Use of antipsychotics and the risk of acute respiratory failure among adults: A disease risk score-matched nested case-control study

Lithium and the risk of severe COVID-19 infection: A retrospective population-based register study

OBJECTIVES

Previous research has suggested antiviral properties for lithium, including potential effectiveness against COVID-19 in vitro. This study aimed to investigate the impact of lithium and other psychotropic drugs on the risks of mortality, hospitalization, and ICU admission due to COVID-19 among individuals with bipolar disorder. The primary objective was to assess whether lithium was beneficial in COVID-19-infection in a real-world population.

METHODS

Retrospective register study using data from multiple Swedish patient registers, including 39,063 individuals in Sweden with bipolar disorder and prescribed mood stabilizers. Outcomes included COVID-19-associated death, hospitalization, and ICU admission between 11 March 2020 and 10 March 2021. Multivariate logistic regression adjusted for age, sex, and somatic comorbidities was conducted.

RESULTS

Lithium were prescribed to 44.2 % of patients, either as mono- or combination therapy; other mood stabilizers were prescribed to 55.8 %. There were no significant associations between lithium and COVID-19-associated death, hospitalization, or ICU admission. Atypical antipsychotics were associated with increased odds ratios for COVID-19-associated death (OR 1.58 [95 % CI 1.01-2.47]), hospitalization (OR 1.80 [95 % CI 1.49-2.18]), and ICU admission (OR 2.25 [95 % CI 1.33-3.80]). Benzodiazepines were associated with a significant increase in COVID-19-associated death (OR 1.54 [95 % CI 1.01-2.35]) and hospitalization OR 1.26 [95 % CI 1.03-1.53]). In an ad hoc analysis, lithium monotherapy was, however, associated with reduced hospitalizations and ICU admissions.

CONCLUSIONS

Our findings weaken the hypothesis that lithium reduces the risk of severe events associated with COVID-19 infection in bipolar disorder.

Antipsychotics and Risk of Acute Respiratory Failure in U.S. Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease

IMPORTANCE

Acute respiratory failure (ARF) associated with antipsychotic use has been documented through case reports and population-based studies.

OBJECTIVE

To assess whether the recent use of antipsychotics is associated with an increased risk of ARF in U.S. Medicare beneficiaries with chronic obstructive pulmonary disease.

DESIGN, SETTING, AND PARTICIPANTS

Case-crossover study conducted among U.S. Fee-for-Service Medicare beneficiaries with chronic obstructive pulmonary disease hospitalized with ARF, from January 1, 2007, through December 31, 2019.

EXPOSURE

Oral antipsychotics.

MAIN OUTCOME(S) AND MEASURE(S)

Adjusted odds ratios (aOR) and 95% confidence intervals (CI) for ARF requiring invasive mechanical ventilation associated with the use of antipsychotics in the case period (days -14 to -1) compared to the control period (days -75 to -88).

RESULTS

We identified 145,018 cases (mean age 69.4 years, 57.2% female). Of these, 2,003 had antipsychotic use only during the case period and 1,728 only during the control period. The aOR of ARF within 14 days after antipsychotic use was 1.13 (95% CI, 1.06, 1.20). The risk increased with increasing age, being statistically significant in patients ages 75-84 years (aOR: 1.37 [95% CI, 1.17, 1.60]) and 85 + years (aOR: 1.50 [95% CI, 1.20, 1.89]), but not in beneficiaries under 75 years of age (aOR 18-49 years: 1.01 [95% CI, 0.85, 1.20]; 50-64 years: 1.03 [95% CI, 0.92, 1.15]; 65-74 years: 1.12 [95% CI, 0.98, 1.27]).

CONCLUSIONS AND RELEVANCE

Recent antipsychotic use by Medicare beneficiaries with chronic obstructive pulmonary disease was associated with an increased risk of ARF in those aged 75 years and older.

Antipsychotic medications and risk of respiratory failure in the respiratory high dependency unit

BACKGROUND

There is a high incidence of serious mental illness (SMI) and antipsychotic use in the respiratory high dependence unit (HDU) compared with the general population. However, there is a paucity of data in the extant literature evaluating the relationships between respiratory failure and antipsychotics.

AIMS

To investigate the relationship between antipsychotics and respiratory failure in people admitted to a respiratory HDU, and to gain a better understanding of the potential impact of antipsychotic medications on respiratory outcomes.

METHOD

Medical, demographic and clinical outcome data were collected for a consecutive sample of 638 individuals admitted to a respiratory HDU between the dates 1 January 2018 and 29 May 2021 at a large quaternary hospital.

