Haloperidol in palliative care: Indications and risks

An evaluation of the adequacy of Indian national and state essential medicines lists (EMLs) for palliative care medical needs-a comparative analysis

Objectives

Essential medicines lists (EMLs) guide the public sector procurement and supply of medications to impact access to adequate and appropriate palliative care drugs. This study evaluates the adequacy of India's national and sub-national EMLs that can directly impact palliative care for 5.4 million patients.

Methods

In this qualitative document review, we compared Indian national, and state EMLs acquired from official government websites with the International Association for Hospice and Palliative Care (IAHPC) EML recommendations. We analysed data on the indication and formulation of drugs under the different categories of formulations present (all, some and no), and drugs absent. Literature review and inputs from palliative care experts provided alternatives of absent medications to assess the adequacy of lists in managing the symptoms listed by IAPHC.

Results

We analysed 3 national and 27 state lists for 33 recommended drugs. The Central Government Health Services list had the maximum availability of all formulations of drugs (16 [48%]) nationally. Among states and union territories, the Delhi EML was the closest to IAHPC with 17 (52%) drugs with all formulations present. Karnataka had the most incomplete EML with only 3 (9%) drugs with all formulations present. No EML had all the recommended formulations of morphine. In one national and seventeen state EMLs, oral morphine was absent.

Conclusion

While Indian EMLs lack drugs for palliative care when compared with the IAHPC EML, symptom management is adequate. There is a need for countries with limited resources to modify the IAPHC list for their settings.

Histopathological evidence of cellular alterations in the dentate gyrus is associated with aberrant RB1CC1-ATG16L1 expression in the hippocampus among older adults with chronic schizophrenia: A pilot post-mortem study

BACKGROUND

Recent evidence brings autophagy, and specifically the RB1CC1 gene into sharp focus as aetiologically relevant to Schizophrenia. Our understanding of whether and how these genetic signatures translate to cellular functions remains limited.

MATERIAL AND METHODS

Post-mortem study of 10 individuals with Schizophrenia and 18 individuals without any neurological/psychiatric disorder, matched for age, sex, post-mortem-interval, pH and BRAAK score. Formalin-fixed, paraffin-embedded, 6 μm sections cut through segments of the anterior, middle and posterior left or right hippocampus were examined for histopathological differences and immunohistochemical expression of RB1CC1 and ATG16L1 proteins.

RESULTS

Dentate gyrus (DG) granule cells area (p = 0.005) and circularity (p = 0.012) were significantly lower among Schizophrenia vs. controls. Antipsychotics were associated with lower circularity (p = 0.007). RB1CC1 and ATG16L1 immunoexpression were positively correlated (p < 0.001) and significantly lower in the CA1 (p = 0.047, p = 0.005, respectively). RB1CC1 immunoexpression was significantly higher in the DG among Schizophrenia vs. controls (p = 0.047,). The latter was more pronounced among donors treated with antipsychotics. Lower ATG16L1 CA1 immunoreactivity was correlated with lower granule cell area (p < 0.001).

CONCLUSIONS

For the first time, we present histopathological evidence of morphological alterations in the DG of the human brain in Schizophrenia. We propose that these changes indicate DG developmental arrest, which is associated with diminished RB1CC1-ATG16L1-mediated autophagy initiation in the CA1. We suggest that this is a pathological process, whereas RB1CC1-ATG16L1 upregulation in the DG, and possibly in the CA4, may represent a compensatory/restorative mechanism. Antipsychotics may upregulate RB1CC1-ATG16L1 autophagy initiation. Larger studies are required to validate these findings and explore clinical correlations.

