Adverse events following emergent prehospital sedation of patients with behavioral emergencies: A retrospective cohort study

BACKGROUND

Patients presenting to emergency medical services (EMS) with behavioral emergencies may require emergent sedation to facilitate care, but concerns about sedation-related adverse events (AEs) exist. This study aimed to describe the frequency of AEs following emergent prehospital sedation with three types of sedative agents: ketamine, benzodiazepines and antipsychotics.

METHODS

This retrospective cohort study included patients ≥ 15 years who presented to 1031U.S. EMS agencies in calendar year 2019 with behavioral emergencies necessitating emergent prehospital sedation. Serious AEs (SAE) included cardiac arrest, invasive airway placement, and severe oxygen desaturation (<75%). Less-serious AEs included positive pressure ventilation, any oxygen desaturation (<90%), oropharyngeal or nasopharyngeal airway placement, and suctioning. The need for additional sedation was also assessed.

FINDINGS

Of 7973 patients, 1996 received ketamine; 4137 received a benzodiazepine; 1532 received an antipsychotic agent; and 308 received an indeterminant agent. Cardiac arrest occurred in 11 patients (0·1%) and any SAE occurred in 165 patients (2·1%). Invasive airway placement was more frequent with ketamine (40, 2·0%) compared with benzodiazepines (17, 0·4%) or antipsychotics (3, 0·2%). Oxygen desaturation below 75% also occurred more frequently with ketamine (51, 2·6%) than with benzodiazepines (52, 1·3%) or antipsychotics (14, 0·9%). Patients sedated with ketamine were less likely to require additional sedation. Propensity-matching to minimize potential confounding between patient condition, sedative choice and AEs did not meaningfully alter the results.

INTERPRETATION

Although SAEs were rare among patients receiving emergent prehospital sedation, prehospital clinicians should remain mindful of the potential risks and monitor patients closely.

FUNDING

None.

Use of chlorprothixene and the risk of diabetes and major adverse cardiovascular events: a nation-wide cohort study

Chlorprothixene is commonly used off‐label in low doses for sedative‐hypnotic purposes although it might carry a risk of cardiometabolic adverse events due to its pharmacodynamic profile. We investigated the risk of diabetes and major adverse cardiovascular events (MACE) with use of low‐dose chlorprothixene, compared with use of low‐dose quetiapine in a nationwide cohort study, including all new users of low‐dose chlorprothixene (n = 81 328) and low‐dose quetiapine (n = 91 163) in Denmark 2000–2017. Main outcomes were diabetes and MACE (myocardial infarction, stroke and death from cardiovascular causes). The association between cumulative dose of chlorprothixene and the outcomes was tested in a case–control analysis. Low‐dose chlorprothixene use was associated with increased risk of diabetes (intention‐to‐treat [ITT]‐hazard ratio [HR]: 1.16; 95% CI: 1.08–1.25), compared with low‐dose quetiapine use. This association strengthened when follow‐up was restricted to time on treatment (as‐treated [AT]‐HR: 1.34; 95% CI: 1.14–1.56). Low‐dose chlorprothixene use was also associated with increased risk of MACE (ITT‐HR: 1.12; 95% CI: 1.04–1.21) and stroke (ITT‐HR: 1.21; 95% CI: 1.06–1.37) but not with myocardial infarction (ITT‐HR: 1.11; 95% CI: 0.95–1.30) nor death from cardiovascular causes (ITT‐HR: 1.07; 95% CI: 0.96–1.20). Cumulative dose of chlorprothixene ≥6000 mg was associated with increased risk of diabetes (OR: 1.15–1.63; test for trend: p < 0.001), whereas cumulative dose of chlorprothixene ≥1500 mg was associated with increased risk of MACE (OR: 1.10–1.85; test for trend: p < 0.001). In conclusion, low‐dose chlorprothixene use is associated with increased risk of cardiometabolic adverse events compared with low‐dose quetiapine use.

