Prescriptions of Antipsychotics in Younger and Older Geriatric Patients with Polypharmacy, Their Safety, and the Impact of a Pharmaceutical-Medical Dialogue on Antipsychotic Use
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Study Population
2.3. Statistical Methods
2.4. Ethics Consideration
3. Results
3.1. Prescribing Patterns
3.2. Safety of Medications Used
3.3. Impact of a Pharmaceutical Medical Consolation
4. Discussion
4.1. Prescribing Patterns
4.2. Safety of Medications Used
4.3. Impact of a Pharmaceutical Medical Consolation
4.4. Strengths and Weaknesses
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Age 70–84 n = 113 (%) | Age 85–100 n = 93 (%) | p-Value | |
---|---|---|---|
Age, years (mean ± SD) | 79 ± 4 | 90 ± 4 | <0.001 T-Test |
Female gender | 69 (61.1%) | 51 (54.8%) | 0.37 |
Polypharmacy (>10 drugs) | 90 (79.6%) | 68 (73.1%) | 0.27 |
Number of drugs per patient | |||
Before recommendation a | 14 ± 4 | 13 ± 4 | 0.30 T-Test |
After recommendation a | 14 ± 4 | 13 ± 4 | 0.47 T-Test |
Renal insufficiency stages | <0.001 | ||
stage 1 | 37 (32.7%) | 9 (9.7%) | |
stage 2 | 40 (35.4%) | 31 (33.3%) | |
stage 3 | 33 (29.2%) | 44 (47.3%) | |
stage 4 | 3 (2.7%) | 9 (9.7%) | |
stage 5 | 0 (0.0%) | 0 (0.0%) | |
Renal glomerular filtration rate | 0.03 | ||
>30 mL/min (stage ≤3) | 110 (97.3%) | 84 (90.3%) | |
≤30 mL/min (stage ≥4) | 3 (2.7%) | 9 (9.7%) |
Age 70–84 n = 113 (%) | Age 85–100 n = 93 (%) | p-Value | |
---|---|---|---|
Antipsychotics | |||
High potency (monotherapy) | 18 (15.9%) | 11 (11.8%) | 0.40 |
Aripiprazole | 0 (0%) | 0 (0%) | |
Haloperidol | 5 (4.4%) | 2 (2.2%) | 0.46 * |
Olanzapine | 3 (2.7%) | 1 (1.1%) | 0.63 * |
Risperidone | 10 (8.8%) | 8 (8.6%) | 0.95 |
Medium potency (monotherapy) | 38 (33.6%) | 25 (26.9%) | 0.30 |
Clozapine | 3 (2.7%) | 1 (1.1%) | 0.63 * |
Quetiapine | 34 (30.1%) | 22 (23.7%) | 0.30 |
Sulpiride | 1 (0.9%) | 1 (1.1%) | 1.00 * |
Tiapride | 0 (0%) | 1 (1.1%) | 0.45 * |
Low potency (monotherapy) | 23 (20.4%) | 22 (23.7%) | 0.57 |
Melperone | 3 (2.7%) | 6 (6.5%) | 0.31 * |
Pipamperone | 16 (14.2%) | 16 (17.2%) | 0.57 |
Prothipendyl | 4 (3.5%) | 0 (0%) | 0.13 * |
Combination of different Potencies a | 34 (30.1%) | 35 (37.6%) | 0.25 |
Pipamperone + Risperidone | 17 (15.0%) | 28 (30.1%) | 0.01 |
Pipamperone + Quetiapine | 4 (3.5%) | 1 (1.1%) | 0.38 * |
Other combinations b | 13 (11.5%) | 6 (6.5%) | 0.21 |
Antipsychotic Drug | Indication | Loading Dose a | Increase/Maximum Dose a |
---|---|---|---|
Haloperidol | Delirium in dementia a (2nd choice) | Loading dose 0.5 mg (oral) | If necessary, gradually increase up to max 5 mg/day in 2 doses. |
Melperone | Sleeping disorders, psychomotor agitation | Gradual dosing with 25 mg (oral) at night | If necessary, increase in 25 mg increments. Max. 150 mg/day in 2–4 doses. |
Pipamperone | Sleeping disorders, psychomotor agitation | Gradual dosing with 20 mg (oral) at night | If necessary, increase dose to 40 mg single dose, Max. three times daily (=120 mg/day) |