Intricate mechanism of anxiety disorder, recognizing the potential role of gut microbiota and therapeutic interventions

Anxiety is a widespread psychological disorder affecting both humans and animals. It is a typical stress reaction; however, its longer persistence can cause severe health disorders affecting the day-to-day life activities of individuals. An intriguing facet of the anxiety-related disorder can be addressed better by investigating the role of neurotransmitters in regulating emotions, provoking anxiety, analyzing the cross-talks between neurotransmitters, and, most importantly, identifying the biomarkers of the anxiety. Recent years have witnessed the potential role of the gut microbiota in human health and disorders, including anxiety. Animal models are commonly used to study anxiety disorder as they offer a simpler and more controlled environment than humans. Ultimately, developing new strategies for diagnosing and treating anxiety is of paramount interest to medical scientists. Altogether, this review article shall highlight the intricate mechanisms of anxiety while emphasizing the emerging role of gut microbiota in regulating metabolic pathways through various interaction networks in the host. In addition, the review will foster information about the therapeutic interventions of the anxiety and related disorder.

Influence of polystyrene nanoplastics on the toxicity of haloperidol to amphibians: An in vivo and in vitro approach

Chemical pollution is a major driver for the current worldwide crisis of amphibian decline. The present study aimed to assess the influence of polystyrene nanoplastics (PS-NPLs) on the toxicity of haloperidol to aquatic life stages of amphibians, by using in vivo (tadpoles of Xenopus laevis and Pelophylax perezi) and in vitro (A6 and XTC-2 cell lines of X. laevis) biological models. Tadpoles of both species were exposed, for 96 h, to haloperidol: 0.404 to 2.05 mg l-1 (X. laevis) or 0.404 to 3.07 mg L-1 (P. perezi). The most sensitive species to haloperidol (X. laevis) was exposed to haloperidol's LC50,96h combined with two PS-NPLs concentrations (0.01 mg L-1 or 10 mg L-1); the following endpoints were monitored: mortality, malformations, body lengths and weight. In vitro cytotoxicity was assessed by exposing the two cell lines, for 72 h, to: haloperidol (0.195 to 100 mg L-1) alone and combined with 0.01 mg L-1 or 10 mg L-1 of PS-NPLs. Xenopus laevis tadpoles revealed a higher lethal and sublethal sensitivity to haloperidol than those of P. perezi, with LC50,96h of 1.45 and 2.20 mg L-1. In vitro assays revealed that A6 cell line is more sensitive haloperidol than XTC-2: LC50,72h of 13.2 mg L-1 and 5.92 mg L-1, respectively. Results also suggested a higher sensitivity of in vivo models when compared to in vitro biological. Overall, PS-NPLs did not influence haloperidol's toxicity for in vivo and in vitro biological models, except for a reduction on the incidence of malformations while increasing the lethal toxicity (at the lowest concentration) in tadpoles. These opposite interaction patterns highlight the need for a deeper comprehension of NPLs and pharmaceuticals interactions. Results suggest a low risk of haloperidol for anuran tadpoles, though in the presence of PS-NPLs the risk may be increased.

Review of Dopamine Antagonists for Nausea and Vomiting in Palliative Care Patients

Symptoms of nausea and vomiting are common in palliative care and hospice patients. One of the many classes of medications used for the treatment of nausea and vomiting is dopamine receptor antagonists which are particularly helpful for treating nausea mediated by the chemoreceptor trigger zone (CTZ) and impaired gastrointestinal function. While dopamine antagonists can be very effective treatments for nausea they should be used with caution as they carry the risk of QTc prolongation, have a FDA black box warning for tardive dyskinesia (TD), and increased risk of precipitating psychosis and death in patients with dementia. This review will cover haloperidol, olanzapine, prochlorperazine, and metoclopramide for treatment of nausea and vomiting including evidence of efficacy, pharmacokinetics, and pharmacodynamics to improve safe and effective utilization in clinical practice. This includes medication receptor site affinities at histaminic, muscarinic, serotonergic, and alpha-adrenergic receptors which can help providers anticipate potential adverse effects and risk of extrapyramidal symptoms (EPS), TD, and QTc prolongation. This review also includes considerations for dose adjustments based on renal function, hepatic function, and age. Understanding the pharmacology of dopamine antagonists can help providers choose the best treatment for control of nausea and vomiting and subsequently improve patients' quality of life.

