Deprescribing Antipsychotics: New Algorithm

Linda Brookes, MSc

Disclosures

March 27, 2018

The third clinical practice guideline to be published in the series developed by the Deprescribing guidelines for the elderly project, based at the Bruyère Research Institute in Ottawa, Ontario, Canada, is focused on antipsychotic drugs.[1] The aim is to help clinicians determine whether an antipsychotic drug is being used appropriately or whether (and how) it can be stopped. Lead author Lise Bjerre, MD, PhD, spoke with Medscape about the widespread overuse of these drugs and the development of the guideline and algorithm. Bjerre is a pharmacoepidemiologist, practicing family physician, assistant professor, and clinician investigator at the Department of Family Medicine at the University of Ottawa and the Bruyère Research Institute.

The three other guidelines in the series[2,3,4] discussed proton pump inhibitors, antihyperglycemics, and cholinesterase inhibitors.

Deprescribing Antipsychotics

Antipsychotic drugs are approved for a range of psychiatric disorders including schizophrenia and bipolar disorder, but they are also widely prescribed for control of behavioral and psychological symptoms of dementia (BPSD), such as delusions, hallucinations, aggression, agitation, anxiety, irritability, depression, apathy, and psychosis, in elderly patients. Antipsychotics are also used to treat insomnia. In the United States and Canada, these uses are all off-label, with the exception that in Canada risperidone is approved for short-term use for treatment of some symptoms associated with severe dementia.[5]

Is Antipsychotic Use in Dementia Ever Warranted?

Image from iStock

Clinical studies with antipsychotic drugs showed small but statistically significant improvements in BPSD compared with placebo,[6] but the treatment was associated with an increased risk for adverse events, particularly cerebrovascular events including stroke, and death, as well as somnolence, extrapyramidal symptoms, urinary tract infections, edema, gait abnormalities, and major cardiovascular events.[6,7,8] Both the US Food & Drug Administration[9] and Health Canada[10] issued warnings about the increased mortality risk associated with antipsychotic drug use in older adults with dementia. In the United States, these drugs now carry a "boxed warning" about this risk. Health Canada also issued three separate warnings to health professionals about serious adverse events.[11,12,13]

Clinical practice guidelines all urge extreme caution with antipsychotics reserved as a last resort for dementia patients.

In its 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,[14] the American Geriatrics Society advises that antipsychotics should be avoided for BPSD unless nonpharmacologic options such as behavioral intervention have failed or are not possible and the patient is threatening "substantial" self-harm or harm to others. Clinical practice guidelines[15,16,17,18,19,20,21] all urge extreme caution with antipsychotics reserved as a last resort for treatment of behavioral symptoms in dementia patients.

Despite the warnings, antipsychotics are often prescribed for BPSD. In 2014, 39% of seniors in long-term care (LTC) facilities in Canada had one or more claims for an antipsychotic, and almost one quarter (22%) were chronic users of antipsychotic medications.[23] Almost a third of these residents did not have a diagnosis of psychosis.[24] "We focused on that in our guideline because it appears to be a common practice that is potentially problematic," Bjerre said. "Dementia is a difficult condition, with no proven treatment, and nonpharmacologic approaches to managing these behavioral symptoms are quite resource-intensive. So it is understandable, particularly in a cost-cutting context, that the easiest or often the only resource available is to sedate people or at least to control agitation behaviors with medication. In some cases it may be necessary, where patients are at risk of harming themselves or others. We are not saying that antipsychotics are inappropriate in all circumstances," Bjerre stressed.

The Evidence for the Guideline

The guideline and algorithm are based on evidence from studies of withdrawal versus continuation of antipsychotics used for BPSD.[25] Overall, these studies suggest that many older people with BPSD can be withdrawn from chronic antipsychotic medication without detrimental effects on their behavior.

Because no deprescribing studies of antipsychotics used to treat insomnia had been published, Bjerre and her colleagues based their recommendations on their own systematic review of studies of the efficacy of antipsychotics in treating insomnia.[26] They concluded that atypical antipsychotics should be avoided as first-line treatment of primary insomnia until further evidence is available and that more studies are needed.

While developing this guideline, Bjerre and her team piloted it at three primary care clinics and three LTC facilities for 3-4 months and incorporated their feedback into the final version, an unusual step in the development of guidelines. "The algorithm was reported to be the most helpful part because it was so concise," she recalled.

"The main message of the guideline is that we should ask why the patient is taking the drug, whether it was appropriate initially, and whether it is still needed," Bjerre said. "It may be that the final decision is to continue the medication at the same or a reduced dose or to try to stop it completely."

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