RESULTS

Multivariate models controlling for confounders found that antipsychotic medications increased risk of admission for type 2 respiratory failure and chronic obstructive pulmonary disease exacerbation without hypercapnia by 3.7 and 11.45 times, respectively. For people admitted with type 2 respiratory failure, antipsychotic use increased the risk of requiring non-invasive ventilation by 4.9 times. Those prescribed an antipsychotic were more likely to be readmitted within 30 days. Over 30% of individuals were prescribed antipsychotics for an unlicensed indication.

CONCLUSIONS

Poor respiratory outcomes may be a previously unknown adverse drug reaction of antipsychotics. Modifications to clinical care and clinical pathways for those with SMI prescribed antipsychotic medications, including optimising their chronic health and deprescribing where appropriate, should be prioritised.

The association between respiratory failure and psychotropic medications: A systematic review

OBJECTIVE

To examine the association between psychotropic medication usage and respiratory failure.

METHODS

A systematic search of Embase, PubMed, CINAHL, PsycINFO, and the Cochrane Trial Registry databases for publications that evaluated the association between respiratory failure and the use of psychotropic medications in patients with chronic mental health disorders was performed.

RESULTS

Nine studies were included, with a total of 170,435 participants. There was no association between antidepressant use and respiratory failure reported in the antidepressant studies, however no formal odds ratio was reported in any of these studies. Three antipsychotic studies met inclusion criteria, which included a total of 169,919 participants. However, two of these studies were derived from overlapping datasets, and one of these studies was reported as an abstract. None controlled for the key confounder of smoking status. All three demonstrated an increased risk of respiratory failure with antipsychotic use (adjusted odds ratio ranged from 1.13 95% CI: 1.2-1.89; to 2.33 95% CI: 2.06-2.64). Two out of three antipsychotic studies had a low risk of bias.

CONCLUSIONS

No clear association between antidepressants and respiratory failure was identified. Three studies examining antipsychotic medications and respiratory failure indicated an increased risk for respiratory failure. However, studies demonstrated significant heterogeneity and confounding factors (e.g. smoking status) and strategies to deal with these were absent. Two studies were derived from overlapping datasets and one study was an abstract. Given the signal towards increased risk of respiratory failure with antipsychotic medications, further reporting on this association through large matched and independent datasets is required to allow meta-analysis to quantify the nature and extent of this increased risk.

Monitoring the Effectiveness of Treatment in Women with Schizophrenia: New Specialized Cooperative Approaches

Women with schizophrenia have specific health needs that differ from those of men and that change through successive life stages. We aimed to review the biopsychosocial literature on schizophrenia that addresses clinically important questions related to the treatment of women, including somatic morbi-mortality, hyperprolactinemia, comorbid substance use disorders, social risk factors, and medication effectiveness/safety. Data search terms were as follows: (Morbidity AND mortality) OR hyperprolactinemia OR ("substance use disorders" OR addictions) OR ("social risk factors") OR ("drug safety" OR prescription) AND women AND schizophrenia. A secondary aim was to describe a method of monitoring and interdisciplinary staff strategies. Schizophrenia patients show an increased risk of premature death from cardiovascular/respiratory disease and cancer compared to the general population. The literature suggests that close liaisons with primary care and the introduction of physical exercise groups reduce comorbidity. Various strategies for lowering prolactin levels diminish the negative long-term effects of hyperprolactinemia. Abstinence programs reduce the risk of victimization and trauma in women. Stigma associated with women who have serious psychiatric illness is often linked to reproductive functions. The safety and effectiveness of antipsychotic drug choice and dose differ between men and women and change over a woman's life cycle. Monitoring needs to be multidisciplinary, knowledgeable, and regular.

Possible involvement of apoptosis in the antipsychotics side effects: A minireview

Antipsychotics are used in the treatment of schizophrenia and other psychiatric disorders. Generally they are divided into typical and atypical ones, according to the fact that atypical antipychotics induce less side effects and are more effective in terms of social and cognitive improvements. Their pharmacological effects are mediated via broad range of receptors that consequently influence different cellular signaling pathways. Antipsychotics produce udesirable side effects that range from relatively minor to life-threatening ones. In vitro and in vivo studies have pointed to neurotoxic effect exerted by some antipsychotics and have shown that apoptosis might play role in some side effects induced by antipsyschotics, including tardive dyskinesia, weight gain, agranulocytosis, osteoporosis, myocarditis, etc. Although cumulative data have suggested safety of atypical antipsychotics use during pregnancy some of them have been shown to induce apoptotic neurodegenerative and structural changes in fetal brains with long-lasting impact on cognitive impairment of offsprings. Typical antipsychotics seem to be more cytotoxic than atypical ones. Recently, epidemiological studies have shown lower incidence of cancer in schizophrenic patients what suggest ability of antipsychotics to suppress risk of cancer development. Some antipsychotics have been reported to inhibit cancer cell proliferation and induce their apoptosis. Thus, antipsychotics apoptotic effect may be used as a tool in the treatmnet of some types of cancer, especially in combinatorial therapies. In this minireview, we focused on pro- and anti-apototic or "Dr. Jekyll and Mr. Hyde" effects of antipsychotics, which can be involved in their side effects, as well as their promising therapeutical indications. This article is protected by copyright. All rights reserved.