Deprescribing Tool for Older PeoPle with Limited-life Expectancy (De-TOPPLE) version 1: Development and validation using a modified Delphi technique

Deprescribing decision making in older adults with limited life expectancy is often challenging for clinicians. We aimed to develop and validate a Deprescribing Tool for Older People with Limited-life Expectancy (De-TOPPLE). Modified Delphi technique was used to gain experts' consensus on the tool and further develop using their feedback. Experts [Round-1 (n = 13), Round-2 (n = 7)] had clinical and/or research background on geriatric medicine, geriatrics, family medicine or pharmacotherapy. Round-1 consensus was achieved on approach taken by the tool to evaluate risk and benefit; distinguishing medications as preventive, symptom control or dual-purpose; referring to established deprescribing process; stepwise approach to deprescribing; and the overall concept. Common feedback was to reflect upon harm-benefit analysis, distinguish medication types earlier, qualify adverse events, use time-to-benefit (TTB), prioritise symptom relief, monitor post-deprescribing, include shared decision making and define terms for clinical familiarisation. After tool update, Round-2 consensus was achieved on usability in clinical setting, flexibility of implicit judgement, ceasing preventive medication with inadequate TTB, ceasing symptom control medication with inadequate symptom relief, ceasing dual-purpose medication (DPM) with inadequate TTB and symptom relief, and continuing DPM with adequate TTB and symptom relief. De-TOPPLE version 1 was developed and validated through two rounds of the Delphi process. Clinical use of the tool needs final validation following the addition of contextual statements to the tool.

Effects of haloperidol on peripheral erythrocytes and brain neurotransmitter levels of juvenile African Sharptooth Catfish Clarias gariepinus

OBJECTIVE

The study investigated the effects of haloperidol on peripheral erythrocytes and brain neurotransmitter levels of juvenile African Sharptooth Catfish Clarias gariepinus.

METHODS

Juveniles were exposed to different concentrations of haloperidol (0.12, 0.24, and 0.48 mg/L) for 15 days and subsequently withdrawn from the drug for 5 days. Blood samples from the fish on days 1, 5, 10, and 15 and after the 5-day withdrawal period were analyzed for mutagenic changes, after which the fish were sacrificed. The brain was sampled for serotonergic and dopaminergic analyses.

RESULT

There was formation of micronuclei in the peripheral fish blood, which increased as the duration and concentrations of the drug increased. The drug significantly reduced the serotonin activity but increased dopamine activity. Some of the studied parameters, however, recovered from the effects of the drug after the 5-day withdrawal period.

CONCLUSION

Haloperidol is toxic to fish, and its use in the environment should be guarded to avoid adverse impacts on nontarget species like fish.

Prenatal exposition to haloperidol: A preclinical narrative review

Pre-existing maternal mental disorders may affect the early interactions between mother and baby, impacting the child's psychoemotional development. The typical antipsychotic haloperidol can be used during pregnancy, even with some restrictions. Its prescription is not limited to psychotic disorders, but also to other psychiatric conditions of high incidence and prevalence in the woman's fertile period. The present review focused on the preclinical available data regarding the biological and behavioral implications of embryonic exposure to haloperidol. The understanding of the effects of psychotropic drugs during neurodevelopment is important for its clinical aspect since there is limited evidence regarding the risks of antipsychotic drug treatment in pregnant women and their children. Moreover, a better comprehension of the mechanistic events that can be affected by antipsychotic treatment during the critical period of neurodevelopment may offer insights into the pathophysiology of neurodevelopmental disorders. The findings presented in this review converge to the existence of several risks associated with prenatal exposure to such medication and emphasize the need for further studies regarding its dimensions.

A systematic review on methods for developing and validating deprescribing tools for older adults with limited life expectancy

OBJECTIVES

A number of deprescribing tools are available to assist clinicians to make decisions on medication management. We aimed to review deprescribing tools that may be used with older adults that have limited life expectancy (LLE), including those at the palliative and end-of-life stage, and consider the rigour with which the tools were developed and validated.