Randomised, placebo-controlled trial on topiramate add-on therapy for weight reduction and symptomatology in overweight/obese persons with schizophrenia

INTRODUCTION

Higher cardiovascular mortality is seen with schizophrenia due to the disorder itself and antipsychotic use. South Asians are more vulnerable to developing metabolic disorders than others. Resource-limited settings in South Asia have only a few mental health professionals, and individualised case management is mostly unavailable. Therefore, there is less monitoring and personalised support for diet and physical exercise programmes. Topiramate is useful for weight reduction and improvement of psychopathology in schizophrenia. However, there has been only one previous randomised controlled trial (RCT) done in South Asia, which possesses a quarter of the world's population.

METHODS

We conducted a double-blind RCT in an outpatient setting in Sri Lanka. We compared topiramate 100 mg/day with a placebo in overweight/obese adults with schizophrenia who have been on antipsychotics for at least a year. We obtained monthly anthropometric measurements and assessed the symptomatology using the brief psychiatric rating scale (BPRS).

RESULTS

Fifty patients each in the topiramate and placebo arms completed the study. Topiramate add-on therapy led to significant weight/Body Mass Index reduction and improved symptomatology as measured by the BPRS compared to the placebo. The topiramate group had significantly more reporting of loss of appetite.

DISCUSSION

According to available data, this is the RCT with most participants assessing the use of topiramate in schizophrenia and only the second in South Asia. Topiramate was shown to be useful for weight reduction and symptomatic improvement in persons with schizophrenia in a resource-limited setting in South Asia.

Can Neutrophil-Lymphocyte Ratio Be a Useful Criterion for Neuroleptic Malignant Syndrome in the Absence of Leukocytosis?

Objective: Neuroleptic malignant syndrome (NMS) is a rare but severe side effect of antipsychotic medication. Neutrophil-lymphocyte ratio (NLR) is a simple marker used to measure systemic inflammation. Method : In this case report we explore the relationship of inflammation in the etiology of NMS. In our case involving NMS, although there was no leukocytosis, the NLR was increased up to systemic infection levels. Conclusion: We hypothesized that systemic inflammation may take a role in developing NMS. If so, NLR could be a new marker of NMS that may be able to provide more sensitive results than leukocyte levels.

Effects of Olanzapine Combined With Samidorphan on Weight Gain in Schizophrenia: A 24-Week Phase 3 Study

OBJECTIVE

A combination of olanzapine and the opioid receptor antagonist samidorphan is under development for the treatment of schizophrenia and bipolar I disorder. The single-tablet combination treatment is intended to provide the efficacy of olanzapine while mitigating olanzapine-associated weight gain. In this phase 3 double-blind trial, the authors evaluated the weight profile of combined olanzapine/samidorphan compared with olanzapine in patients with schizophrenia.

METHODS

Adults (ages 18‒55 years) with schizophrenia were randomly assigned to receive either combination treatment with olanzapine and samidorphan or olanzapine treatment for 24 weeks. Primary endpoints were percent change from baseline in body weight and proportion of patients with ≥10% weight gain at week 24. The key secondary endpoint was the proportion of patients with ≥7% weight gain. Waist circumference and fasting metabolic laboratory parameters were also measured.

RESULTS

Of 561 patients who underwent randomization (olanzapine/samidorphan combination, N=280; olanzapine, N=281), 538 had at least one postbaseline weight assessment. At week 24, the least squares mean percent weight change from baseline was 4.21% (SE=0.68) in the olanzapine/samidorphan group and 6.59% (SE=0.67) in the olanzapine group (the difference of -2.38% [SE=0.76] was significant). Significantly fewer patients in the olanzapine/samidorphan combination group compared with the olanzapine group had weight gain ≥10% (17.8% and 29.8%, respectively; number needed to treat [NNT]=7.29; odds ratio=0.50) and weight gain ≥7% (27.5% and 42.7%, respectively; NNT=6.29; odds ratio=0.50). Increases in waist circumference were smaller in the olanzapine/samidorphan combination group compared with the olanzapine group. Schizophrenia symptom improvement was similar between treatment groups. Adverse events (in ≥10% of the groups) in the olanzapine/samidorphan and olanzapine groups included weight gain (24.8% and 36.2%), somnolence (21.2% and 18.1%), dry mouth (12.8% and 8.0%), and increased appetite (10.9% and 12.3%). Metabolic changes were small and similar between treatments.

