roger Y Chung
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Patsy Y K Chau
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Eliza L Y Wong
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Eng-Kiong Yeoh
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China
| | - Samuel Y S Wong
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China.
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Basciotta M, Herzig SJ. Reply to Comment on: Antipsychotics and the Risk of Mortality or Cardiopulmonary Arrest in Hospitalized Adults. J Am Geriatr Soc 2020; 68:1881-1882. [PMID: 32462654 DOI: 10.1111/jgs.16546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Basciotta
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Hospital Medicine, North Shore Medical Center, Salem, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Sato I, Onishi H, Kawanishi C, Yamada S, Ishida M, Kawakami K. Neuroleptic malignant syndrome in patients with cancer: a systematic review. BMJ Support Palliat Care 2020; 10:265-270. [PMID: 32414787 DOI: 10.1136/bmjspcare-2020-002200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/07/2020] [Accepted: 04/20/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Antipsychotics potentially cause a low incidence of the side effect called neuroleptic malignant syndrome (NMS), which has a high mortality rate. However, few studies on NMS among patients with cancer exist. AIMS We aimed to examine the characteristics of antipsychotic-induced NMS among patients with cancer. METHODS We conducted a systematic review of published reports on NMS described during the treatment of patients with any type of cancer. Articles were identified by a comprehensive search of PubMed, Web of Science, the Cochrane Library and reference lists from relevant articles published until 25 December 2019. Original articles or case reports on humans published in English were included. This review summarises the symptoms, characteristics, treatment course and prognosis of patients with cancer with NMS. RESULTS Eleven patients with various cancer types from ten case reports published from 1988 to 2013 met the eligibility criteria. Mean age of the 11 patients was 52.5 (range, 32-83) years. NMS developed mostly during the postoperative period, and haloperidol and D2 receptor antagonists were determined as the common causative drugs. Ten patients survived following treatment that mostly involved discontinuing the causative drugs and administering dantrolene, if necessary. CONCLUSION Although NMS intrinsically has a low incidence and high mortality, only few reports were available, with most patients surviving after early detection and appropriate treatment. Healthcare providers should consider NMS development while prescribing antipsychotics to ensure prompt recognition of the condition and rapid treatment for preventing unnecessary deaths.
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Affiliation(s)
- Izumi Sato
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,The Keihanshin Consortium for Fostering the Next Generation of Global Leaders in Research (K-CONNEX), Kyoto, Japan
| | - Hideki Onishi
- Department of Psycho-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Chiaki Kawanishi
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Shuhei Yamada
- Department of Quality and Patient Safety Management, Chiba Cancer Center, Chiba, Japan
| | - Mayumi Ishida
- Department of Psycho-Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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Sattler SM, Lubberding AF, Kristensen CB, Møgelvang R, Blanche P, Fink-Jensen A, Engstrøm T, Kääb S, Jespersen T, Tfelt-Hansen J. Effect of the antipsychotic drug haloperidol on arrhythmias during acute myocardial infarction in a porcine model. IJC HEART & VASCULATURE 2020; 26:100455. [PMID: 32140549 PMCID: PMC7046512 DOI: 10.1016/j.ijcha.2019.100455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/27/2019] [Accepted: 12/12/2019] [Indexed: 11/23/2022]
Abstract
Patients receiving psychiatric medication, like the antipsychotic drug haloperidol, are at an increased risk of sudden cardiac death (SCD). Haloperidol blocks the cardiac rapidly-activating delayed rectifier potassium current, thereby increasing electrical dispersion of repolarization which can potentially lead to arrhythmias. Whether these patients are also at a higher risk to develop SCD during an acute myocardial infarction (AMI) is unknown. AMI locally shortens action potential duration, which might further increase repolarization dispersion and increase the risk of arrhythmia in the presence of haloperidol compared to without. Our aim was to test whether treatment with haloperidol implies an increased risk of SCD when eventually experiencing AMI. Twenty-eight female Danish Landrace pigs were randomized into three groups: low dose haloperidol (0.1 mg/kg), high dose (1.0 mg/kg) or vehicle-control group. One hour after haloperidol/vehicle infusion, AMI was induced by balloon-occlusion of the mid-left anterior descending coronary artery and maintained for 120 min, followed by 60 min of reperfusion. VF occurred during occlusion in 7/11 pigs in the control group, 3/11 in the low dose (p = 0.198) and 2/6 in the high dose group (p = 0.335). High dose haloperidol significantly prolonged QT, and reduced heart rate, vascular resistance and blood pressure before and during AMI. Premature ventricular contractions in phase 1b during AMI were reduced with high dose haloperidol. AMI-induced arrhythmia was not aggravated in pigs with haloperidol treatment. Our results do not suggest that AMI is contributing to the excess mortality in patients treated with antipsychotic drugs seen in epidemiological studies.
