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Nham T, Garcia MC, Tsang KLJ, Silva JM, Schneider T, Deng J, Lohit S, Mbuagbaw L, Holbrook A. Proarrhythmic major adverse cardiac events with donepezil: A systematic review with meta-analysis. J Am Geriatr Soc 2024; 72:2552-2565. [PMID: 38580328 DOI: 10.1111/jgs.18909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 02/05/2024] [Accepted: 03/16/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Cholinesterase inhibitors (ChEIs) are regularly used in Alzheimer's disease. Of the three ChEIs approved for dementia, donepezil is among the most prescribed drugs in the United States with nearly 6 million prescriptions in 2020; however, it is classified as a "known risk" QT interval-prolonging medication (QTPmed). Given this claim is derived from observational data including single case reports, we aimed to evaluate high-quality literature on the frequency and nature of proarrhythmic major adverse cardiac events (MACE) associated with donepezil. METHODS We searched Medline, Embase, International Pharmaceutical Abstracts, and Cochrane Central from 1996 onwards for randomized controlled trials (RCTs) involving patients age ≥18 years comparing donepezil to placebo. The MACE composite included mortality, sudden cardiac death, non-fatal cardiac arrest, Torsades de pointes, ventricular tachyarrhythmia, seizure or syncope. Random-effects meta-analyses were performed with a treatment-arm continuity correction for single and double zero event studies. RESULTS Sixty RCTs (n = 12,463) were included. Twenty-five of 60 trials (n = 5886) investigated participants with Alzheimer's disease and 33 trials monitored electrocardiogram data. The mean follow-up duration was 31 weeks (SD = 36). Mortality was the most commonly reported MACE (252/331, 75.8% events), the remainder were syncope or seizures, with no arrhythmia events. There was no increased risk of MACE with exposure to donepezil compared to placebo (risk ratio [RR] 1.08, 95% CI 0.88-1.33, I2 = 0%) and this was consistent in the subgroup analysis of trials including participants with cardiovascular morbidities (RR 1.14, 95% CI 0.88-1.47). Subgroup analysis suggested a trend toward more events with donepezil with follow-up ≥52 weeks (RR: 1.32, 0.98-1.79). CONCLUSIONS This systematic review with meta-analysis found donepezil may not be arrhythmogenic. Donepezil was not associated with mortality, ventricular arrhythmias, seizure or syncope, although longer durations of therapy need more study. Further research to clarify actual clinical outcomes related to QTPmed is important to inform prescribing practices.
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Affiliation(s)
- Tina Nham
- Division of Geriatrics, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Cristian Garcia
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kai La Jennifer Tsang
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Biomedical and Molecular Sciences, Queens University, Kingston, Ontario, Canada
| | - Jessyca Matos Silva
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tyler Schneider
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simran Lohit
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, St Joseph's Healthcare, Hamilton, Ontario, Canada
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Havreng-Théry C, Oquendo B, Zolnowski-Kolp V, Krolak-Salmon P, Bertin-Hugault F, Lafuente-Lafuente C, Belmin J. Cholinesterase inhibitors and memantine are associated with a reduced mortality in nursing home residents with dementia: a longitudinal observational study. Alzheimers Res Ther 2024; 16:117. [PMID: 38812028 PMCID: PMC11134888 DOI: 10.1186/s13195-024-01481-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/13/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND A large proportion of nursing home (NH) residents suffer from dementia and effects of conventional anti-dementia drugs on their health is poorly known. We aimed to investigate the associations between exposure to anti-dementia drugs and mortality among NH residents. METHODS This retrospective longitudinal observational study involved 329 French NH and the residents admitted in these facilities since 2014 and having major neurocognitive disorder. From their electronic health records, we obtained their age, sex, level of dependency, Charlson comorbidity index, and Mini mental examination score at admission. Exposure to anti-dementia drugs was determined using their prescription into 4 categories: none, exposure to acetylcholinesterase inhibitors (AChEI) alone, exposure to memantine alone, exposure to AChEI and memantine. Survival until the end of 2019 was studied in the entire cohort by Cox proportional hazards. To alleviate bias related to prescription of anti-dementia drugs, we formed propensity-score matched cohorts for each type of anti-dementia drug exposure, and studied survival by the same method. RESULTS We studied 25,358 NH residents with major neurocognitive disorder. Their age at admission was 87.1 + 7.1 years and 69.8% of them were women. Exposure to anti-dementia drugs occurred in 2,550 (10.1%) for AChEI alone, in 2,055 (8.1%) for memantine alone, in 460 (0.2%) for AChEI plus memantine, whereas 20,293 (80.0%) had no exposure to anti-dementia drugs. Adjusted hazard ratios for mortality were significantly reduced for these three groups exposed to anti-dementia drugs, as compared to reference group: HR: 0.826, 95%CI 0.769 to 0.888 for AChEI; 0.857, 95%CI 0.795 to 0.923 for memantine; 0.742, 95%CI 0.640 to 0.861 for AChEI plus memantine. Results were consistent in propensity-score matched cohorts. CONCLUSION The use of conventional anti-dementia drugs is associated with a lower mortality in nursing home residents with dementia and should be widely used in this population.