Quetiapine | Psychotic symptoms in Parkinson’s disease | Gradual dosing with 12.5 mg (oral) | If response is inadequate, increase dose to 25 mg, then further increase in 25 mg increments if necessary. Max. 150 mg/day in 2 doses. |
Risperidone | Delir in dementiaa (1st choice) | Gradual dosing with 2 × 0.25 mg/day (oral) | If response is inadequate, increase dose by 0.25 mg increments to up to 1 mg twice daily. For the majority of patients, the optimal dose is 2 × 0.5 mg/day. |
Age 70–84 n = 113 (%) | Age 85–100 n = 93 (%) | p-Value | |
---|---|---|---|
Indication and drug selection | 12 (10.6%) | 7 (7.5%) | 0.45 |
Overuse b | 8 (7.1%) | 1 (1.1%) | 0.04 * |
Underuse b | 0 (0%) | 0 (0%) | |
Inadequate care b | 4 (3.5%) | 6 (6.5%) | 0.35 * |
Dosage c | 4 (3.5%) | 1 (1.1%) | 0.38 * |
Application d | 2 (1.8%) | 0 (0%) | 0.50 * |
Interaction e | 19 (16.8%) | 11 (11.8%) | 0.33 |
Side effects f | 0 (0%) | 1 (1.1%) | 0.45 * |
Drug documentation error | 2 (1.8%) | 3 (3.2%) | 0.66 * |
Dependent Variables | |||||||||||||||||||
Total study population (n = 206) | Independent variables | Total ADRs b | ADR Sub-Items: | ||||||||||||||||
Indication/Drug Selection | Overuse | Inadequate Care | Dosage | Application | Interaction c | Side Effects | Drug Documentation Error | ||||||||||||
adjOR | 95% CI | adjOR | 95% CI | adjOR | 95% CI | adjOR | 95% CI | adjOR | 95% CI | adjOR | 95% CI | adjOR | 95% CI | adjOR | 95% CI | adjOR | 95% CI | ||
Gender | 0.98 | 0.51-.1.89 | 1.04 | 0.40–2.74 | 0.70 | 0.17–2.90 | d | 0.27 | 0.03–2.76 | 1.62 | 0.08–31.37 | 1.03 | 0.46–2.33 | d | 2.09 | 0.34–12.89 | |||
Age | 0.95 | 0.90–1.00 | 1.01 | 0.94–1.10 | 0.98 | 0.88–1.09 | d | 0.85 | 0.72–1.01 | 0.89 | 0.66–1.20 | 0.95 | 0.89–1.02 | d | 1.01 | 0.87–1.18 | |||
GFR | 1.01 | 1.00–1.03 | 1.02 | 0.99–1.04 | 1.01 | 0.97–1.04 | d | 1.00 | 0.96–1.05 | d | 1.02 | 1.00–1.04 | d | 0.98 | 0.94–1.03 | ||||
Number of drugs | 1.10 | 1.02–1.20 | 1.03 | 0.91–1.16 | 0.95 | 0.80–1.14 | d | 1.16 | 0.93–1.46 | 0.88 | 0.55–1.43 | 1.12 | 1.02–1.24 | d | 0.97 | 0.78–1.21 | |||
Age 70–84 (n = 113) | Gender | 0.82 | 0.35–1.90 | 0.59 | 0.14–2.43 | 0.65 | 0.11–3.75 | 0.38 | 0.03–4.37 | 0.40 | 0.04–4.50 | 2.12 | 0.09–51.77 | 0.83 | 0.29–2.38 | d | 0.78 | 0.03–19.67 | |
Age | 0.97 | 0.87–1.07 | 1.21 | 0.99–1.48 | 1.38 | 1.02–1.89 | 1.00 | 0.76–1.31 | 0.81 | 0.63–1.05 | 0.96 | 0.65–1.41 | 0.92 | 0.81–1.04 | d | 1.11 | 0.71–1.73 | ||
GFR | 1.01 | 0.99–1.03 | 1.02 | 0.99–1.05 | 1.01 | 0.97–1.05 | 1.06 | 0.98–1.14 | 1.02 | 0.96–1.08 | d | 1.01 | 0.98–1.03 | d | 0.94 | 0.87–1.03 | |||
Number of drugs | 1.05 | 0.95–1.17 | 1.00 | 0.84–1.20 | 0.89 | 0.70–1.13 | 1.23 | 0.92–1.63 | 1.13 | 0.86–1.48 | 0.85 | 0.51–1.42 | 1.06 | 0.93–1.20 | d | 0.96 | 0.65–1.40 | ||
Age 85–100 (n = 93) | Gender | 1.28 | 0.42–3.93 | 2.95 | 0.53–16.44 | d | 2.31 | 0.39–13.74 | d | d | 1.55 | 0.36–6.62 | d | 2.10 | 0.18–24.74 | ||||
Age | 0.80 | 0.65–0.99 | 0.88 | 0.66–1.16 | d | 0.86 | 0.62–1.18 | d | d | 0.79 | 0.60–1.06 | d | 0.86 | 0.55–1.33 | |||||
GFR | 1.03 | 1.00–1.06 | 1.00 | 0.96–1.04 | d | 1.02 | 0.97–1.06 | d | d | 1.04 | 1.00–1.08 | d | 1.01 | 0.95–1.07 | |||||