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Affiliation(s)
- Stefan M Sattler
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany
| | - Anniek F Lubberding
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte B Kristensen
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rasmus Møgelvang
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Paul Blanche
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Anders Fink-Jensen
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services - Capital Region of Denmark, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stefan Kääb
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany
| | - Thomas Jespersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Denmark
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Basciotta M, Zhou W, Ngo L, Donnino M, Marcantonio ER, Herzig SJ. Antipsychotics and the Risk of Mortality or Cardiopulmonary Arrest in Hospitalized Adults. J Am Geriatr Soc 2019; 68:544-550. [PMID: 31743435 DOI: 10.1111/jgs.16246] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 10/06/2019] [Accepted: 10/07/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Prior studies in outpatient and long-term care settings demonstrated increased risk for sudden death with typical and atypical antipsychotics. To date, no studies have investigated this association in a general hospitalized population. We sought to evaluate the risk of death or nonfatal cardiopulmonary arrest in hospitalized adults exposed to antipsychotics. DESIGN Retrospective cohort study. SETTING Large academic medical center in Boston, Massachusetts. PARTICIPANTS All hospitalizations between 2010 and 2016 were eligible for inclusion. We excluded those admitted directly to the intensive care unit (ICU), obstetric and gynecologic or psychiatric services, or with a diagnosis of a psychotic disorder. INTERVENTION Typical and atypical antipsychotic administration, defined by pharmacy charges. MEASUREMENTS The primary outcome was death or nonfatal cardiopulmonary arrest during hospitalization (composite). RESULTS Of 150 948 hospitalizations in our cohort, there were 691 total events (515 deaths, 176 cardiopulmonary arrests). After controlling for comorbidities, ICU time, demographics, admission type, and other medication exposures, typical antipsychotics were associated with the primary outcome (hazard ratio [HR] = 1.6; 95% confidence interval [CI] = 1.1-2.4; P = .02), whereas atypical antipsychotics were not (HR = 1.1; 95% CI = .8-1.4; P = .5). When focusing on adults age 65 years and older, however, both typical and atypical antipsychotics were associated with increased risk of death or cardiopulmonary arrest (HR = 1.8; 95% CI = 1.1-2.9; and HR = 1.4; 95% CI = 1.1-2.0, respectively). Sensitivity analyses using a propensity score approach and a cohort of only patients with delirium both yielded similar results. CONCLUSION In hospitalized adults, typical antipsychotics were associated with increased mortality or cardiopulmonary arrest, whereas atypical antipsychotics were only associated with increased risk among adults age 65 years and older. Providers should be thoughtful when prescribing antipsychotic medications, especially to older adults in settings where data regarding benefit are lacking. J Am Geriatr Soc 68:544-550, 2020.
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Affiliation(s)
- Matthew Basciotta
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Hospital Medicine, North Shore Medical Center, Salem, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Wenxiao Zhou
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Michael Donnino
- Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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11
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Pahwa AK, Qureshi I, Cumbler E. Things We Do For No Reason™: Use of Antipsychotic Medications in Patients with Delirium. J Hosp Med 2019; 14:565-567. [PMID: 30897059 DOI: 10.12788/jhm.3166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/23/2018] [Accepted: 01/07/2019] [Indexed: 01/24/2023]
Abstract
Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™" (TWDFNR™) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR™ series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.
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Affiliation(s)
- Amit K Pahwa
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Imran Qureshi
- Johns Hopkins Hospital Department of Pharmacy, Baltimore, Maryland
| | - Ethan Cumbler
- University of Colorado School of Medicine, Denver, Colorado
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12
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Bhattacharjee S, Patanwala AE, Lo-Ciganic WH, Malone DC, Lee JK, Knapp SM, Warholak T, Burke WJ. Alzheimer's disease medication and risk of all-cause mortality and all-cause hospitalization: A retrospective cohort study. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2019; 5:294-302. [PMID: 31338414 PMCID: PMC6626065 DOI: 10.1016/j.trci.2019.05.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Identifying Alzheimer's disease (AD) pharmacologic treatment options that effectively reduce the risk of mortality and hospitalization in real-world settings is critical. METHODS We compared donepezil, galantamine, memantine, oral rivastigmine, and transdermal rivastigmine with regard to all-cause mortality and all-cause hospitalization risk among fee-for-service Medicare beneficiaries with AD (aged ≥ 65 years) using a retrospective cohort study design. Our primary analysis was based on intention to treat (ITT), but we also present as-treated analysis. RESULTS In our final study sample (N = 21,558), significant difference in survival among index AD medication groups were observed with donepezil being associated with better survival than memantine, and oral and transdermal forms of rivastigmine for both ITT and as-treated analysis. Difference in hazards of all-cause hospitalization among index AD medication groups was observed in ITT analysis but not in as-treated analysis. DISCUSSION Significant differences exist in terms of mortality and hospitalization risk with different AD medication initiation in real-world setting.
