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Yokoyama A, Jo T, Sakamoto Y, Urushiyama H, Tamiya H, Tanaka G, Kumazawa R, Matsui H, Fushimi K, Yasunaga H, Nagase T. Effectiveness and safety of the co-administration of Yokukan-San (Japanese herbal medicine) with antipsychotics in hospitalized older patients with pneumonia. Geriatr Gerontol Int 2023; 23:849-854. [PMID: 37804182 DOI: 10.1111/ggi.14696] [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: 06/29/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 10/09/2023]
Abstract
AIM Behavioral and psychological symptoms and delirium frequently occur in hospitalized older patients with pneumonia and are associated with longer hospital stays. Yokukan-San (YKS, traditional Japanese [Kampo] medicine) and antipsychotics are often used to treat delirium and behavioral and psychological symptoms in Japan. Hence, this study aimed to assess the effectiveness and safety of the co-administration of YKS with atypical antipsychotics in older patients with pneumonia. METHODS We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively identify older patients (≥65 years) hospitalized for pneumonia who received antipsychotics within 3 days of hospitalization. The patients were divided into two groups: those who received atypical antipsychotics alone (control group) and those who received both atypical antipsychotics and YKS (YKS group). We compared length of hospital stay, in-hospital mortality, bone fractures, and administration of potassium products between the two groups using propensity score overlap weighting. RESULT We identified 4789 patients in the YKS group and 61 641 in the control group. After propensity score overlap weighting, length of hospital stay was statistically significantly shorter in the YKS group (percentage difference -3.0%; 95% confidence interval -5.8% to -0.3%). The proportion of patients who received potassium products was higher in the YKS group (odds ratio 1.34; 95% confidence interval 1.15-1.55). In-hospital death and bone fractures were not significantly different. CONCLUSION Co-administration of YKS with atypical antipsychotics could be a reasonable treatment option for hospitalized older patients with pneumonia and aggressive psychiatric symptoms. Geriatr Gerontol Int 2023; 23: 849-854.
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Affiliation(s)
- Akira Yokoyama
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Health Services Research, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yukiyo Sakamoto
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hirokazu Urushiyama
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hiroyuki Tamiya
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Division for Health Service Promotion, University of Tokyo, Tokyo, Japan
| | - Goh Tanaka
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Ryosuke Kumazawa
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Rogowska M, Thornton M, Creese B, Velayudhan L, Aarsland D, Ballard C, Tsamakis K, Stewart R, Mueller C. Implications of Adverse Outcomes Associated with Antipsychotics in Older Patients with Dementia: A 2011-2022 Update. Drugs Aging 2023; 40:21-32. [PMID: 36513918 PMCID: PMC9747539 DOI: 10.1007/s40266-022-00992-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 12/15/2022]
Abstract
Neuropsychiatric symptoms affect most patients with dementia over the course of the disease. They include a wide variety of symptoms from apathy and depression to psychosis, irritability, impulsivity and agitation. These symptoms are associated with significant distress to the patient and caregivers, as well as more rapid progression of dementia, institutionalisation and higher mortality. The first-line management of the neuropsychiatric symptoms of dementia should be non-pharmacological. If medications are required, antipsychotics are commonly chosen. Second-generation antipsychotics such as risperidone, olanzapine, quetiapine and aripiprazole are prescribed more often than first-generation antipsychotics, such as haloperidol. The aim of this review is to provide an update on findings on adverse outcomes and clinical implications of antipsychotic use in dementia. These medications may increase mortality and can be associated with adverse events including pneumonia, cerebrovascular events, parkinsonian symptoms or higher rates of venous thromboembolism. Risks related to antipsychotic use in dementia are moderated by a number of modifiable and non-modifiable factors such as co-prescribing of other medications, medical and psychiatric co-morbidities, and demographics such as age and sex, making individualised treatment decisions challenging. Antipsychotics have further been associated with an increased risk of reliance on long-term care and institutionalisation, and they might not be cost-effective for healthcare systems. Many of these risks can potentially be mitigated by close physical health monitoring of antipsychotic treatment, as well as early withdrawal of pharmacotherapy when clinically possible.
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Affiliation(s)
- Marianna Rogowska
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK.
| | - Mary Thornton
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
| | - Byron Creese
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- University of Exeter Medical School, Exeter, UK
| | - Latha Velayudhan
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dag Aarsland
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Stavanger University Hospital, Stavanger, Norway
| | - Clive Ballard
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Stavanger University Hospital, Stavanger, Norway
| | - Konstantinos Tsamakis
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Second Department of Psychiatry, National and Kapodistrian University of Athens, School of Medicine, University General Hospital 'ATTIKON', Athens, Greece
| | - Robert Stewart
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Christoph Mueller
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Is There a Role for Medication in Managing Delirium with Dementia? Geriatrics (Basel) 2022; 7:geriatrics7050114. [PMID: 36286217 PMCID: PMC9602311 DOI: 10.3390/geriatrics7050114] [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: 09/05/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
People with dementia are more likely to develop delirium. We conducted a brief literature search and give a pragmatic overview of the key issues. Making rational and safe prescribing decisions is highly influenced by organisational culture and embedded staff practices. Comprehensive assessment for unmet physical, psychological, and social needs is an important intervention in itself. Taking a broad overview of possible pharmacological interventions should include stopping inappropriate medications and prescribing for key drivers of the underlying causes of delirium. Prescribing psychotropic medications may be indicated where there is significant distress or risk to the person with dementia and risk to those around them. It is vital to consider the dementia subtype and, where possible, involve family and friend carers in the decision-making process. Medications should be prescribed at the lowest possible dose for the least amount of time after carefully weighing risks versus benefits and documenting these. While these cases are challenging for staff and families, it can be rewarding to improve the quality of life and lessen distress for the person with dementia. There are also opportunities for informing family and friend carers, educating the wider multidisciplinary team, and promoting organisational change.