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Affiliation(s)
- Charlotte Havreng-Théry
- Laboratoire LIMICS, Sorbonne Université, Paris, France
- Service de Gériatrie, Hôpital Charles Foix, Ivry-sur-Seine, 94200, France
- Présage Care, Paris, France
| | - Bruno Oquendo
- Service de Gériatrie, Hôpital Charles Foix, Ivry-sur-Seine, 94200, France
| | | | | | | | - Carmelo Lafuente-Lafuente
- Service de Gériatrie, Hôpital Charles Foix, Ivry-sur-Seine, 94200, France
- Laboratoire CEPIA, Université Paris Est, Créteil, France
| | - Joël Belmin
- Laboratoire LIMICS, Sorbonne Université, Paris, France.
- Service de Gériatrie, Hôpital Charles Foix, Ivry-sur-Seine, 94200, France.
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3
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Pagan FL, Schulz PE, Torres-Yaghi Y, Pontone GM. On the Optimal Diagnosis and the Evolving Role of Pimavanserin in Parkinson's Disease Psychosis. CNS Drugs 2024; 38:333-347. [PMID: 38587586 PMCID: PMC11026222 DOI: 10.1007/s40263-024-01084-1] [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] [Accepted: 03/11/2024] [Indexed: 04/09/2024]
Abstract
Parkinson's disease (PD) is associated with the development of psychosis (PDP), including hallucinations and delusions, in more than half of the patient population. Optimal PD management must therefore involve considerations about both motor and non-motor symptoms. Often, clinicians fail to diagnosis psychosis in patients with PD and, when it is recognized, treat it suboptimally, despite the availability of multiple interventions. In this paper, we provide a summary of the current guidelines and clinical evidence for treating PDP with antipsychotics. We also provide recommendations for diagnosis and follow-up. Finally, an updated treatment algorithm for PDP that incorporates the use of pimavanserin, the only US FDA-approved drug for the treatment of PDP, was developed by extrapolating from a limited evidence base to bridge to clinical practice using expert opinion and experience. Because pimavanserin is only approved for the treatment of PDP in the US, in other parts of the world other recommendations and algorithms must be considered.