Number of drugs | 1.24 | 1.05–1.47 | 1.06 | 0.87–1.28 | d | 1.06 | 0.87–1.31 | d | d | 1.31 | 1.07–1.61 | d | 0.99 | 0.73–1.33 |
Age 70–84 n = 113 (%) | Age 85–100 n = 93 (%) | p-Value | |
---|---|---|---|
TDM recommendations a | |||
Accepted | 10 (8.8%) | 6 (6.5%) | 0.52 * |
Laboratory control | 0 (0.0%) | 2 (2.2%) | 0.20 |
ECG check | 6 (5.3%) | 2 (2.2%) | 0.30 |
Patient monitoring for symptoms, side effects, and/or effect alone | 4 (3.5%) | 2 (2.2%) | 0.69 |
Rejected | 2 (1.8%) | 0 (0.0%) | 0.50 |
No recommendation | 101 (89.4%) | 87 (93.5%) | 0.29 * |
Medication modification recommendations | |||
Accepted | 20 (17.7%) | 13 (14.0%) | 0.47 * |
Drug onset | 0 (0.0%) | 1 (1.1.%) | 0.45 |
Drug discontinuation | 16 (14.2%) | 6 (6.5%) | 0.08 * |
Drug changes | 0 (0.0%) | 2 (2.2%) | 0.20 |
Dosage changes | 2 (1.8%) | 4 (4.3%) | 0.41 |
Dosage form changes | 2 (1.8%) | 0 (0.0%) | 0.50 |
Rejected | 4 (3.5%) | 0 (0.0%) | 0.13 |
No recommendation | 89 (78.8%) | 80 (86.0%) | 0.18 * |
Active Agent/s | Adverse Drug Reaction | Pharmaceutical Intervention Recommendation | Geriatrician’s Measure |
---|---|---|---|
Carbamazepine and quetipaine | CYP3A4- interaction: Loss of effect of quetiapine may occur. | Risk-benefit consideration of carbamazepine due to high side effect potential and interactions. Tapering of carbamazepine. | Tapering of carbamazepine (with concomitant administration of other anticonvulsants). |
Quetiapine sustained-release tablets | Quetiapine sustained-release tablets are mortared as a non-mortar dosage form. Loss of the retarded effect. | Change to unretarded dosage form with examination and, if necessary, adjustment of the dose interval. | Changeover to unretarded dosage form occurs. |
Quetiapine and citalopram | Risk of QT prolongation with arrhythmia. | ECG * and electrolyte controls with drug combination. | Close ECG and electrolyte controls were ordered. |
Quinagolide and pipamperone | Dopamin-Agonist vs. Dopamin- Antagonist. Mutual loss of effect possible. | Deprescribing of pipamperone recommended. | Pipamperone discontinued and patient observed for the need of further drug therapy. |
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Gebauer, E.-M.; Lukas, A. Prescriptions of Antipsychotics in Younger and Older Geriatric Patients with Polypharmacy, Their Safety, and the Impact of a Pharmaceutical-Medical Dialogue on Antipsychotic Use. Biomedicines 2022, 10, 3127. https://doi.org/10.3390/biomedicines10123127
Gebauer E-M, Lukas A. Prescriptions of Antipsychotics in Younger and Older Geriatric Patients with Polypharmacy, Their Safety, and the Impact of a Pharmaceutical-Medical Dialogue on Antipsychotic Use. Biomedicines. 2022; 10(12):3127. https://doi.org/10.3390/biomedicines10123127
Chicago/Turabian StyleGebauer, Eva-Maria, and Albert Lukas. 2022. "Prescriptions of Antipsychotics in Younger and Older Geriatric Patients with Polypharmacy, Their Safety, and the Impact of a Pharmaceutical-Medical Dialogue on Antipsychotic Use" Biomedicines 10, no. 12: 3127. https://doi.org/10.3390/biomedicines10123127