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Correll CU, Solmi M, Croatto G, Schneider LK, Rohani-Montez SC, Fairley L, Smith N, Bitter I, Gorwood P, Taipale H, Tiihonen J. Mortality in people with schizophrenia: a systematic review and meta-analysis of relative risk and aggravating or attenuating factors. World Psychiatry 2022; 21:248-271. [PMID: 35524619 PMCID: PMC9077617 DOI: 10.1002/wps.20994] [Citation(s) in RCA: 171] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
People with schizophrenia die 15-20 years prematurely. Understanding mortality risk and aggravating/attenuating factors is essential to reduce this gap. We conducted a systematic review and random-effects meta-analysis of prospective and retrospective, nationwide and targeted cohort studies assessing mortality risk in people with schizophrenia versus the general population or groups matched for physical comorbidities or groups with different psychiatric disorders, also assessing moderators. Primary outcome was all-cause mortality risk ratio (RR); key secondary outcomes were mortality due to suicide and natural causes. Other secondary outcomes included any other specific-cause mortality. Publication bias, subgroup and meta-regression analyses, and quality assessment (Newcastle-Ottawa Scale) were conducted. Across 135 studies spanning from 1957 to 2021 (schizophrenia: N=4,536,447; general population controls: N=1,115,600,059; other psychiatric illness controls: N=3,827,955), all-cause mortality was increased in people with schizophrenia versus any non-schizophrenia control group (RR=2.52, 95% CI: 2.38-2.68, n=79), with the largest risk in first-episode (RR=7.43, 95% CI: 4.02-13.75, n=2) and incident (i.e., earlier-phase) schizophrenia (RR=3.52, 95% CI: 3.09-4.00, n=7) versus the general population. Specific-cause mortality was highest for suicide or injury-poisoning or undetermined non-natural cause (RR=9.76-8.42), followed by pneumonia among natural causes (RR=7.00, 95% CI: 6.79-7.23), decreasing through infectious or endocrine or respiratory or urogenital or diabetes causes (RR=3 to 4), to alcohol or gastrointestinal or renal or nervous system or cardio-cerebrovascular or all natural causes (RR=2 to 3), and liver or cerebrovascular, or breast or colon or pancreas or any cancer causes (RR=1.33 to 1.96). All-cause mortality increased slightly but significantly with median study year (beta=0.0009, 95% CI: 0.001-0.02, p=0.02). Individuals with schizophrenia <40 years of age had increased all-cause and suicide-related mortality compared to those ≥40 years old, and a higher percentage of females increased suicide-related mortality risk in incident schizophrenia samples. All-cause mortality was higher in incident than prevalent schizophrenia (RR=3.52 vs. 2.86, p=0.009). Comorbid substance use disorder increased all-cause mortality (RR=1.62, 95% CI: 1.47-1.80, n=3). Antipsychotics were protective against all-cause mortality versus no antipsychotic use (RR=0.71, 95% CI: 0.59-0.84, n=11), with largest effects for second-generation long-acting injectable anti-psychotics (SGA-LAIs) (RR=0.39, 95% CI: 0.27-0.56, n=3), clozapine (RR=0.43, 95% CI: 0.34-0.55, n=3), any LAI (RR=0.47, 95% CI: 0.39-0.58, n=2), and any SGA (RR=0.53, 95% CI: 0.44-0.63, n=4). Antipsychotics were also protective against natural cause-related mortality, yet first-generation antipsychotics (FGAs) were associated with increased mortality due to suicide and natural cause in incident schizophrenia. Higher study quality and number of variables used to adjust the analyses moderated larger natural-cause mortality risk, and more recent study year moderated larger protective effects of antipsychotics. These results indicate that the excess mortality in schizophrenia is associated with several modifiable factors. Targeting comorbid substance abuse, long-term maintenance antipsychotic treatment and appropriate/earlier use of SGA-LAIs and clozapine could reduce this mortality gap.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Giovanni Croatto
- Mental Health Department, AULSS 3 Serenissima, Mestre, Venice, Italy
| | | | | | | | | | - István Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Philip Gorwood
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), Paris, France
- GHU Paris Psychiatrie et Neurosciences (CMME, Sainte-Anne Hospital), Université de Paris, Paris, France
| | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
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Ozenberger K, Alexander GC, Shin J, Whitsel EA, Qato DM. Use of Prescription Medications With Cardiovascular Adverse Effects Among Older Adults in the United States. Pharmacoepidemiol Drug Saf 2022; 31:1027-1038. [PMID: 35569118 PMCID: PMC9545984 DOI: 10.1002/pds.5477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 05/01/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022]
Abstract
Background Many commonly used prescription medications have cardiovascular adverse effects, yet the cumulative risk of cardiovascular events associated with the concurrent use of these medications is unknown. We examined the association between the concurrent use of prescription medications with known risk of a major adverse cardiovascular event (MACE) (“MACE medications”) and the risk of such events among older adults. Methods A multi‐center, population‐based study from the Atherosclerosis Risk in Communities (ARIC) study of a cohort of 3669 community‐dwelling adults aged 61–86 years with no history of cardiovascular disease who reported the use of at least one medication between September 2006 and August 2013 were followed up until August 2015. Exposure defined as time‐varying and time‐fixed use of 1, 2 or ≥3 MACE medications with non‐MACE medications serving as negative control. Primary outcome was incident MACE defined as coronary artery revascularization, myocardial infarction, fatal coronary heart disease, stroke, cardiac arrest, or death. Results In fully adjusted models, there was an increased risk of MACE associated with use of 1, 2, or ≥3 MACE medications (1 MACE: hazards ratio [HR], 1.21; 95% confidence interval [CI], 0.94–1.57); 2 MACE: HR 1.89, CI 1.42–2.53; ≥3 MACE: HR 2.22, CI 1.61–3.07) compared to use of non‐MACE medications. These associations persisted in propensity score‐matched analyses and among new users of MACE medications, never users of cardiovascular medications and subgroups of participants with increased risk of MACE. There was no association between the number of non‐MACE medications used and MACE. Conclusions and Relevance In this community‐based cohort of older adults with no prior cardiovascular disease, the use of MACE medications was independently and consistently associated with an increased risk of such events in a dose–response fashion.
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Affiliation(s)
- Katharine Ozenberger
- Program on Medicines and Public Health, Titus Family Department of Clinical Pharmacy University of Southern California Los Angeles California
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago College of Pharmacy Chicago Illinois
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
| | - Jung‐Im Shin
- Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
| | - Eric A. Whitsel
- Department of Epidemiology, Gillings School of Global Public Health; Department of Medicine, School of Medicine University of North Carolina Chapel Hill NC
| | - Dima M. Qato
- Program on Medicines and Public Health, Titus Family Department of Clinical Pharmacy University of Southern California Los Angeles California
- Leonard D. Schaeffer Center for Health Policy and Economics University of Southern California Los Angeles California
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6
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Dai L, Zuo Q, Chen F, Chen L, Shen Y. The Association and Influencing Factors between Antipsychotics Exposure and the Risk of VTE and PE: A Systematic Review and Meta-analysis. Curr Drug Targets 2021; 21:930-942. [PMID: 32321400 DOI: 10.2174/1389450121666200422084414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Different clinical studies have given inconsistent results on whether the use of antipsychotics increases the risk of thromboembolism. In this paper, we reviewed all relevant literature to provide suggestions for clinical diagnosis and treatment. METHODS PubMed, Web of Science, EMBASE, MEDLINE, Cochrane and Scopus databases were thoroughly searched up to June 2019. Two researchers independently searched the literature, extracted data. Data were analyzed by Stata 12.0 software. RESULTS A total of 22 studies involving 31514226 subjects were included. This meta-analysis showed that patients taking the first- or second-generation antipsychotics had a higher risk of venous thromboembolism and pulmonary embolism than those who did not, and low potency first-generation agents increased the risk of venous thromboembolism more than high potency antipsychotics, and olanzapine, clozapine, haloperidol, perphenazine and risperidone also significantly increased the risk of it. The risk of venous thrombosis in obese people was higher than that in overweight people, patients not less than 65 years old had an increased risk compared with younger patients. In addition, women taking antipsychotics had a higher risk of pulmonary embolism than men. CONCLUSION The use of antipsychotics will increase the risk of venous thromboembolism and pulmonary embolism, which will be affected by the type of antipsychotics and patient characteristics.
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Affiliation(s)
- Luqi Dai
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qiunan Zuo
- Department of Geriatric Respiratory Medicine, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, Sichuan 610072, China
| | - Fangying Chen
- Department of Tuberculosis, the Third People's Hospital of Tibet Autonomous Region, Lhasa 850000, China
| | - Lei Chen
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yongchun Shen
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
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Behavioral and Psychological Symptoms in Dementia (BPSD) and the Use of Antipsychotics. Pharmaceuticals (Basel) 2021; 14:ph14030246. [PMID: 33803277 PMCID: PMC8002184 DOI: 10.3390/ph14030246] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 12/19/2022] Open
Abstract
Dementia affects about 47 million people worldwide, number expected to exponentially increase within 30 years. Alzheimer’s disease (AD) is the most common dementia type, accounting on its own for almost 70% of all dementia cases. Behavioral and psychological symptoms (BPSD) frequently occur during the disease progression; to treat agitation, aggressiveness, delusions and hallucinations, the use of antipsychotic drugs should be limited, due to their safety issues. In this literature review regarding the use of antipsychotics for treating BPSD in dementia, the advantages and limitation of antipsychotic drugs have been evaluated. The available medications for the management of behavioral and psychological symptoms are the antipsychotics, classed into typical and atypical, depending on their action on dopamine and serotonin receptors. First generation, or typical, antipsychotics exhibit lack of tolerability and display a broad range of side effects such as sedation, anticholinergic effects and extrapyramidal symptoms. Atypical, or second generation, antipsychotics bind more selectively to dopamine receptors and simultaneously block serotonin receptors, resulting in higher tolerability. High attention should be paid to the management of therapy interruption or switch between antipsychotics, to limit the possible rebound effect. Several switching strategies may be adopted, and clinicians should “tailor” therapies, accounting for patients’ symptoms, comorbidities, polytherapies and frailty.
