Reducing Off-Label Antipsychotic Use in Older Community-Dwelling Adults With Dementia: A Narrative Review

Bain, K.T.; Schwartz, Emily; Chan-Ting, Rengena

doi:10.7556/jaoa.2017.090

Cited by 6 publications

(7 citation statements)

References 36 publications

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“…31,32 Furthermore, antipsychotics, antihistamine, opioid analgesics, and proton pump inhibitors are often implicated in adverse effects such as infection, falls, hospitalization, emergency department visits, and death, 12,[33][34][35] yet these drug classes are commonly used among older patients, especially those dwelling in LTC facilities. 36,37 For instance, there have been reports of off-label use of antipsychotics in long-stay nursing homes without qualifying diagnoses 36 and in older community-dwelling adults with dementia, 37 despite modest benefit and high risk of harm. Findings from this systematic review provide additional evidence against such practices as it predisposes older persons to an increased risk of severe COVID-19 infection and mortality.…”

Section: Discussionmentioning

confidence: 99%

Polypharmacy among COVID-19 patients: A systematic review

Iloanusi¹,

Mgbere²,

Essien³

2021

Journal of the American Pharmacists Association

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Background: Polypharmacy, the concomitant use of 5 or more medications, is highly prevalent among older adults and individuals with multimorbid conditions and has been linked to suboptimal clinical outcomes in various diseases. However, little is known about the impact of polypharmacy on clinical outcomes among coronavirus disease 2019 (COVID-19) patients. Objective: This systematic review summarizes the available literature on the association between polypharmacy and specific drug classes, and clinical outcomes among COVID-19 patients. Methods: We conducted an electronic database search on Embase, Medline, Cochrane, Scopus, Google Scholar, clinicaltrials.gov, LITCOVID, PubMed, PubMed Central (PMC), and China national knowledge infrastructure for studies on Polypharmacy among COVID-19 patients using relevant combinations of the keywords. Only studies published between November 2019 to September 2020 were included. Seven articles out of 1502 unique articles met the inclusion criteria and were used for the current study. We adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in conducting and reporting this systematic review. Results: The total sample size of all studies was 474,342, out of which 10,519 patients were COVID-19 positive, and 4818 COVID-19 positive patients experienced polypharmacy. Five out of the 7 included studies found associations between polypharmacy and negative clinical outcomes among COVID-19 patients. Polypharmacy was associated with increase in the relative risk of a positive COVID-19 test result (P < 0.01), death among male COVID-19 patients (P < 0.001), increase in the rate of acute kidney injury (P ¼ 0.003), and adverse drug reactions (P < 0.001). Antipsychotic drugs were associated with severe COVID-19 morbidity (OR ¼ 2.79; 95% CI 2.23e3.49) and increased risk of death among COVID-19 infected men (OR ¼ 1.71; 95% CI 1.18e2.48) and women (OR ¼ 1.96; 95% CI 1.41e2.73). Conclusion: Polypharmacy and selected drug classes are associated with increased risk of adverse clinical outcomes among COVID-19 patients. Understanding these relationships can enhance risk stratification and evidence-based decision-making that may improve care and clinical outcomes of COVID-19 patients.

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Section: Discussionmentioning

confidence: 99%

Polypharmacy among COVID-19 patients: A systematic review

Iloanusi¹,

Mgbere²,

Essien³

2021

Journal of the American Pharmacists Association

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“…Abbreviations: AP = antipsychotic, CYP = cytochrome P450, DDI = drug-drug interaction, Rx = prescription. 1 Data are indicated as number (percentage). 2 Victim refers to the antipsychotic "suffering from" the potential DDI, whereas perpetrator refers to the antipsychotic "causing" the potential DDI.…”

Section: Resultsmentioning

confidence: 99%

“…Abbreviations: CYP = cytochrome P450, DDI = drug-drug interaction. 1 Examples of co-prescribed medications involved in potentially clinically relevant DDIs associated with the top 3 prescribed atypical antipsychotics. For example, aripiprazole was the perpetrator of potential DDIs mediated by the CYP2D6 isoenzyme, and metoprolol was the victim, whereas paroxetine was the perpetrator of potential DDIs mediated by the CYP2D6 isoenzyme, and aripiprazole was the victim.…”

Section: Resultsmentioning

confidence: 99%

“…Antipsychotic use among older Americans has been well studied, particularly in long-term care settings such as nursing homes [1,2]. Findings from a large population-based study, for instance, indicated that in 2012 approximately 33% of Medicare beneficiaries with dementia who resided in nursing homes were prescribed antipsychotics [2].…”

Section: Introductionmentioning

confidence: 99%

“…Most frequently prescribed atypical antipsychotics considering commonly co-prescribed medications1 .…”

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confidence: 99%

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Cytochrome P450 (CYP450) Interactions Involving Atypical Antipsychotics Are Common in Community-Dwelling Older Adults Treated for Behavioral and Psychological Symptoms of Dementia

Matos¹,

Bain²,

Bankes³

et al. 2020

Pharmacy

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Treatment of behavioral and psychological symptoms of dementia (BPSD) and comorbidities often necessitates the concomitant use of antipsychotics and non-antipsychotic drugs, thereby potentiating the risk for drug–drug interactions (DDIs). The primary objective of our study was to identify potentially clinically relevant cytochrome P450 (CYP)-mediated DDIs involving antipsychotics among participants enrolled in the Program of All-Inclusive Care for the Elderly (PACE) with BPSD. Additionally, we wanted to determine the prevalence of antipsychotic use in this population. The study included 10,001 PACE participants. The practice setting used a proprietary clinical decision support system (CDSS) to analyze simultaneous multidrug interactions. A retrospective analysis of pharmacy claims data was conducted to identify DDIs involving antipsychotics prescribed for BPSD, using snapshots of medication profiles paired with the CDSS. Of the participants who met inclusion criteria, 1190 (11.9%) were prescribed an antipsychotic; of those, 1071 (90.0%) were prescribed an atypical antipsychotic. Aripiprazole commonly caused (being a perpetrator drug 94.6% of the time) potential DDIs with antidepressants (e.g., duloxetine, venlafaxine, mirtazapine), opioids (e.g., hydrocodone, oxycodone, tramadol) and metoprolol via the CYP2D6 isoform. Risperidone commonly caused (85.7%) potential DDIs with donepezil, lamotrigine and trazodone via the CYP3A4 isoform. Quetiapine exclusively suffered (100%) from potential DDIs with amlodipine, buspirone, omeprazole or topiramate via the CYP3A4 isoform. Antipsychotics are commonly prescribed to PACE participants for BPSD treatment and they may interact with other drugs used to treat comorbidities. A thorough review of concomitant medications will help mitigate the likelihood of potentially dangerous CYP-mediated DDIs involving antipsychotics.

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