CONCLUSIONS

Olanzapine/samidorphan combination treatment was associated with significantly less weight gain and smaller increases in waist circumference than olanzapine and was well tolerated. The antipsychotic efficacy of the combination treatment was similar to that of olanzapine monotherapy.

Antipsychotic Polypharmacy in Treatment of Schizophrenia; Should or Should Not?

Antipsychotics have been utilized as the standard treatment for schizophrenia regardless of illness phase where antipsychotic monotherapy (APM) is routinely recommended as the gold standard rather than antipsychotic polypharmacy (APP). However, approximately 20 to 40% of patients with schizophrenia do not respond to APM based on randomized controlled clinical trials and large practical clinical trials indicating that the subgroup of patients with schizophrenia would need differential treatment approaches beyond traditional treatment strategies such as APM. Numerous studies have supported the use of APP in particular for patients with certain clinical situations including: failure to show efficacy or tolerability from treatment with APM, need for different treatment for targeting specific symptom domains, severe illness, failure to treatment with clozapine, skepticism about following treatment guidelines, or cross titration periods. Furthermore, recent large cohort studies and practical clinical trials have proposed more benefits of APP rather than APM in terms of rehospitalization, mortality, and specific symptoms. APP has recently become more widely utilized and recognized as one of the next treatment strategies to clinicians for patients with schizophrenia. Some experts have already proposed the revision of treatment guidelines incorporating APP as evidence-based treatment option for certain patients with schizophrenia. Taken together, APP now deserves an evidence-based and acceptable treatment strategy, not an empirical or preferential treatment approach for treatment of schizophrenia in contemporary clinical practice.

Emerging of Explosive Speech after Olanzapine in Multiple System Atrophy Patient

Background

Cerebellum has an important role in sensorimotor control including speech. Multiple system atrophy (MSA) is a sporadic and rapidly progressive neurodegenerative disorder that presents with autonomic failure in combination with Parkinsonism or cerebellar ataxia.

Case Report

We report a case of MSA-cerebellum subtype associated with emergence of irreversible explosive speech following olanzapine therapy.

Conclusions

Further investigation into speech problems in MSA according to subtype and disease severity is needed, and side effects of olanzapine therapy should also be considered.

[Schizophrenia: What Non-Psychiatrist Physicians Need to Know]

Schizophrenia is a disabling and severe mental illness that affects all social classes and racial and ethnic groups, spreading across every part of the world. It's more frequent in males and it usually manifests itself in late adolescence or early adulthood and its early detection by all clinicians is important so that there is a proper referral to specialized psychiatric care. This article intends to update the knowledge regarding the diagnosis, treatment and prognosis of schizophrenia, with an emphasis on the warning signs for a timely referral to psychiatric evaluation. We conducted a literature search across through articles available in databases of scientific articles but also in scientific and technical books specialized in the field of schizophrenia. The clinical presentation of this illness is heterogeneous and complex, with a typical evolution based on several episodes of acute decompensation requiring hospitalization. The diagnosis of schizophrenia relies on some key symptoms, and the various international diagnostic criteria vary in relation to the temporal window with productive symptomatology required to establish a diagnosis. The prognosis is variable, not always deteriorating and is all the better when the treatment is started as early as possible. Treatment requires a multidisciplinary approach and is based primarily on antipsychotic drugs. This medication although very effective for the typical symptoms of this illness, entails some adverse effects with medical consequences that are important in the clinical practice of all doctors of other specialties.

Paliperidone Palmitate-Induced Delirium in an Adolescent with Schizophrenia: Case report

Schizophrenia is a serious long-term mental disorder which usually presents in adolescence or early adulthood. However, poor adherence to oral antipsychotics can lead to relapse and rehospitalisation. We report an adolescent male with schizophrenia who was referred to the South London & Maudsley National Health Service Foundation Trust, London, UK, in 2015 due to worsening psychotic symptoms. Following poor compliance with oral medications, a four-week regimen of paliperidone palmitate long-acting injections was initiated, with an initial positive response. However, 10 days after the second dose, the patient developed severe acute-onset delirium with fluctuating levels of consciousness. Paliperidone palmitate was discontinued and the patient instead underwent a course of zuclopenthixol decanoate long-acting injections with a favourable outcome.