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Does Recent Hospitalization Increase Antipsychotic Initiation Among Community Dwellers With Alzheimer's Disease? J Am Med Dir Assoc 2021; 22:1543-1547.e3. [PMID: 33460619 DOI: 10.1016/j.jamda.2020.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Antipsychotics are often prescribed to persons with cognitive impairment in the hospital, but it is not known whether recent hospital care increases the risk of antipsychotic initiation in community dwellers with Alzheimer's disease (AD). We studied whether hospital care during the previous 2 weeks is associated with antipsychotic initiation in persons with AD. DESIGN Register-based study. PARTICIPANTS AND SETTING The nationwide Medication use and Alzheimer's disease (MEDALZ) cohort containing Finnish community dwellers with AD between 2005 and 2011 (N = 70,718) was used. METHODS Incident antipsychotic use was identified with a 1-year washout period. Each new initiator was matched with noninitiator according to age, sex, and time since AD diagnosis (n = 22,281 matched pairs). The use of antipsychotics was identified from the Prescription Register. Information on hospital discharge within the past 2 weeks of antipsychotic initiation was extracted from the Hospital Discharge Register. RESULTS Antipsychotic initiators were 5 times more likely to have recently been discharged from the hospital compared with the matched noninitiators (29.8% and 5.3%, respectively). In adjusted regression analyses, a hospital stay longer than a week and especially more than 2 months [odds ratio (OR) 4.40, 95% confidence interval (CI) 3.51-5.53], use of benzodiazepines and related drugs (OR 1.66, 95% CI 1.44-1.92), and memantine (OR 1.30, 95% CI 1.12-1.52) were associated with antipsychotic initiation. Older age (OR 0.77, 95% CI 0.62-0.95), asthma or chronic obstructive pulmonary disease (OR 0.73, 95% CI 0.60-0.89), diabetes (OR 0.82, 95% CI 0.69-0.97), and cardiovascular disease (OR 0.82, 95% CI 0.72-0.94) were associated with a lower risk of initiation. CONCLUSIONS AND IMPLICATIONS Recent hospital care seems to be a risk factor for antipsychotic initiation in community-dwelling persons with AD. The need of antipsychotic treatment must be carefully assessed at the time of discharge. Well planned hospital discharge and home care might reduce antipsychotic initiation.
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Mortensen SJ, Mohamadi A, Wright CL, Chan JJ, Weaver MJ, von Keudell A, Nazarian A. Medications as a Risk Factor for Fragility Hip Fractures: A Systematic Review and Meta-analysis. Calcif Tissue Int 2020; 107:1-9. [PMID: 32253446 DOI: 10.1007/s00223-020-00688-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/26/2020] [Indexed: 12/13/2022]
Abstract
Fragility hip fractures and their associated morbidity and mortality pose a global healthcare problem. Several pharmaceutical products have been postulated to alter bone architecture and contribute to fragility hip fractures. We searched four electronic databases from inception to September 2017. Inclusion criteria were the following: (1) adult patients with fragility hip fractures, (2) full text in English, (3) minimum one-year follow-up, and (4) reporting of at least one risk factor. To minimize heterogeneity among the studies, we performed subgroup analyses. Whenever heterogeneity remained significant, we employed random effect meta-analysis for data pooling. Thirty-eight studies were included, containing 1,244,155 subjects and 188,966 cases of fragility hip fractures. Following medications were significantly associated with fragility hip fractures: Antidepressants (OR 2.07, 95% CI 1.98-2.17), antiparkinsonian drugs (OR 2.21, 95% CI 1.15-4.24), antipsychotic drugs (OR 2.0, 95% CI 1.50-2.66), anxiolytic drugs (OR 1.44, 95% CI 1.19-1.75), benzodiazepines (OR 1.84, 95% CI 1.26-2.69), sedatives (OR 1.33, 95% CI 1.14-1.54), systemic corticosteroids (OR 1.65, 95% CI 1.37-1.99), H2 antagonists (OR 1.21, 95% CI 1.18-1.24), proton pump inhibitors (OR 1.41, 95% CI 1.16-1.71), and thyroid hormone (OR 1.29, 95% CI 1.13-1.47). Hormone replacement therapy with estrogen (HRT) was associated with decreased risk of hip fracture (OR 0.80, 95% CI 0.65-0.98). There are several medications associated with sustaining a fragility hip fracture. Medical interventions should be considered for patients on these medications, including information about osteoporosis and fracture prevention.
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Affiliation(s)
- Sharri J Mortensen
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Amin Mohamadi
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Casey L Wright
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jimmy J Chan
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, USA
| | - Arvind von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, USA
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
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Is Antipsychotic Treatment Associated With Risk of Pneumonia in People With Serious Mental Illness?: The Roles of Severity of Psychiatric Symptoms and Global Functioning. J Clin Psychopharmacol 2020; 39:434-440. [PMID: 31425461 DOI: 10.1097/jcp.0000000000001090] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Most pneumonia-related researches in people with severe mental illness were based on insurance claims data. This study aimed for a comprehensive analysis of factors potentially associated with risk of pneumonia in psychiatric inpatients. METHODS Inpatients at a large psychiatric hospital diagnosed with pneumonia during the course of hospitalization were enrolled as cases. Controls were matched by ward and date. The diagnosis of pneumonia was confirmed by physicians based on clinical features, chest radiographs, and blood tests. A stepwise conditional logistic regression model was used to identify potential risk factors for pneumonia. RESULTS Seventy-five pneumonia cases and 436 matched controls were enrolled. Conditional logistic regression revealed 3 variables significantly associated with an increased risk of pneumonia: a higher score on the Clinical Global Impression-Severity scale (adjusted odds ratio [aOR], 3.7; 95% confidence interval [CI]. 1.5-9.1), a higher score on the Charlson comorbidity index (aOR, 2.2; 95% CI, 1.5-3.2), and a longer duration of antipsychotic treatment (aOR, 1.0; 95% CI, 1.0-1.0). Two variables were significantly associated with a decreased risk of pneumonia: a higher score on the Global Assessment of Functioning scale (aOR, 0.9; 95% CI, 0.8-0.9) and an older age of onset (aOR, 0.9; 95% CI, 0.9-1.0). After adjusting for potential confounders, use of antipsychotic or other psychotropic medications was not found to be a significant risk factor for pneumonia. CONCLUSIONS Physical comorbidities, long duration of antipsychotic treatment, early onset, severe psychiatric symptoms, and poor global functioning are associated with pneumonia in people with serious mental illness.