Typical antipsychotics is associated with increased risk of severe exacerbation in asthma patients: a nationwide population-based cohort study

Background

Severe asthma exacerbation reduces patients’ quality of life, results in visits to the emergency department (ED) and hospitalization, and incurs additional medical costs. Antipsychotics block receptors with bronchodilation function; however, the association between antipsychotic use and severe asthma exacerbation is unknown. This study aimed to investigate the effects of antipsychotics on asthma-related ED visits and hospitalizations.

Methods

A case-crossover design was used in this study. Using the 2003–2017 Taiwan National Health Insurance Reimbursement Database, we established a cohort of 18,657 adults with asthma exacerbation leading to ED visits or hospitalization. Univariate and multivariate conditional logistic regressions were conducted to explore the association between antipsychotic use and severe asthma exacerbation. Subgroup analyses of different classes, doses, receptor functions of antipsychotics, different psychiatric disease, and sensitivity analyses of excluding patients with schizophrenia were also performed.

Results

Antipsychotic use was associated with a higher risk of severe asthma exacerbation (adjusted odds ratio [OR]: 1.27; 95% confidence interval [CI] 1.05–1.54; P = 0.013) compared with no use of antipsychotics. The use of typical antipsychotics increased the risk of severe asthma exacerbation (adjusted OR: 1.40, 95% CI 1.10–1.79, P = 0.007), whereas the use of atypical antipsychotics did not. These results did not change after the exclusion of patients with schizophrenia. There was a dose-dependent effect of antipsychotics (trend test, P = 0.025). Antipsychotics that block the M2 muscarinic or D2 dopaminergic receptors were associated with an increased risk of severe asthma exacerbation (adjusted OR: 1.39, 95% CI 1.10–1.76, P = 0.007 and adjusted OR: 1.33, 95% CI 1.08–1.63, P = 0.008, respectively). However, use of antipsychotics did not increase risk of severe asthma exacerbation in patients with psychiatric disorder.

Conclusions

The use of typical antipsychotics is associated with a dose-dependent increased risk of severe asthma exacerbation, especially for patients without psychiatric disorders. Further research on the impact of typical antipsychotics on asthma exacerbation is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01883-6.

Use of antipsychotics and the risk of acute respiratory failure among adults: A disease risk score-matched nested case-control study

AIMS

Evidence on acute respiratory failure (ARF) from antipsychotics is scant, and only 1 population-based study examined this drug safety issue in chronic obstructive pulmonary disease patients. Antipsychotics have been frequently prescribed off-label in adults, but whether antipsychotic use carries an increased ARF risk among adult patients is uncertain.

METHODS

We adopted a nested case-control study analysing 716 493 adults aged ≥20 years, identified from the Taiwan nationwide healthcare claims records between January 2000 and December 2013. Among the study cohort, 7084 adults with ARF and 12,785 disease risk scored-matched randomly selected controls were analysed. Multivariable logistic regression models were employed to estimate odds ratios of ARF with antipsychotic usages.

RESULTS

Current, recent, and recent past use of antipsychotics was associated with a 2.33-fold (95% confidence interval [CI] = 2.06-2.64), 1.79-fold (95% CI = 1.43-2.25) and 1.41-fold (95% CI = 1.20-1.66) increased risk of ARF, respectively, compared with nonuse, while antipsychotics discontinued >90 days carried no risk. A dose-dependent association was observed with current therapy of antipsychotics (test for trend, P < .001), in which antipsychotic use at >1 defined daily dose yielded the highest risk of 6.53-fold (95% CI = 3.33-12.79). The findings were robust to using carbamazepine as an active comparator.

CONCLUSION

Antipsychotic use was associated with an increased risk of ARF in adult patients. The risk was dose-dependent and markedly higher with current use of antipsychotic agents at doses of 1 defined daily dose and above, <10% of this cohort. Physicians should be vigilant about any respiratory symptoms in patients currently receiving antipsychotics at such dose.