Last week PubMed made available an abstract* of a new study on the dangers of using antipsychotics in older adults with dementia. The study was done in Canada. The medical journal article was published in the 6/5/07 issue of the Annals of Internal Medicine. (See the bottom of this post for the abstract.)
The UPI had a news story on Monday about this research. The story mentions an '05 FDA warning on antipsychotics. You can find the April '05 FDA warning on fda.gov at:
http://www.fda.gov/cder/drug/advisory/a ... hotics.htm
The UPI news story quotes the researchers as saying that they think the FDA should consider extending the warning on antipsychotics to point out that the risk with conventionals is even greater.
Here's a link to the UPI story as well as the full text:
http://www.upi.com/Health_Business/Anal ... eath/6137/
Analysis: Antipsychotics linked to death
Published: June 4, 2007 at 6:16 PM
By Steve Mitchell, UPI Senior Medical Correspondent
WASHINGTON, June 4 (UPI) -- Both newer atypical antipsychotics and older conventional drugs in this class increase the risk of death when used in older adults with dementia, according to a study released Monday.
The Food and Drug Administration added a warning about the death risk to the labeling of atypical antipsychotics in 2005, but the researchers of the new study say the agency may want to consider a similar warning for conventional antipsychotics because the risk may be even greater with these medications.
"I hope there would be some consideration of extending the warning," Sudeep Gill, a geriatric medicine specialist at Providence Care-St. Mary's of the Lake Hospital and the study's lead author, told United Press International.
Conventional antipsychotics include chlorpromazine and haloperidol. Atypicals include Eli Lilly's Zyprexa, Johnson & Johnson's Risperdal and AstraZeneca's Seroquel.
One reason for adding the warning is to inform physicians who may be considering putting their patients on conventional antipsychotics in an attempt to avoid the life-threatening risk associated with the atypicals.
"Physicians may want to switch back to conventionals, but that may be the wrong thing to do because, if anything, the risk may be higher," Gill said.
He said part of the reason the FDA and other regulatory bodies may not have applied the warning to conventional antipsychotics is the paucity of clinical data on these drugs made it difficult to draw any definitive conclusions about their risk. But his study may help shed some light on the issue.
The findings, which are published in the June 5 issue of Annals of Internal Medicine, also suggest the death risk associated with atypicals persists for up to six months.
In the study, Gill and colleagues analyzed data from healthcare databases in Canada of more than 27,000 people 66 years of age or older with dementia between 1997 and 2002. Atypical antipsychotics increased the risk of death within the first month of use and the risk may last as long as six months into treatment. Conventional antipsychotics were associated with a greater risk of death than atypicals at both one month and six months.
The risk/benefit ratio of these drugs "is a very delicate balance," Gill said. "There are patients that need these drugs but probably more patients are getting them than need them."
For this reason, there should be a very careful discussion between the physician and the patient when considering using these drugs in older patients, and there should be more of an emphasis on non-drug treatments, Gill said.
The FDA gave only general comments that shed no light on how the agency may be viewing this class of drugs.
"As part of our commitment to drug safety, we continuously analyze products throughout their life cycle to better understand and quantify potential or real risks," FDA spokeswoman Sandy Walsh told UPI. "FDA remains committed to working to advance the scientific understanding and regulatory approaches needed for safe use of marketed drug products."
Some experts in this area thought the data was not enough to warrant adding a warning to conventional antipsychotics.
"This is not enough to change the warning on the labeling of conventional antipsychotics," Lon Schneider, a professor of psychiatry, neurology and gerontology at the University of Southern California's Keck school of medicine, told UPI.
Schneider, who led a 2005 study published in the Journal of the American Medical Association that found atypical antipsychotics could increase the risk of death in dementia patients, said because the current study was observational and not a clinical trial, there could be confounders that might erase or diminish the increased risk of death. As it was the risk was "really very, very small," he said.
Another factor that may be influencing the findings is inappropriate use of these medications by physicians.
"Physicians shouldn't be using some of these drugs the way they're using them," Schneider said, noting that they may not be carefully monitoring patients while they're taking the drugs and they may keep them on the medications longer than appropriate.
However, Harold Sox, editor of Annals of Internal Medicine, thought the methodology of the study was sound enough that the FDA should take a close look at the medications.
"If I were the FDA I would have to think hard about these findings and whether to add a warning for conventional antipsychotics," Sox told UPI. "It's really a wake up call for the FDA to look at this issue carefully."
* Here's the abstract published this week on PubMed (see pubmed.gov):
Annals of Internal Medicine. 2007 Jun 5;146(11):775-86.
Antipsychotic drug use and mortality in older adults with dementia.
Gill SS, Bronskill SE, Normand SL, Anderson GM, Sykora K, Lam K, Bell CM, Lee PE, Fischer HD, Herrmann N, Gurwitz JH, Rochon PA.
Queen's University, Kingston, Ontario, Canada.
BACKGROUND: Antipsychotic drugs are widely used to manage behavioral and psychological symptoms in dementia despite concerns about their safety.
OBJECTIVE: To examine the association between treatment with antipsychotics (both conventional and atypical) and all-cause mortality.
DESIGN: Population-based, retrospective cohort study.
SETTING: Ontario, Canada.
PATIENTS: Older adults with dementia who were followed between 1 April 1997 and 31 March 2003.
MEASUREMENTS: The risk for death was determined at 30, 60, 120, and 180 days after the initial dispensing of antipsychotic medication. Two pairwise comparisons were made: atypical versus no antipsychotic use and conventional versus atypical antipsychotic use. Groups were stratified by place of residence (community or long-term care). Propensity score matching was used to adjust for differences in baseline health status.
RESULTS: A total of 27,259 matched pairs were identified. New use of atypical antipsychotics was associated with a statistically significant increase in the risk for death at 30 days compared with nonuse in both the community-dwelling cohort (adjusted hazard ratio, 1.31 [95% CI, 1.02 to 1.70]; absolute risk difference, 0.2 percentage point) and the long-term care cohort (adjusted hazard ratio, 1.55 [CI, 1.15 to 2.07]; absolute risk difference, 1.2 percentage points). Excess risk seemed to persist to 180 days, but unequal rates of censoring over time may have affected these results. Relative to atypical antipsychotic use, conventional antipsychotic use was associated with a higher risk for death at all time points. Sensitivity analysis revealed that unmeasured confounders that increase the risk for death could diminish or eliminate the observed associations.
LIMITATIONS: Information on causes of death was not available. Many patients did not continue their initial treatments after 1 month of therapy. Unmeasured confounders could affect associations.
CONCLUSIONS: Atypical antipsychotic use is associated with an increased risk for death compared with nonuse among older adults with dementia. The risk for death may be greater with conventional antipsychotics than with atypical antipsychotics.
PubMed ID#: 17548409