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Papola D, Ostuzzi G, Gastaldon C, Morgano GP, Dragioti E, Carvalho AF, Fusar-Poli P, Correll CU, Solmi M, Barbui C. Antipsychotic use and risk of life-threatening medical events: umbrella review of observational studies. Acta Psychiatr Scand 2019; 140:227-243. [PMID: 31264708 DOI: 10.1111/acps.13066] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To quantify the risk of hip fracture, thromboembolism, stroke, myocardial infarction, pneumonia and sudden cardiac death associated with exposure to antipsychotics. METHODS Systematic searches were conducted in Medline, Embase and PsycINFO from inception until 30/07/2018 for systematic reviews of observational studies. AMSTAR-2 was used for the quality assessment of systematic reviews, while the strength of associations was measured using GRADE and quantitative umbrella review criteria (URC). RESULTS Sixty-eight observational studies from six systematic reviews were included. The association between antipsychotic exposure and pneumonia was the strongest [URC = class I; GRADE = low quality; odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.62-2.09; participants = 28 726; age = 76.2 ± 12.3 years], followed by the association with hip fracture (URC = class II; GRADE = low quality; OR = 1.57, 95% CI = 1.42-1.74; participants = 5 288 118; age = 55.4 ± 12.5 years), and thromboembolism (URC = class II; GRADE = very low quality; OR = 1.55, 95% CI = 1.31-1.83; participants = 31 417 175; age = 55.5 ± 3.2 years). The association was weak for stroke (URC = class III; GRADE = very low quality; OR = 1.45, 95% CI = 1.24-1.70; participants = 65 700; age = 68.7 ± 13.8 years), sudden cardiac death (URC = class III; GRADE = very low quality; OR = 2.24, 95% CI = 1.45-3.46; participants = 77 488; age = 52.2 ± 6.2 years) and myocardial infarction (URC = class III; GRADE = very low quality; OR = 2.21, 95% CI = 1.41-3.46; participants = 399 868; age = 74.1 ± 9.3 years). CONCLUSION The most robust results were found for the risk of pneumonia, followed by the risk of hip fracture and thromboembolism. For stroke, sudden cardiac death and myocardial infarction, the strength of association was weak. The observational nature of the primary studies may represent a source of bias.
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Affiliation(s)
- D Papola
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Science, Section of Psychiatry, University of Verona, Verona, Italy
| | - G Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Science, Section of Psychiatry, University of Verona, Verona, Italy
| | - C Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Science, Section of Psychiatry, University of Verona, Verona, Italy
| | - G P Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - E Dragioti
- Pain and Rehabilitation centre and Department of Medicine and Health Sciences (IMH), Faculty of Health Sciences, University of Linköping, Linköping, SE, Sweden
| | - A F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - P Fusar-Poli
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - C U Correll
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, NY, USA.,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - M Solmi
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Neuroscience Centre, University of Padua, Padua, Italy.,Department of Neuroscience, University of Padua, Padua, Italy
| | - C Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Science, Section of Psychiatry, University of Verona, Verona, Italy
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12
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Randle JM, Heckman G, Oremus M, Ho J. Intermittent antipsychotic medication and mortality in institutionalized older adults: A scoping review. Int J Geriatr Psychiatry 2019; 34:906-920. [PMID: 30907448 DOI: 10.1002/gps.5106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 03/17/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE/BACKGROUND Antipsychotic use appears to increase mortality risk among older adults with dementia. Whether this risk is similar for regular or intermittent use is unknown. This scoping review aims to explore the temporal association between antipsychotic use and mortality risk for older institutionalized adults. METHOD We conducted a scoping review using Medline (PubMed), EMBASE, CINAHL, and the Cochrane libraries between October 2018 and January 2019. RESULTS Twenty-eight articles met review criteria. We found that different antipsychotic medications present different safety profiles. The risk of mortality was highest with conventional antipsychotic use and within 40 days of antipsychotic initiation. CONCLUSIONS Conventional antipsychotic use increases mortality for older institutionalized adults. The evidence for atypical antipsychotics is less clear. Mortality risk appears highest within 30 to 40 days of initiating antipsychotic treatment. This temporal association suggests increased mortality may actually be the result of some previously unrecognized illness, comorbidity, change in health status, or increased frailty, rather than an idiosyncrasy of the antipsychotic itself.
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Affiliation(s)
- Jason M Randle
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,Schlegel Research Institute for Aging, Waterloo, Ontario, Canada
| | - Mark Oremus
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Joanne Ho
- Schlegel Research Institute for Aging, Waterloo, Ontario, Canada.,Department of Medicine, McMaster University, Kitchener, Ontario, Canada
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Gathering tips from carers to support people with dementia: an adaptation of the TOP 5 program for community use. INT J EVID-BASED HEA 2018; 16:128-135. [PMID: 29432396 DOI: 10.1097/xeb.0000000000000136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM Behavioral and psychological symptoms of dementia are often managed inappropriately with antipsychotic medicines. The TOP 5 program, which involves recording up to five relevant and meaningful tips that assist in personalizing care for the person with dementia, has been tested in the hospital setting and transitions of care in Australia, and has been found to be useful. Our study aimed to adapt the TOP 5 program as a strategy to support people with dementia in a primary care setting and to test the acceptability of our adapted TOP 5 program materials. METHODS The adapted TOP 5 program materials were delivered as part of a larger intervention by the Australian Government Department of Veterans' Affair's Veterans' Medicines Advice & Therapeutic Education Services program to reduce inappropriate antipsychotic use in veterans with dementia. This study focuses on the acceptability of our adapted TOP 5 program materials for ascertaining carer or family members' advice about what actions might help to calm their relative when she or he is agitated. Educational materials relating to the resources for implementing the adapted TOP 5 program together with the one-page survey response to evaluate acceptability of our adapted TOP 5 program materials were mailed to 4827 general practitioners (GPs), 8381 accredited pharmacists, and 2510 Residential Aged Care Facilities. RESULTS We received survey response forms from 350 (7%) GPs, 366 (4%) pharmacists, and 196 (8%) residential aged care facilities. Although the response rate was low, 90% of respondents in all groups indicated they were very likely or moderately likely to assist family members and carers of patients with dementia to identify their top tips to personalize care. GPs who found the information useful more frequently indicated that they were likely to assist family members and carers in identifying their top tips. Approximately one-third of respondents reported they had received positive feedback from families regarding the helpfulness of sharing their practical tips for care of their loved one. Pharmacists indicated having the tips would assist them when undertaking medicines reviews. CONCLUSIONS Our findings suggest that the TOP 5 program, or an adaptation of the TOP 5 program, such as ours, has potential to improve the health and care of people with dementia and their carers by using patient centerd nonpharmacological approaches and avoiding the unnecessary use of antipsychotics for behavioral and psychological symptoms of dementia. Longer-term follow-up would help to establish whether the apparent benefits persist.
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14
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Ralph SJ, Espinet AJ. Increased All-Cause Mortality by Antipsychotic Drugs: Updated Review and Meta-Analysis in Dementia and General Mental Health Care. J Alzheimers Dis Rep 2018; 2:1-26. [PMID: 30480245 PMCID: PMC6159703 DOI: 10.3233/adr-170042] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
It is almost ten years since the Banerjee 2009 report established that inappropriate prescribing of antipsychotics in the elderly was occurring in the UK and such patients had an 85% increased risk of adverse events and greater mortality. This report was a critical analysis addressing the outcomes of treatment practices for dementia in UK patients and globally, aimed at reducing prescribing of antipsychotic drugs for dementia. Since 2009, many significant studies worldwide (including several more recent large retrospective studies) provide more extensive longitudinal data for the adverse impacts of antipsychotic drugs in dementia. We have used the data in these studies including from over 380,000 dementia patients, with 85,069 prescribed antipsychotic agents as well as from 359,235 non-dementia antipsychotic drug users to provide an up-dated meta-analysis. This is the first meta-analysis to include evidence from general mental health studies showing that antipsychotic drugs precipitate excessive mortality across the spectrum. Prescribing of antipsychotic drugs for dementia or for other mental health care should be avoided and alternative means sought for handling behavioral disorders of such patients.