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Affiliation(s)
- Fernando L Pagan
- Department of Neurology, Georgetown University Hospital, Washington DC, USA
| | - Paul E Schulz
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yasar Torres-Yaghi
- Department of Neurology, Georgetown University Hospital, Washington DC, USA
| | - Gregory M Pontone
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St., Phipps 300, Baltimore, MD, 21287, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Truong C, Recto C, Lafont C, Canoui-Poitrine F, Belmin JB, Lafuente-Lafuente C. Effect of Cholinesterase Inhibitors on Mortality in Patients With Dementia: A Systematic Review of Randomized and Nonrandomized Trials. Neurology 2022; 99:e2313-e2325. [PMID: 36096687 DOI: 10.1212/wnl.0000000000201161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cholinesterase inhibitors (ChEIs) have cardiovascular effects in addition to their neurologic activity and might alter mortality. We wanted to know whether treatment with ChEIs modifies mortality in patients with dementia. METHODS We searched PubMed, Embase, Cochrane CENTRAL, ClinicalTrials.gov, and ICRTP, from their inception to November 2021, and screened bibliographies of reviews, guidelines, and included studies. We included randomized controlled trials (RCTs) and nonrandomized controlled studies at lower risk of bias comparing ChEI treatment with placebo or usual treatment, for 6 months or longer, in patients with dementia of any type. Two investigators independently assessed studies for inclusion, assessed their risk of bias, and extracted data using predefined forms. Any discordance between investigators was solved by discussion and consensus. Data on all-cause and cardiovascular mortality, measured as either crude death rates or multivariate adjusted hazard ratios (HRs), were pooled using a random-effect model. Information size achieved was assessed using trial sequential analysis (TSA). We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS Twenty-four studies (12 RCTs, 12 cohorts, mean follow-up 6-120 months), cumulating 79,153 patients with Alzheimer (13 studies), Parkinson (1), vascular (1), or any type (9) dementia, fulfilled inclusion criteria. Pooled all-cause mortality in control patients was 15.1 per 100 person-years. Treatment with ChEIs was associated with lower all-cause mortality (unadjusted risk ratio [RR] 0.74, 95% CI 0.66-0.84; adjusted HR 0.77, 95% CI 0.70-0.84, moderate-quality to high-quality evidence). This result was consistent between randomized and nonrandomized studies and in several sensitivity analyses. No difference appeared between subgroups by type of dementia, age, individual drug, or dementia severity. Less data were available for cardiovascular mortality (3 RCTs, 2 cohorts, 9,182 patients, low-quality to moderate-quality evidence), which was also lower in patients treated with ChEIs (unadjusted RR 0.61, 95% CI 0.40-0.93, adjusted HR 0.47, 95% CI 0.32-0.68). In TSA analysis, the results for all-cause mortality were conclusive but not those for cardiovascular mortality. DISCUSSION There is moderate-quality to high-quality evidence of a consistent association between long-term treatment with ChEIs and a reduction in all-cause mortality in patients with dementia. These findings may influence decisions to prescribe ChEIs in those patients. TRIAL REGISTRATION INFORMATION This systematic review was registered in the PROSPERO international prospective register of systematic reviews with the number CRD42021254458 (June 11, 2021).
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Affiliation(s)
- Céline Truong
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Caryn Recto
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Charlotte Lafont
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Florence Canoui-Poitrine
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Joel Belmin Belmin
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France
| | - Carmelo Lafuente-Lafuente
- From the AP-HP (C.T., C.R., J.B.B., C.L.-L.), Sorbonne Université, Hôpitaux universitaires Pitie-Salpêtrière-Charles Foix, Service de Gériatrie à orientation Cardiologique et Neurologique, Ivry-sur-Seine; Université Paris Est Créteil (UPEC) (C.L., F.C.-P., C.L.-L.), INSERM, IMRB, Clinical Epidemiology and Ageing (CEpiA) Team; and APHP (C.L., F.C.-P.), Hôpital Henri Mondor, Service de Santé Publique, Créteil, France.
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Mohamed Yusof NIS, Abdullah ZL, Othman N, Mohd Fauzi F. Structure–Activity Relationship Analysis of Flavonoids and Its Inhibitory Activity Against BACE1 Enzyme Toward a Better Therapy for Alzheimer’s Disease. Front Chem 2022; 10:874615. [PMID: 35832462 PMCID: PMC9271896 DOI: 10.3389/fchem.2022.874615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022] Open
Abstract
Drug development in Alzheimer’s disease (AD) suffers from a high attrition rate. In 2021, 117 agents tested in phases I and II and 36 agents tested in phase III were discontinued. Natural product compounds may be good lead compounds for AD as they contain functional groups that are important for binding against key AD targets such as β-secretase enzyme (BACE1). Hence, in this study, 64 flavonoids collected from rigorous literature search and screening that have been tested from 2010 to 2022 against BACE1, which interferes in the formation of amyloid plaque, were analyzed. The 64 unique flavonoids can be further classified into five core fragments. The flavonoids were subjected to clustering analysis based on its structure, and each representative of the clusters was subjected to molecular docking. There were 12 clusters formed, where only 1 cluster contained compounds from two different core fragments. Several observations can be made where 1) flavanones with sugar moieties showed higher inhibitory activity compared to flavanones without sugar moieties. The number of sugar moieties and position of glycosidic linkage may also affect the inhibitory activity. 2) Non-piperazine-substituted chalcones when substituted with functional groups with decreasing electronegativity at the para position of both rings result in a decrease in inhibitory activity. Molecular docking indicates that ring A is involved in hydrogen bond, whereas ring B is involved in van der Waals interaction with BACE1. 3) Hydrogen bond is an important interaction with the catalytic sites of BACE1, which are Asp32 and Asp228. As flavonoids contain favorable structures and properties, this makes them an interesting lead compound for BACE1. However, to date, no flavonoids have made it through clinical trials. Hence, these findings may aid in the design of highly potent and specific BACE1 inhibitors, which could delay the progression of AD.