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Affiliation(s)
- Sandipan Bhattacharjee
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Asad E. Patanwala
- The University of Sydney School of Pharmacy, Royal Prince Alfred Hospital, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Daniel C. Malone
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Jeannie K. Lee
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Shannon M. Knapp
- Statistics Consulting Laboratory, Bio5 Institute, The University of Arizona, Tucson, AZ, USA
| | - Terri Warholak
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - William J. Burke
- Banner Alzheimer's Institute, Phoenix, AZ, USA
- Department of Psychiatry, University of Arizona College of Medicine, Phoenix, AZ, USA
- Arizona Alzheimer's Consortium, Phoenix, AZ, USA
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13
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Avidan MS, Ioannidis JPA, Mashour GA. Independent discussion sections for improving inferential reproducibility in published research. Br J Anaesth 2019; 122:413-420. [PMID: 30857597 PMCID: PMC6435840 DOI: 10.1016/j.bja.2018.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 01/15/2023] Open
Abstract
There is a reproducibility crisis in science. There are many potential contributors to replication failure in research across the translational continuum. In this perspective piece, we focus on the narrow topic of inferential reproducibility. Although replication of methods and results is necessary to demonstrate reproducibility, it is not sufficient. Also fundamental is consistent interpretation in the Discussion section. Current deficiencies in the Discussion sections of manuscripts might limit the inferential reproducibility of scientific research. Lack of contextualisation using systematic reviews, overinterpretation and misinterpretation of results, and insufficient acknowledgement of limitations are common problems in Discussion sections; these deficiencies can harm the translational process. Proposed solutions include eliminating or not reading Discussions, writing accompanying editorials, and post-publication review and comments; however, none of these solutions works very well. A second Discussion written by an independent author with appropriate expertise in research methodology is a new testable solution that could help probe inferential reproducibility, and address some deficiencies in primary Discussion sections.
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Affiliation(s)
- Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA.
| | - John P A Ioannidis
- Departments of Health Research and Policy, Medicine, Biomedical Data Science, and Statistics, Meta-Research Innovation Center, Stanford University, Palo Alto, CA, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
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14
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Kovacic NL, Gagnon DJ, Riker RR, Wen S, Fraser GL. An Analysis of Psychoactive Medications Initiated in the ICU but Continued Beyond Discharge: A Pilot Study of Stewardship. J Pharm Pract 2019; 33:760-767. [PMID: 30813837 DOI: 10.1177/0897190019830518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Psychoactive medications (PM) are frequently administered in the intensive care unit (ICU) to provide comfort. Interventions focused on preventing their continuation after the acute phase of illness are needed. OBJECTIVE To determine the frequency that patients with ICU-initiated PM are continued upon ICU and hospital discharge. METHODS This single-center, prospective, observational study assessed consecutive adult ICU patients who received scheduled PM. Frequency of PM continued at ICU and hospital discharge was recorded. The patient's primary treatment team was contacted by the pharmacist within 72 hours of ICU discharge to establish rationale for continued use or to suggest discontinuation. RESULTS Of the 60 patients included, 72% were continued on PM at ICU discharge and 30% at hospital discharge. The pharmacist contacted 40% of treatment teams after ICU discharge and intervention resulted in PM discontinued in 50% of patients. Post ICU discharge, the indication of 41% of patients' PM was unknown by the non-ICU care team or incorrect. Medical ICU patients or those transferred to an outside facility were more likely remain on PM at hospital discharge. CONCLUSION PM are frequently continued during transitions of care and often without knowledge of the initial indication. Future studies should establish effective PM stewardship methods.
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Affiliation(s)
- Nicole Lynn Kovacic
- WVU Medicine, Morgantown, WV, USA.,West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - David J Gagnon
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Richard R Riker
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Sijin Wen
- Health Science Center, 24041West Virginia University, Morgantown, WV, USA
| | - Gilles L Fraser
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
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