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Affiliation(s)
- Stephen J Ralph
- School of Medical Science, Griffith University, Gold Coast, Southport, QLD, Australia
| | - Anthony J Espinet
- School of Medicine, Griffith University, Gold Coast, Southport, QLD, Australia
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15
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Jansen K, Haugen DF, Pont L, Ruths S. Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life-A Systematic Literature Review. J Pain Symptom Manage 2018; 55:508-521.e3. [PMID: 28803078 DOI: 10.1016/j.jpainsymman.2017.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/04/2017] [Accepted: 06/21/2017] [Indexed: 11/27/2022]
Abstract
CONTEXT Dying patients commonly experience potentially distressing symptoms. Palliative care guidelines recommend opioids, anticholinergics, antipsychotics, and benzodiazepines for symptom relief. OBJECTIVES The objective of this study was to systematically review the effectiveness and safety of palliative drug treatment in the last days of life of adult patients, focusing on the management of pain, dyspnea, anxiety, restlessness, and death rattle. METHODS A systematic search of the literature was published before December 2016 in PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Cochrane, ClinicalTrials.gov, and SveMed+. Studies on safety or effectiveness of drug therapy in dying adults with at least one outcome on symptom control, adverse effects, or survival were included. Data for included studies were extracted. Study quality was assessed using the Effective Public Health Practice Quality assessment tool for quantitative studies. RESULTS Of the 5940 unique titles identified, 12 studies met the inclusion criteria. Five studies assessed anticholinergics for death rattle, providing no evidence that scopolamine hydrobromide and atropine were superior to placebo. Five studies examined drugs for dyspnea, anxiety, or terminal restlessness, providing some evidence supporting the use of morphine and midazolam. Two studies examined opioids for pain, providing some support for morphine, diamorphine, and fentanyl. Eight studies included safety outcomes, revealing no important differences in adverse effects between the interventions and no evidence for midazolam shortening survival. CONCLUSION There is a lack of evidence concerning the effectiveness and safety of palliative drug treatment in dying patients, and the reviewed evidence provides limited guidance for clinicians to assist in a distinct and significant phase of life.
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Affiliation(s)
- Kristian Jansen
- Research Group for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Dagny F Haugen
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Lisa Pont
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Sabine Ruths
- Research Group for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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16
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Ralph SJ, Espinet AJ. Use of antipsychotics and benzodiazepines for dementia: Time for action? What will be required before global de-prescribing? DEMENTIA 2017; 18:2322-2339. [PMID: 29271252 DOI: 10.1177/1471301217746769] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Comparing how nations including the UK, USA, Canada, Australia and others have made attempts aimed at improving the care and treatment of dementia patients can provide useful insights into methods that prove successful. The UK-based 2009 Banerjee Report provided international leadership in addressing treatment and practices for dementia patients with an aim to reduce prescribing of antipsychotic drugs. A historical account of the different government policies and developments with the similar aims of de-prescribing are examined. Using Australia as one example, different national strategies are discussed in the context of those that have been tried and failed. In addition, policies that have successfully reduced the controversial current practices of overprescribing antipsychotics or related psychotropic drugs for dementia patients are presented. The evidence overwhelmingly indicates such treatments only exacerbate the disease or precipitate death – giving justification to the recent call for use of chemical restraints such as antipsychotics to be included under ‘Elder Abuse’ when considering law reform necessary to regulate compliance .
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17
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Huang KL, Fang CJ, Hsu CC, Wu SI, Juang JJ, Stewart R. Myocardial infarction risk and antipsychotics use revisited: a meta-analysis of 10 observational studies. J Psychopharmacol 2017; 31:1544-1555. [PMID: 28613100 DOI: 10.1177/0269881117714047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Associations between antipsychotic agent (AP) use and myocardial infarction (MI) risk have been inconsistent and remain controversial. We therefore conducted a meta-analysis of observational studies to address this knowledge gap. METHOD Detailed electronic database searches were performed to identify reports of observational studies that evaluated the association between AP use and the risk of MI. Pooled odds ratios (ORs) were calculated using random or fixed-effects models. RESULTS In total, four case-control studies, two case-crossover studies, one case-case time control study, three cohort studies, and one self-controlled case series were included. The pooled OR (95% confidence interval (CI)) between any AP use and MI risk was 1.55 (1.33-1.79) compared with non-use: 1.39 (1.06-1.82) for atypical AP use and 1.57 (1.29-1.91) for typical AP use. Subgroup analyses indicated that male gender, schizophrenia diagnosis, and AP exposure periods ≤60 days were associated with higher risk of MI. CONCLUSION Current evidence, based on 10 observational studies, suggested that AP use might be a potential risk factor of MI. However, we cannot conclude at this time due to significant heterogeneity among studies. We suggest that, instead of not using APs in fear of MI risk, careful cardiovascular monitoring before and during AP treatment in high-risk patients is needed. Additional high-quality prospective studies are required to evaluate the association between APs and the risk of MI.
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Affiliation(s)
- Kai-Lin Huang
- 1 Department of Pharmacy, Mackay Memorial Hospital, Taipei, Taiwan.,2 Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Ching-Ju Fang
- 3 Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Chi Hsu
- 4 Department of Medicine, Mackay Medical College, Taipei, Taiwan.,5 Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-I Wu
- 4 Department of Medicine, Mackay Medical College, Taipei, Taiwan.,5 Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,6 Department of Audiology and Speech and Language Pathology, Mackay Medical College, Taipei, Taiwan
| | - Jimmy Jm Juang
- 7 Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Robert Stewart
- 8 Department of Psychological Medicine, King's College London, London, UK
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18
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Biological substantiation of antipsychotic-associated pneumonia: Systematic literature review and computational analyses. PLoS One 2017; 12:e0187034. [PMID: 29077727 PMCID: PMC5659779 DOI: 10.1371/journal.pone.0187034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/12/2017] [Indexed: 02/07/2023] Open
Abstract
Introduction Antipsychotic (AP) safety has been widely investigated. However, mechanisms underlying AP-associated pneumonia are not well-defined. Aim The aim of this study was to investigate the known mechanisms of AP-associated pneumonia through a systematic literature review, confirm these mechanisms using an independent data source on drug targets and attempt to identify novel AP drug targets potentially linked to pneumonia. Methods A search was conducted in Medline and Web of Science to identify studies exploring the association between pneumonia and antipsychotic use, from which information on hypothesized mechanism of action was extracted. All studies had to be in English and had to concern AP use as an intervention in persons of any age and for any indication, provided that the outcome was pneumonia. Information on the study design, population, exposure, outcome, risk estimate and mechanism of action was tabulated. Public repositories of pharmacology and drug safety data were used to identify the receptor binding profile and AP safety events. Cytoscape was then used to map biological pathways that could link AP targets and off-targets to pneumonia. Results The literature search yielded 200 articles; 41 were included in the review. Thirty studies reported a hypothesized mechanism of action, most commonly activation/inhibition of cholinergic, histaminergic and dopaminergic receptors. In vitro pharmacology data confirmed receptor affinities identified in the literature review. Two targets, thromboxane A2 receptor (TBXA2R) and platelet activating factor receptor (PTAFR) were found to be novel AP target receptors potentially associated with pneumonia. Biological pathways constructed using Cytoscape identified plausible biological links potentially leading to pneumonia downstream of TBXA2R and PTAFR. Conclusion Innovative approaches for biological substantiation of drug-adverse event associations may strengthen evidence on drug safety profiles and help to tailor pharmacological therapies to patient risk factors.