Clinical Consensus Recommendations for Urine Testing of Adherence to Antipsychotics Among People With Serious Mental Illness

OBJECTIVE

This study developed clinical recommendations for the use of proven urine testing technologies to assess antipsychotic medication adherence among people with serious mental illness.

METHODS

Guided by the RAND/UCLA Appropriateness Method, researchers conducted a literature review and semistructured interviews and convened an expert panel to develop clinical consensus recommendations for the use of urine monitoring to assess antipsychotic medication adherence.

RESULTS

The expert panel identified six circumstances in which urine monitoring was recommended at initial evaluation and five scenarios in which monitoring was recommended after initial evaluation. Conducting monitoring at the site where psychiatric medication is prescribed and providing education prior to testing and feedback after testing were recommended.

CONCLUSIONS

A consensus was reached on clinical recommendations for use of urine monitoring at intake and during ongoing treatment. There was strong agreement that monitoring can be used to improve assessment and thence clinical care and outcomes.

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

BACKGROUND

Guidelines, policies, and warnings have been applied to reduce the use of medications for behavioral and psychological symptoms of dementia (BPSD). Because of rare dangerous side effects, antipsychotics have been singled out in these efforts. However, antipsychotics are still prescribed "off label" to hundreds of thousands of seniors residing in nursing homes and communities. Our objective was to evaluate how and why primary-care physicians (PCPs) employ nonpharmacologic strategies and drugs for BPSD.

METHODS

Semi-structured interviews analyzed via template, immersion and crystallization, and thematic development of 26 PCPs (16 family practice, 10 general internal medicine) in full time primary-care practice for at least 3 years in Northwestern Virginia.

RESULTS

PCPs described 4 major themes regarding BPSD management: (1) nonpharmacologic methods have substantial barriers; (2) medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate; (3) pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications; and (4) PCPs need practical evidence-based guidelines for all aspects of BPSD management.

CONCLUSIONS

PCPs continue to prescribe medications because they meet patient-oriented goals and because PCPs perceive drugs, including antipsychotics and their alternatives, to be more effective and less dangerous than evidence suggests. To optimally treat BPSD, PCPs need supportive verified prescribing guidelines and access to nonpharmacologic modalities that are as affordable, available, and efficacious as drugs; these require and deserve significant additional research and payer support. Community PCPs should be included in BPSD policy and guideline development.

Prescription Trends of Psychotropics in Children and Adolescents with Autism Based on Nationwide Health Insurance Data

Children with autism are often medicated to manage emotional and behavioral symptoms; yet, data on such pharmacotherapy is insufficient. In this study, we investigated the Korean National Health Insurance Claims Database (NHICD) information related to autism incidence and psychotropic medication use. From the 2010-2012 NHICD, we selected a total of 31,919,732 subjects under 19 years old. To examine the diagnostic incidence, we selected patients who had at least one medical claim containing an 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for pervasive developmental disorder, F84, not diagnosed in the previous 360 days. Psychotropics were categorized into seven classes. Then, we analyzed the data to determine the mean annual diagnostic incidence and psychotropic prescription trends. Diagnostic incidence was 17,606 for the 3 years, with a mean annual incidence per 10,000 population of 5.52. Among them, 5,348 patients were prescribed psychotropics. Atypical antipsychotics were the most commonly used, followed by antidepressants. An older age, male sex, and the availability of medical aid were associated with a higher rate of prescription than observed for a younger age, female sex, and the availability of health insurance. Psychotropic drugs were used for less than one-third of patients newly diagnosed with autism, and prescription differed by sex and age. Increased diagnostic incidence is associated with an increased prescription of psychotropic drugs. Therefore, medication-related safety data and policies for psychotropic drugs in autism should be prepared.