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Affiliation(s)
| | | | - Norodiyah Othman
- Faculty of Pharmacy, Universiti Teknologi MARA Selangor, Selangor, Malaysia
- Haematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health Complex, Selangor, Malaysia
| | - Fazlin Mohd Fauzi
- Faculty of Pharmacy, Universiti Teknologi MARA Selangor, Selangor, Malaysia
- Collaborative Drug Discovery Research, Faculty of Pharmacy, Universiti Teknologi MARA Selangor, Selangor, Malaysia
- *Correspondence: Fazlin Mohd Fauzi,
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Baracaldo-Santamaría D, Llinás-Caballero K, Corso-Ramirez JM, Restrepo CM, Dominguez-Dominguez CA, Fonseca-Mendoza DJ, Calderon-Ospina CA. Genetic and Molecular Aspects of Drug-Induced QT Interval Prolongation. Int J Mol Sci 2021; 22:8090. [PMID: 34360853 PMCID: PMC8347245 DOI: 10.3390/ijms22158090] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/04/2021] [Accepted: 07/06/2021] [Indexed: 12/22/2022] Open
Abstract
Long QT syndromes can be either acquired or congenital. Drugs are one of the many etiologies that may induce acquired long QT syndrome. In fact, many drugs frequently used in the clinical setting are a known risk factor for a prolonged QT interval, thus increasing the chances of developing torsade de pointes. The molecular mechanisms involved in the prolongation of the QT interval are common to most medications. However, there is considerable inter-individual variability in drug response, thus making the application of personalized medicine a relevant aspect in long QT syndrome, in order to evaluate the risk of every individual from a pharmacogenetic standpoint.
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Affiliation(s)
- Daniela Baracaldo-Santamaría
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia; (D.B.-S.); (J.M.C.-R.); (C.A.D.-D.)
| | - Kevin Llinás-Caballero
- GENIUROS Research Group, Center for Research in Genetics and Genomics (CIGGUR), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia; (K.L.-C.); (C.M.R.); (D.J.F.-M.)
- Institute for Immunological Research, University of Cartagena, Cartagena 130014, Colombia
| | - Julián Miguel Corso-Ramirez
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia; (D.B.-S.); (J.M.C.-R.); (C.A.D.-D.)
| | - Carlos Martín Restrepo
- GENIUROS Research Group, Center for Research in Genetics and Genomics (CIGGUR), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia; (K.L.-C.); (C.M.R.); (D.J.F.-M.)
| | | | - Dora Janeth Fonseca-Mendoza
- GENIUROS Research Group, Center for Research in Genetics and Genomics (CIGGUR), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia; (K.L.-C.); (C.M.R.); (D.J.F.-M.)
| | - Carlos Alberto Calderon-Ospina
- GENIUROS Research Group, Center for Research in Genetics and Genomics (CIGGUR), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia; (K.L.-C.); (C.M.R.); (D.J.F.-M.)
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Delirium Superimposed on Dementia in Perioperative Period and Intensive Care. J Clin Med 2020; 9:jcm9103279. [PMID: 33066174 PMCID: PMC7601948 DOI: 10.3390/jcm9103279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 11/30/2022] Open
Abstract
Delirium is a life-threatening condition, the causes of which are still not fully understood. It may develop in patients with pre-existing dementia. Delirium superimposed on dementia (DSD) can go completely unnoticed with routine examination. It may happen in the perioperative period and in the critical care setting, especially in the ageing population. Difficulties in diagnosing and lack of specific pharmacological and non-pharmacological treatment make DSD a seriously growing problem. Patient-oriented, multidirectional preventive measures should be applied to reduce the risk of DSD. For this reason, anesthesiologists and intensive care specialists should be aware of this interesting condition in their everyday clinical practice.
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