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Kjosavik SR, Gillam MH, Roughead EE. Average duration of treatment with antipsychotics among concession card holders in Australia. Aust N Z J Psychiatry 2017; 51:719-726. [PMID: 28195003 DOI: 10.1177/0004867417691851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyse average treatment duration with antipsychotics reimbursed for concession card holders under the Pharmaceutical Benefits Scheme; the proportion of initial prescribing by general practitioners, psychiatrists and other physician; and the trend in drug choice in Australia. METHOD Based on a representative 10% sample of patients receiving Pharmaceutical Benefits Scheme prescriptions since 2005, antipsychotics redeemed by concession card holders in the period from 2010 to 2013 were analysed. A 5-year baseline period was used to exclude prevalent users from incident users. Treatment duration was estimated using the epidemiological equation: prevalence/incidence = average duration. RESULTS The overall average treatment duration was 3.0 years, ranging from 1.5 years in patients aged 75 years and older to more than 4 years among patients aged 25-64 years. The most commonly used antipsychotics were olanzapine, risperidone and quetiapine, with average duration of 2.9, 2.1 and 1.7 years, respectively. Amisulpride was used longest with an average duration of 3.7 years. Quetiapine is currently the most prescribed antipsychotic and the main antipsychotic prescribed by psychiatrists to new users. The increased prescribing of quetiapine among general practitioners explains the rapid increase in the overall use of quetiapine. General practitioners initiated therapy in about 70% of cases, while psychiatrists and other physicians in about 15% each. In children younger than 15 years of age, paediatricians initiated such treatment in 47%. CONCLUSION General practitioners both initiate and maintain treatment with antipsychotics for most adults, while paediatricians mainly begin such treatment in children. The substantial increase in use of quetiapine among general practitioners, along with the short treatment duration for quetiapine, strengthens a concern about antipsychotics increasingly used for less severe disorders. Increased collaboration between paediatricians and psychiatrists regarding the youngest and between general practitioners and psychiatrists or geriatricians regarding adults and older patients seems required.
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Affiliation(s)
- Svein R Kjosavik
- 1 Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
- 2 Centre for Age-Related Diseases, Stavanger University Hospital, Stavanger, Norway
- 3 Research Unit for General Practice in Bergen, Uni Research Health, Bergen, Norway
| | - Marianne H Gillam
- 1 Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
| | - Elisabeth E Roughead
- 1 Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
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Solmi M, Murru A, Pacchiarotti I, Undurraga J, Veronese N, Fornaro M, Stubbs B, Monaco F, Vieta E, Seeman MV, Correll CU, Carvalho AF. Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review. Ther Clin Risk Manag 2017; 13:757-777. [PMID: 28721057 PMCID: PMC5499790 DOI: 10.2147/tcrm.s117321] [Citation(s) in RCA: 248] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Since the discovery of chlorpromazine (CPZ) in 1952, first-generation antipsychotics (FGAs) have revolutionized psychiatric care in terms of facilitating discharge from hospital and enabling large numbers of patients with severe mental illness (SMI) to be treated in the community. Second-generation antipsychotics (SGAs) ushered in a progressive shift from the paternalistic management of SMI symptoms to a patient-centered approach, which emphasized targets important to patients - psychosocial functioning, quality of life, and recovery. These drugs are no longer limited to specific Diagnostic and Statistical Manual of Mental Disorders (DSM) categories. Evidence indicates that SGAs show an improved safety and tolerability profile compared with FGAs. The incidence of treatment-emergent extrapyramidal side effects is lower, and there is less impairment of cognitive function and treatment-related negative symptoms. However, treatment with SGAs has been associated with a wide range of untoward effects, among which treatment-emergent weight gain and metabolic abnormalities are of notable concern. The present clinical review aims to summarize the safety and tolerability profile of selected FGAs and SGAs and to link treatment-related adverse effects to the pharmacodynamic profile of each drug. Evidence, predominantly derived from systematic reviews, meta-analyses, and clinical trials of the drugs amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, ziprasidone, CPZ, haloperidol, loxapine, and perphenazine, is summarized. In addition, the safety and tolerability profiles of antipsychotics are discussed in the context of the "behavioral toxicity" conceptual framework, which considers the longitudinal course and the clinical and therapeutic consequences of treatment-emergent side effects. In SMI, SGAs with safer metabolic profiles should ideally be prescribed first. However, alongside with safety, efficacy should also be considered on a patient-tailored basis.
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Affiliation(s)
- Marco Solmi
- Neuroscience Department, University of Padua
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Andrea Murru
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Juan Undurraga
- Department of Psychiatry, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo
- Early Intervention Program, J. Horwitz Psychiatric Institute, Santiago, Chile
| | - Nicola Veronese
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- National Research Council, Ageing Section, Padua
| | - Michele Fornaro
- Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, School of Medicine, University “Federico II”, Naples, Italy
- New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Brendon Stubbs
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London
- Faculty of Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Francesco Monaco
- Institute for Clinical Research and Education in Medicine, Padua, Italy
| | - Eduard Vieta
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | | | - Christoph U Correll
- Department of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks
- Department of Psychiatry and Molecular Medicine Hempstead, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - André F Carvalho
- Institute for Clinical Research and Education in Medicine, Padua, Italy
- Translational Psychiatry Research Group and Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
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21
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Hsu WT, Esmaily-Fard A, Lai CC, Zala D, Lee SH, Chang SS, Lee CC. Antipsychotics and the Risk of Cerebrovascular Accident: A Systematic Review and Meta-Analysis of Observational Studies. J Am Med Dir Assoc 2017; 18:692-699. [PMID: 28431909 DOI: 10.1016/j.jamda.2017.02.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Studies investigating the association between antipsychotic use and the risk of cerebrovascular accident (CVA) showed inconsistent results. AIM Conduct a systematic review and meta-analysis to evaluate whether use of antipsychotics is associated with increased risk of CVA. METHODS Major electronic databases were searched from 1970 to October 2016 for observational studies investigating the risk of CVA among users of antipsychotics. Pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were obtained by random effects meta-analysis. RESULTS Of 1171 citations identified, 10 studies were considered eligible. Significant increase in risk of CVA was associated with first-generation antipsychotics (OR 1.49; 95% CI 1.24-1.77) but not with second-generation antipsychotics (OR 1.31; 95% CI 0.74-2.30). Use of any antipsychotics in patients with dementia was associated with a low risk of CVA (OR 1.17; 95% CI 1.08-1.26). CONCLUSIONS The available evidence suggests use of with first-generation antipsychotics as opposed to second-generation antipsychotics significantly increased the risk of CVA.
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Affiliation(s)
- Wan-Ting Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Health Economics and Outcome Research Group, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Darshan Zala
- Institute of Psychiatry, Psychology and Neuroscience at King's College London, London, United Kingdom
| | - Sie-Huei Lee
- Institute of Psychiatry, Psychology and Neuroscience at King's College London, London, United Kingdom; Department of Medicine, College of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Shy-Shin Chang
- Department of Family Medicine, Chang-Gung University Hospital, Linkou, Taiwan; Graduate Institute of Clinical Medicine, Chang-Gung University Hospital, Linkou, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Health Economics and Outcome Research Group, National Taiwan University Hospital, Taipei, Taiwan.