KEY FINDINGS

Literature was searched in PubMed, Embase, CINHAL and Google Scholar until February 2021 for studies involving the development and/or consensus validation of deprescribing tools targeting those aged ≥65 years with LLE. We were interested in the tool development process, tool validation process and clinical components addressed by the tool.Six studies were included. The approaches followed for tool development were systematic review (n = 3), expert-literature review (n = 2) and concept data (n = 1). The content included a list of disease-non-specific medications divided with or without recommendations (n = 4) and disease-specific medications with recommendations (n = 2). The tool validation was performed using the Delphi method (n = 4) or GRADE framework (n = 2) with panel size ranging from 8 to 17 and 60-80% consensus agreement with or without a rating scale. LLE targeted were ≤1 year (n = 2) or ≤3 months (n = 1).

SUMMARY

There is a limited number of deprescribing tools with consensus validation available for use in older adults with LLE. These tools are either targeted for disease-specific medication/medication class guided by the GRADE framework or targeted for a list of medications or medication classes irrespective of disease that are developed using a combination of approaches and validated using a Delphi method.

Haloperidol Instigates Endometrial Carcinogenesis and Cancer Progression by the NF-κB/CSF-1 Signaling Cascade

Simple Summary

Haloperidol, a typical antipsychotic, is widely used in schizophrenia and palliative care of cancer; however, the role and impact of chronic haloperidol treatment in endometrial cancer (EC) development are unclear. Here, we showed that haloperidol is a carcinogenic compound capable of inducing endometrial hyperplasia and promoting EC progression in rodents. Mechanistically, haloperidol stimulates the production of colony-stimulating factor 1 (CSF-1) on tumor cells by activating nuclear factor kappa B (NF-κB), and its downstream autocrine oncogenic CSF-1 receptor signaling contributes to this carcinogenesis. Furthermore, we demonstrated that the use of haloperidol is associated with increased EC-specific mortality in EC patients. Overall, these findings highlighted that physicians should be cautious about the use of haloperidol in female patients.

Abstract

Haloperidol is a routine drug for schizophrenia and palliative care of cancer; it also has antitumor effects in several types of cancer. However, the role of haloperidol in endometrial cancer (EC) development is still unclear. Here, we show that chronic haloperidol treatment in clinically relevant doses induced endometrial hyperplasia in normal mice and promoted tumor growth and malignancy in mice with orthotopic EC. The pharmacokinetic study indicated that haloperidol highly accumulated in the uterus of mice. In vitro studies revealed that haloperidol stimulated the cellular transformation of human endometrial epithelial cells (HECCs) and promoted the proliferation, migration, and invasion of human endometrial carcinoma cells (HECCs) by activating nuclear factor kappa B (NF-κB) and its downstream signaling target, colony-stimulating factor 1 (CSF-1). Gain of function of CSF-1 promotes the cellular transformation of HEECs and the malignant progression of HECCs. Moreover, blockade of CSF-1 inhibited haloperidol-promoted EC progression in vitro and in vivo. A population-based cohort study of EC patients further demonstrated that the use of haloperidol was associated with increased EC-specific mortality. Collectively, these findings indicate that clinical use of haloperidol could potentially be harmful to female patients with EC.

Pharmacokinetic drug interactions with oral haloperidol in adults: dose correction factors from a combined weighted analysis

INTRODUCTION

Pharmacokinetic (PK) drug-drug interactions (DDIs) of oral haloperidol, a first-generation antipsychotic, are systematically reviewed.

AREAS COVERED

After exclusions, the search for DDIs with oral haloperidol provided 47 articles as victim and 7 as perpetrator. Changes in mean haloperidol concentration-to-dose (C/D) ratios after weighting each study's size were used to calculate the effects of other drugs (inhibitors/inducers) on haloperidol. These changes of haloperidol C/D ratio were used to estimate dose-correction factors (<1 for inhibitors and >1 for inducers).