[A qualitative exploration of the chronic use of psychotropic drugs in nursing homes]

BACKGROUND

Although guidelines put forward non-pharmacological therapies and advise against the chronic use of psychotropic drugs, these are still being prescribed regularly in Belgian nursing homes.

GOAL

To explore the reasons for initiation, continuation and cessation of psychotropic drug treatment of elderly with dementia and behavioral problems, residing in the nursing home.

METHOD

Twenty-seven interviews from an earlier project were used, in which a semi-structured interview was conducted with the nursing staff, the physicians and the caretakers of eleven randomly selected residents from three nursing homes. A qualitative analysis was performed by three independent researchers according to 'The Qualitative Analysis Guide of Leuven (QUAGOL)'. A first analysis focused on the process of initiation, continuation and cessation of medication. A second analysis compared the different participants of each interview and looked for similarities and differences.

RESULTS

Seventeen codes were developed for four themes: (1) To initiate, to continue or to cease?; (2) Behavior; (3) Therapy; and (4) Alternatives. The reasons for initiating psychotropic drugs were reducing disruptive behavior and improving the quality of life of the resident. A comparison between the interviewed showed that psychotropic drugs were initiated at the request of the nursing staff. Neither doctors nor nurses considered the monitoring of the drug therapy their task, and tended to pass on this responsibility. Once psychotropic drugs were started, the treatment was chronic but remained part of a dynamic process in which a balance was sought between benefits and adverse effects. More insights into the behavior of the resident led to a better treatment of the behavioral problems.

CONCLUSION

Nurses play an important role in the initiation and continuation of psychotropic drugs. Physicians should take a more active role in the process of indication and monitoring of psychopharmaceuticals. Discontinuation of psychotropic drugs and the use of non-pharmacological alternatives are important bottlenecks in nursing homes. Education and training, updated practice guidelines, appropriate research, professionalization and management elements can, in a complex interaction, change this situation for the better.

Second Generation Antipsychotics in the Treatment of Major Depressive Disorder: An Update

Less than one third of patients who suffer from major depressive disorder (MDD) report remission following antidepressant treatments requiring more diverse treatment approaches. Augmentation of second generation antipsychotics (SGAs) has been increasingly recognized as an important treatment option. The authors have previously provided a comprehensive review of SGAs for the treatment of MDD in 2013. Since then, numerous additional clinical trials have been conducted to investigate diverse issues regarding the utility of SGAs in MDD. Moreover, a new SGA, brexpiprazole, was recently approved by the Food and Drug Administration in July 2015 for the treatment of MDD as an augmentation agent to antidepressants. Thus, the aim of this study was to provide a concise update of all the available SGAs for the treatment of MDD, in particular on the additional clinical trials which have been published since 2013.

[Efficiency of a pharmaceutical care program for long-acting parenteral antipsychotics in the health area of Santiago de Compostela]

In the healthcare area of Santiago de Compostela (Spain), the therapeutic subgroup "other antipsychotics" represented the fifth largest outpatient expenditure in 2013. More than half of this expenditure corresponded to long-acting parenteral forms of paliperidone and risperidone. Over a 12-month period, the implementation of a pharmaceutical care program based on process management and coordination of actions between health professionals in both levels of care represented savings of € 636,391.01 for the organization and a direct saving of € 16,767.36 and 9,008 trips to the pharmacy for patients. This study shows the efficiency of the program, which was facilitated by its situation in an area of integrated management and the use the unified medical records and electronic prescription, elements that will enable the future implementation of similar programmes. The new registries and healthcare interventions will allow reliable evaluation of their effectiveness in terms of treatment adherence, relapses and hospitalisations.

Pharmacogenetic study of second-generation antipsychotic long-term treatment metabolic side effects (the SLiM Study): rationale, objectives, design and sample description

AIM

Weight gain is an important and common side effect of second generation antipsychotics (SGAs). Furthermore, these drugs can induce other side effects associated with higher cardiovascular morbidity and mortality, such as insulin resistance, diabetes or metabolic syndrome. Preliminary studies show that inter-individual genetic differences produce varying degrees of vulnerability to the different SGA-induced side effects. The Second-generation antipsychotic Long-term treatment Metabolic side effects (SLiM) study aims to identify clinical, environmental and genetic factors that explain inter-individual differences in weight gain and metabolic changes in drug-naïve patients after six months of treatment with SGAs.