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Lee SH, Hsu WT, Lai CC, Esmaily-Fard A, Tsai YW, Chiu CC, Wang J, Chang SS, Lee CC. Use of antipsychotics increases the risk of fracture: a systematic review and meta-analysis. Osteoporos Int 2017; 28:1167-1178. [PMID: 28083669 DOI: 10.1007/s00198-016-3881-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/11/2016] [Indexed: 01/19/2023]
Abstract
UNLABELLED Our systematic review and meta-analysis of observational studies indicated that the use of antipsychotics was associated with a nearly 1.5-fold increase in the risk of fracture. First-generation antipsychotics (FGAs) appeared to carry a higher risk of fracture than second-generation antipsychotics (SGAs). INTRODUCTION The risk of fractures associated with the use of antipsychotic medications has inconsistent evidence between different drug classes. A systematic review and meta-analysis was conducted to evaluate whether there is an association between the use of antipsychotic drugs and fractures. METHODS Searches were conducted through the PubMed and EMBASE databases to identify observational studies that had reported a quantitative estimate of the association between use of antipsychotics and fractures. The summary risk was derived from random effects meta-analysis. RESULTS The search yielded 19 observational studies (n = 544,811 participants) with 80,835 fracture cases. Compared with nonuse, use of FGAs was associated with a significantly higher risk for hip fractures (OR 1.67, 95% CI, 1.45-1.93), and use of second generation antipsychotics (SGAs) was associated with an attenuated but still significant risk for hip fractures (OR 1.33, 95% CI, 1.11-1.58). The risk of fractures associated with individual classes of antipsychotic users was heterogeneous, and odds ratios ranged from 1.24 to 2.01. Chlorpromazine was associated with the highest risk (OR 2.01, 95% CI 1.43-2.83), while Risperidone was associated with the lowest risk of fracture (OR 1.24, 95% CI 0.95-1.83). CONCLUSIONS FGA users were at a higher risk of hip fracture than SGA users. Both FGAs and SGAs were associated with an increased risk of fractures, especially among the older population. Therefore, the benefit of the off-label use of antipsychotics in elderly patients should be weighed against any risks for fracture.
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Affiliation(s)
- S-H Lee
- Department of Rehabilitation and Physical Medicine, Taipei Veteran General Hospital, Taipei, Taiwan
- Department of Medicine, College of Medicine, National Yang Ming University, Taipei, Taiwan
| | - W-T Hsu
- Health Economics and Outcome Research Group, Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung Shan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan
| | - C-C Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - A Esmaily-Fard
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y-W Tsai
- Department of Family Medicine, Chang Gung Memorial Hospital, University College of Medicine, Taoyuan, Taiwan
| | - C-C Chiu
- Department of Rehabilitation and Physical Medicine, Taipei Veteran General Hospital, Taipei, Taiwan
| | - J Wang
- University of Nevada School of Medicine, Las Vegas, Nevada, USA
| | - S-S Chang
- Department of Family Medicine, Chang Gung Memorial Hospital, No.5. Fu-Hsing street, Kuei Shan Hsiang, Taoyuan, Hsien, Taiwan.
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - C C Lee
- Health Economics and Outcome Research Group, Department of Emergency Medicine, National Taiwan University Hospital, No.7, Chung Shan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan.
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Dennis M, Shine L, John A, Marchant A, McGregor J, Lyons RA, Brophy S. Risk of Adverse Outcomes for Older People with Dementia Prescribed Antipsychotic Medication: A Population Based e-Cohort Study. Neurol Ther 2017; 6:57-77. [PMID: 28054240 PMCID: PMC5447553 DOI: 10.1007/s40120-016-0060-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Over recent years there has been growing evidence of increased risk of mortality associated with antipsychotic use in older people with dementia. Although this concern combined with limited evidence of efficacy has informed guidelines restricting antipsychotic prescription in this population, the use of antipsycotics remains common. Many published studies only report short-term outcomes, are restricted to examining mortality and stroke risk or have other limitations. The aim of this study was to assess adverse outcomes associated with the use of antipsychotics in older people living with dementia in Wales (UK). METHODS This was a retrospective study of a population-based dementia cohort using the Welsh Secure Anonymised Information Linkage databank. The prior event rate ratio (PERR) was used to estimate the influence of exposure to antipsychotic medication on acute cardiac events, venous thromboembolism, stroke and hip fracture, and adjusted Cox proportional hazard models were used to compare all-cause mortality. RESULTS A total of 10,339 people aged ≥65 years were identified with newly diagnosed dementia. After excluding those who did not meet the inclusion criteria, 9674 people remained in the main cohort of whom 3735 were exposed to antipsychotic medication. An increased risk of a venous thromboembolic episode [PERR 1.95, 95% confidence interval (CI) 1.83-2.0], stroke (PERR 1.41, 95% CI 1.4-1.46) and hip fracture (PERR 1.62, 95% CI 1.59-1.65) was associated with antipsychotic use. However, there was no long-term increased mortality in people exposed to antipsychotics (adjusted hazard ratio 1.06, 95% CI 0.99-1.13). CONCLUSIONS The increase in adverse medical events supports guidelines restricting antipsychotic use in this population.
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Affiliation(s)
- Michael Dennis
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK.
| | - Laura Shine
- Cwm Taf Health Board, Port Talbot, Wales, UK
| | - Ann John
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Amanda Marchant
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Joanna McGregor
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Ronan A Lyons
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Sinead Brophy
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
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El-Saifi N, Jones C, Moyle W. Quetiapine adverse events in older adults in Australia. Australas J Ageing 2016; 35:281-284. [DOI: 10.1111/ajag.12347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Najwan El-Saifi
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
| | - Cindy Jones
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
- Centre for Health Practice Innovation; Griffith University; Brisbane Queensland Australia
| | - Wendy Moyle
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
- Centre for Health Practice Innovation; Griffith University; Brisbane Queensland Australia
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Tampi RR, Tampi DJ, Balachandran S, Srinivasan S. Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Ther Adv Chronic Dis 2016; 7:229-45. [PMID: 27583123 DOI: 10.1177/2040622316658463] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The purpose of this review is to evaluate the data on the use of antipsychotics in individuals with dementia from meta-analyses. METHODS We performed a literature search of PubMed, MEDLINE, EMBASE, PsycINFO and Cochrane collaboration databases through 30 November, 2015 using the following keywords: 'antipsychotics', 'dementia' and 'meta-analysis'. The search was not restricted by the age of the patients or the language of the study. However, in the final analysis we only included studies involving patients that were published in English language journals or had official English translations. In addition, we reviewed the bibliographic databases of published articles for additional studies. RESULTS This systematic review of the literature identified a total of 16 meta-analyses that evaluated the use of antipsychotics in individuals with dementia. Overall, 12 meta-analyses evaluated the efficacy of antipsychotics among individuals with dementia. Of these, eight also assessed adverse effects. A further two studies evaluated the adverse effects of antipsychotics (i.e. death). A total of two meta-analyses evaluated the discontinuation of antipsychotics in individuals with dementia. Overall, three meta-analyses were conducted in individuals with Alzheimer's disease (AD) whereas one focused on individuals with Lewy Body Dementia (LBD). The rest of the 12 meta-analyses included individuals with dementia. CONCLUSIONS Antipsychotics have demonstrated modest efficacy in treating psychosis, aggression and agitation in individuals with dementia. Their use in individuals with dementia is often limited by their adverse effect profile. The use of antipsychotics should be reserved for severe symptoms that have failed to respond adequately to nonpharmacological management strategies.