EXPERT OPINION

A box summarizes our recommendations for clinicians regarding our current knowledge of haloperidol PK DDIs, which will need to be updated as new information becomes available. Moderate to strong inducers (carbamazepine, phenobarbital, phenytoin, or rifampin) should be avoided since they required dose-correction factors of 2-5. Smoking appeared to be a weak inducer (dose-correction factor 1.2). Fluvoxamine, promethazine, and combinations of CYP3A4 and CYP2D6 inhibitors should be avoided. There are no long-term studies on fluoxetine to provide a dose correction factor. Limited information suggests that valproate may be an inhibitor (dose-correction factor 0.6). In most patients, haloperidol may not have clinically relevant effects as a perpetrator, but in vitro and clinical studies suggest it is a weak CYP2D6 inhibitor.

Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis

Introduction:

The decision to deprescribe medications used for both disease prevention and symptom control (dual-purpose medications or DPMs) is often challenging for clinicians. We aim to establish the impact of deprescribing DPMs on patient-related outcomes for older adults near end-of-life (EOL).

Methods:

This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google Scholar until December 2019 for studies on deprescribing intervention with a control group (with or without randomisation); targeting ⩾65-year olds, at EOL, with at least one life-limiting illness and at least one potentially inappropriate DPM. We were interested in any patient-related outcomes. Studies with similar outcome assessment criteria were subjected to meta-analysis and narrative synthesis otherwise. The risk of bias was assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised controlled trials (RCTs) and quasi-experimental non-randomised controlled studies, respectively.

Results:

Five studies covering 689 participants with mean age 81.6–85.7 years, the majority (74.6–100%) with dementia were included. The risk of bias was moderate to low. The deprescribing of DPMs lowered the risk of mortality (risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44–0.79) and referral to acute care facilities (RR = 0.40, 95% CI = 0.22–0.73), but did not have a significant impact on the risk of falls, non-vertebral fracture, emergency presentation, unplanned hospital admission, or general practitioner visits. No significant difference was observed in the quality of life, physical and cognitive functions between the intervention and control groups.

Conclusion:

There is some evidence that deprescribing of DPMs for older adults near the EOL can lower the risk of mortality and referral to acute care facilities, but there are insufficient good-quality studies powered to confirm a benefit in terms of quality of life, physical or cognitive function, health service utilisation and adverse events.

Plain Language Summary

What is the health impact of withdrawal or dose reduction of medication used for disease prevention and symptom control in older adults near end-of-life?

Introduction: Older adults (aged ⩾ 65 years) with advanced diseases such as cancer, dementia, and organ failure tend to have a limited life expectancy. With the progression of these diseases towards the end-of-life, the intensity for day-to-day supportive care becomes increasingly necessary. The use of medications for symptom management is a critical part of such care, but the use of medications for long-term disease prevention can become irrelevant due to the already shortened life expectancy and may become harmful due to alterations in physiology and pharmacology associated with age and frailty. This necessitates the withdrawal or dose reduction of inappropriate medications, the process called deprescribing. The decision to deprescribe medications used for both disease prevention and symptom control (DPMs) in this population is often challenging for clinicians. In this context, whether deprescribing of DPMs can improve patient-related health outcomes is unknown.

Methods: Evidence from the literature was reviewed and analysed, and the quality of studies was assessed. Five studies were identified, which had 689 participants with an average age above 80 years and mostly suffering from dementia.

Results: The analysis of these studies showed deprescribing of DPMs lowered the risk of death and referral to acute care facilities at 12 months but had no significant impact on falls, non-vertebral fractures, emergency presentations, unplanned hospital admission, general practitioner visits, quality of life, physical and mental functions.

Conclusion: In conclusion, there were insufficient numbers of high-quality studies powered to confirm whether deprescribing of DPMs reduces adverse events, health service use, or improves the quality of life or functioning in older adults near the end of life.