MATERIALS AND METHODS

The SLIM study is a multicenter, observational, six-month pharmacogenetic study where a cohort of 307 drug-naïve paediatric and adult patients (age range 8.8-90.1 years) and a cohort of 150 age- and sex- matched healthy controls (7.8-73.2 years) were recruited.

RESULTS

This paper describes the rationale, objectives and design of the study and provides a description of the sample at baseline.

CONCLUSIONS

Results from the SLiM study will provide a better understanding of the clinical, environmental, and genetic factors involved in weight gain and metabolic disturbances associated with SGA treatment.

Depot Typical Antipsychotics versus Oral Atypical Antipsychotics in Relapse Rate Among Patients with Schizophrenia: A Five -Year Historical Cohort Study

OBJECTIVE

The present study aimed to review the relapse rate in patients with schizophrenia treated with orally taken atypical agents (serotonin dopamine antagonists, SDAs) and depot preparation of conventional (typical) antipsychotics.

METHODS

In this historical cohort study, mean relapse per month (MRM) index, duration between initiation of antipsychotic treatment and the first relapse episode, and the time gap between successive relapses were compared between 84 patients on SDAs-except clozapine (group 1) and 81 others on depot typical antipsychotics (group 2).

RESULTS

The two groups were comparable regarding mean (±SD) MRM index [0.033 (±0.004) in group1 and 0.044 (±0.05) in group 2; p = 0.345]. Mean (±SD) duration of time between initiation of maintenance treatment and the first relapse was 15.5 (±13.67) months in group 1 and 16.40 (±15.31) months in group 2, (p = 0.876). Mean (±SD) duration of remission periods between successive relapses were 17.92 (±14.2) and 15.8 (±16.9) months for group 1 and group 2, respectively (Mann-Whitney test, (p = 0.048).

CONCLUSION

Orally taken atypical antipsychotics were able to keep the duration of remission periods between successive relapses more prolonged compared to depot conventional preparations. This could be added to their other remarkable benefits especially if the patient is expected to experience multiple relapses.

DECLARATION OF INTEREST

None.

Evaluation of serum prolactin levels in intellectually disabled patients using antipsychotic medications

BACKGROUND

Patients with intellectual disabilities may be treated with antipsychotic medications for a variety of diagnoses. Use of this category of medication can increase prolactin levels and place the patient at risk for sexual dysfunction and lower bone mineral density. The proposed mechanism of action is affinity for the dopamine receptor. Use of bromocriptine, a dopamine receptor antagonist, was proposed to attenuate hyperprolactinemia.

OBJECTIVES

The objectives of this study were to (1) review serum prolactin (PRL) elevations associated with the use of antipsychotic (AP) medications in an intellectually disabled adult population and (2) determine if any association existed between the level of elevation and AP used.

PATIENTS AND METHODS

Medical records for adult patients at two Oklahoma facilities for the intellectually disabled were reviewed to evaluate prolactin levels for individuals prescribed antipsychotics. A linear regression model was used to evaluate the relationship between prolactin levels with intellectual disability level, bromocriptine use, demographics, and antipsychotic.

RESULTS

73 (n = 53 males, n = 20 females) patients met criteria. The average age was 41.2 years. Nearly 70% of the patients had severe to profound levels of disability. 77% were prescribed second generation antipsychotics; 19% received first generation agents. Two variables, gender and bromocriptine use, were found to be significant predictors of prolactin levels. Mean prolactin level for females was 44 ng/mL (normal range: 4-30 ng/mL, males = 4-23 ng/mL). Patients who did not receive bromocriptine had mean levels of 23 ng/mL. No significant difference in prolactin levels was found for type of AP.

CONCLUSIONS

Mean prolactin levels for females were significantly higher than for males. Both sexes were found to have higher-than-normal levels. Use of bromocriptine was associated with higher prolactin levels. In this population of patients, the type of AP used had no significance on prolactin levels.