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Affiliation(s)
- Rajesh R Tampi
- Case Western Reserve University School of Medicine, Vice Chairman for Education and Faculty Development, Program Director, Psychiatry Residency, Department of Psychiatry, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Deena J Tampi
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | | | - Shilpa Srinivasan
- University of South Carolina School of Medicine, Charleston, SC, USA
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Mediators of First- Versus Second-generation Antipsychotic-related Mortality in Older Adults. Epidemiology 2016; 26:700-9. [PMID: 26035686 DOI: 10.1097/ede.0000000000000321] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Observational studies of older adults showed higher mortality for first-generation antipsychotics than their second- generation counterparts, which led to US Food and Drug Administration warnings, but the actual mechanisms involved remain unclear. METHODS A cohort of 9,060 initiators of first-generation antipsychotics and 17,137 of second-generation antipsychotics enrolled in New Jersey and Pennsylvania Medicare were followed for 180 days. Medical events were assessed using diagnostic and procedure codes on inpatient billing claims. For the individual and joint set of medical events (mediators), we estimated the total, direct, and indirect effects of antipsychotic type (first versus second generation) on mortality on the risk ratio scale and the proportion mediated on the risk difference scale, obtaining 95% confidence intervals through bootstrapping. We performed bias analyses for false-negative mediator misclassification in claims data, with sensitivity ranging from 0.25 to 0.75. RESULTS There were 3,199 deaths (outcomes), 862 cardiovascular events, 675 infectious events, and 491 hip fractures (potential mediators). Mortality was higher for first- than second-generation antipsychotic initiators (adjusted risk ratio: 1.14; 95% confidence interval: 1.06, 1.22). In naïve analyses, that ignored potential misclassification, less than 4% of this difference was explained by any particular medical event. In bias analyses, the proportion mediated ranged from 6% to 16% for stroke, 3% to 9% for ventricular arrhythmia, 3% to 11% for myocardial infarction, 0% venous thromboembolism, 3% to 9% for pneumonia, 0% to 1% for other bacterial infection, and 1% to 3% for hip fracture. CONCLUSIONS Acute cardiovascular events and pneumonia may explain part of the mortality difference between first- and second-generation antipsychotic initiators in this analysis.
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Greenblatt HK, Greenblatt DJ. Use of Antipsychotics for the Treatment of Behavioral Symptoms of Dementia. J Clin Pharmacol 2016; 56:1048-57. [PMID: 26953213 DOI: 10.1002/jcph.731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/29/2016] [Indexed: 01/08/2023]
Abstract
Antipsychotic medications are widely used in the management of behavioral and psychological symptoms of dementia. While nonpharmacological interventions should be the first-line treatment for behavioral symptoms of dementia, these are often unfeasible and/or ineffective. Conventional and atypical antipsychotic agents appear to have modest to moderate clinical efficacy in the treatment of these symptoms, though it is unclear which individual agents are most effective. No conclusive evidence exists that any available alternative medications are safer and more effective than antipsychotics. A number of studies have shown an increased risk of mortality associated with antipsychotics in patients with behavioral symptoms of dementia, though the observed risk increase may be partially confounded by illness severity and/or preexisting health determinants. The mechanisms of increased mortality risk are not fully established, but are likely to involve cardiovascular events. It is probable, though not certain, that conventional antipsychotics are associated with a greater number of poor outcomes than atypical antipsychotics. In certain patients with refractory behavioral symptoms, antipsychotics are a viable treatment option. Key considerations for antipsychotic prescribing for this population are published in regulatory guidelines, and include minimization of dosage and duration of treatment, continuous reevaluation of symptoms, and involvement of caregivers.
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Affiliation(s)
- H Karl Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - David J Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
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Risk of Mortality Among Patients Treated With Antipsychotic Medications: A Nationwide Population-Based Study in Taiwan. J Clin Psychopharmacol 2016; 36:9-17. [PMID: 26658260 DOI: 10.1097/jcp.0000000000000451] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this nationwide population-based study, we examined whether haloperidol exposure is associated with a higher risk of mortality than are other antipsychotic medications. Patients who newly received monotherapy with chlorpromazine (n = 2133), haloperidol (n = 4454), quetiapine (n = 1513), and risperidone (n = 1046) between January 1, 2001, and December 31, 2011, were selected from a random sample of the 1 million enrollees of the Taiwan National Health Insurance Research Database. The association between antipsychotic prescription and mortality was estimated through Cox proportional hazard regression. To examine the mortality rates of antipsychotics at different exposure durations, we compared the differences among short-term (≤30 days), midterm (31-90 days), and long-term (>90 days) antipsychotic use. The mortality rates during the follow-up among the chlorpromazine, haloperidol, quetiapine, and risperidone groups were 17.4%, 45.5%, 26.8%, and 25.9%, respectively. The mortality risk among patients receiving haloperidol was the highest within 30 days of the prescription, after which the risk reduced rapidly. Compared with the patients receiving chlorpromazine, the mortality risk was higher in short-term (adjusted hazard ratio, 2.11; 95% confidence interval, 1.87-2.39) and midterm haloperidol users (1.86; 1.54-2.25) than in long-term users (0.99; 0.61-1.61). In conclusion, haloperidol use is associated with higher mortality risk than other antipsychotic medications. The mortality risk varies according to the duration of drug exposure. Underlying characteristics and medical conditions may influence the estimation of the mortality risk. Clinicians should pay attention to the mortality risk when prescribing antipsychotic medications, particularly for the elderly and critically ill patients.
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Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry 2015; 14:119-36. [PMID: 26043321 PMCID: PMC4471960 DOI: 10.1002/wps.20204] [Citation(s) in RCA: 499] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
People with severe mental illness have a considerably shorter lifespan than the general population. This excess mortality is mainly due to physical illness. Next to mental illness-related factors, unhealthy lifestyle, and disparities in health care access and utilization, psychotropic medications can contribute to the risk of physical morbidity and mortality. We systematically reviewed the effects of antipsychotics, antidepressants and mood stabilizers on physical health outcomes in people with schizophrenia, depression and bipolar disorder. Updating and expanding our prior systematic review published in this journal, we searched MEDLINE (November 2009 - November 2014), combining the MeSH terms of major physical disease categories (and/or relevant diseases within these categories) with schizophrenia, major depressive disorder and bipolar disorder, and the three major psychotropic classes which received regulatory approval for these disorders, i.e., antipsychotics, antidepressants and mood stabilizers. We gave precedence to results from (systematic) reviews and meta-analyses wherever possible. Antipsychotics, and to a more restricted degree antidepressants and mood stabilizers, are associated with an increased risk for several physical diseases, including obesity, dyslipidemia, diabetes mellitus, thyroid disorders, hyponatremia; cardiovascular, respiratory tract, gastrointestinal, haematological, musculoskeletal and renal diseases, as well as movement and seizure disorders. Higher dosages, polypharmacy, and treatment of vulnerable (e.g., old or young) individuals are associated with greater absolute (elderly) and relative (youth) risk for most of these physical diseases. To what degree medication-specific and patient-specific risk factors interact, and how adverse outcomes can be minimized, allowing patients to derive maximum benefits from these medications, requires adequate clinical attention and further research.
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Affiliation(s)
- Christoph U Correll
- Department of Psychiatry, Zucker Hillside Hospital, North Shore - Long Island Jewish Health SystemGlen Oaks, New York, NY, USA,Department of Psychiatry and Molecular Medicine, Hofstra North Shore LIJ School of MedicineHempstead, New York, NY, USA,Psychiatric Neuroscience Center of Excellence, Feinstein Institute for Medical ResearchManhasset, New York, NY, USA,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of MedicineBronx, New York, NY, USA
| | - Johan Detraux
- Department of Neurosciences, Catholic University LeuvenB-3070 Kortenberg, Belgium
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, University of LeuvenB-3000 Leuven, Belgium
| | - Marc De Hert
- Department of Neurosciences, Catholic University LeuvenB-3070 Kortenberg, Belgium
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