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Thread: Conventional Antipsychotic Medications Linked to Increased Cardiovascular Death in Elderly Patients

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    Default Conventional Antipsychotic Medications Linked to Increased Cardiovascular Death in Elderly Patients

    Conventional Antipsychotic Medications Linked to Increased Cardiovascular Death in Elderly Patients

    August 28, 2008 Elderly patients prescribed a conventional, first-generation antipsychotic have a 30% increased risk of dying compared with those prescribed atypical, second-generation antipsychotics, new research suggests.

    Half of this increased risk is from cardiovascular disease, and these patients also have a significantly higher risk for death from respiratory causes.

    "This paper and 2 previous papers from our group suggest that conventional antipsychotics are not safer than atypical antipsychotics," study investigator Soko Setoguchi, MD DrPH, from Brigham and Women's Hospital, in Boston, told Medscape Psychiatry.

    However, she cautioned, the findings need to be confirmed, and residual confounding ruled out.

    The study is published online August 6 in the Journal of the American Geriatrics Society.

    FDA Warnings

    In 2005, the Food and Drug Administration (FDA) issued an advisory warning that atypical antipsychotics were associated with a significantly greater risk for death than placebo in elderly people with dementia.

    In June 2008, the warning was extended to both conventional and atypical antipsychotics, based on the results of 2 studies, including 1 from the current group of investigators.

    That study looked at a cohort of all residents of British Columbia who were aged 65 years and older when they began taking an antipsychotic (Schneeweiss S et al. CMAJ 2007;176:627-632). The investigators found a 30% increase in 180-day all-cause mortality among those prescribed conventional vs atypical antipsychotics.

    The current study, in the same cohort, looked at causes of death.

    The study subjects had mean age of 80 years. Participants included 12,882 seniors who started taking conventional antipsychotics, including loxapine (69%), haloperidol (11%), and chlorpromazine (7%).

    Another 24,359 seniors began taking the atypical antipsychotics risperidone (75%), quetiapine (15%), and olanzapine (10%).

    Of 3821 deaths in the 6-month study period, 49% were due to cardiovascular causes. Of these, more than 60% were out-of-hospital cardiovascular deaths and included cardiac arrhythmias, myocardial infarction, pulmonary embolism, or stroke. Another 10% of deaths were due to infections, mostly pneumonia, and 9% of deaths were from respiratory causes other than pneumonia.

    The risk for cardiovascular death, out-of-hospital cardiovascular death, and death from respiratory causes was significantly higher in elderly patients taking conventional vs atypical antipsychotics.

    Interestingly, said Dr. Setoguchi, among the subgroup of elderly patients with dementia, there was no significantly increased risk for cardiovascular or out-of-hospital cardiovascular deaths in patients taking conventional vs atypical antipsychotics. This suggests that in patients with dementia, who are generally sicker than other patients, increased mortality might be due to causes other than cardiovascular-related causes.

    Clearer Warnings Needed

    In another study, researchers, led by Elmira Valiyeva, PhD, from the University of Toronto, in Ontario, assessed the impact of 3 warning letters sent to Canadian healthcare professionals about dangers of prescribing atypical antipsychotic drugs to elderly patients with dementia.

    Although prescribing rates for these drugs slowed after each warning, the overall rate increased over the study period from 1512 per 100,000 elderly patients in 2000 to 1813 per 100,000 elderly patients in 2007.

    The study is published in the August 26 issue of the Canadian Medical Association Journal.

    "If the goal of new information on risk is to motivate prescribers to rethink their therapeutic options, perhaps the warnings should be clear about alternatives and their safety and efficacy," the group writes.

    Warnings for atypical antipsychotic drugs should include comments on the safety and efficacy of conventional antipsychotics and at least a summary of nonpharmacologic interventions for dealing with aggression and agitation, such as those in the current clinical practice guidelines for the treatment of dementia, they add.

    All 3 new atypical drugs risperidone, olanzapine, and quetiapine were approved by Health Canada in the 1990s for treatment of schizophrenia, and risperidone was also approved for short-term management of psychotic or aggressive behavior in patients with dementia.

    The 3 safety warnings relating to risperidone, olanzapine and quetiapine were issued between October 2002 and June 2005.

    Prescribing Practices Largely Unchanged

    The investigators analyzed prescription drug claims in Ontario from May 1, 2000, to February 28, 2007, in patients aged 65 years and older.

    About 70% of individuals receiving antipsychotics lived in nursing homes, and 40% were over age 85 years.

    The first 2 warnings were associated with substantial relative decreases in prescription rates of 11.8% and 14.6%, respectively, in the predicted growth of risperidone and olanzapine. However, prescribers generally switched to another antipsychotic medication. The bottom line, say the researchers, is these warnings did not reduce overall prescription rates of these potentially dangerous drugs.

    "More effective interventions are necessary to improve postmarket drug safety in vulnerable populations. . . . A comprehensive, coordinated approach involving Health Canada, drug manufacturers, private and public drug insurers, and physicians is needed," the authors write.

    In an accompanying commentary, Laurence Y. Katz, MD, from the University of Manitoba, in Winnipeg, says the study results highlight the fact that physicians will return to the familiar, even in the presence of documented risks, if they are not given other options.

    "Healthcare warnings should provide accurate, explicit, and complete information about the risks and efficacy of the identified treatment in addition to providing the same information on alternative treatments," he writes.

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    hey frnds, lets continue this thread on antipsychotics plz..
    all about the drugs, mechanism of action, adverse effects, clinical use etc..

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    How about anti-depressants in the over-medicated American teenager?

    FDA Proposed Medication Guide: About Using Antidepressants in Children or Teenagers

    For current information on medication guides for antidepressant drugs, please see Antidepressant Use in Children, Adolescents and Adults

    The FDA has written a proposed Medication Guide about Using Antidepressants in Children or Teenagers and sent this Medication Guide to all the sponsors on October 21, 2004. It appears here to inform other groups and individuals with an interest in this Medication Guide. The FDA hopes to finalize the language of this Medication Guide by December 2004 so that the Medication Guide can be produced and made available to patients by the end of January 2005.

    What is the most important information I should know about antidepressants?

    Parents or guardians need to know about four important things to help them decide whether their child or teenager should take an antidepressant:

    The risks of self-injury or suicide

    How to try to prevent self-injury or suicide

    What to watch for in children or teens taking antidepressants

    The benefits and risks of antidepressants

    1. Risk of Injury to Self or Suicide

    Children or teenagers with depression sometimes think about suicide. They may even try to kill themselves. Antidepressants may increase suicidal thoughts or actions in some children and teens. Thinking about killing yourself or trying to kill yourself is called suicidality or being suicidal.

    A large study combined the results of 24 different smaller studies of children and teenagers who took either sugar pills or antidepressants for 1 to 4 months. Although no one committed suicide in these studies, some young patients became suicidal. On sugar pills, 2 out of every 100 became suicidal. On the antidepressants, 4 out of every 100 young patients became suicidal.

    2. How to try to prevent self-injury or suicide

    To try to prevent self-injury and suicide in children and teens using antidepressants, everyone (patients, parents, teachers, and other important people in the lives of young people) should pay close attention to sudden changes in their moods or behaviors. These are listed below under “What to Watch For.” Whenever an antidepressant is started or its dose is changed, close attention is needed.

    In general, after starting an antidepressant, patients should see their doctor


    Once a week for four weeks

    Every 2 weeks for the next month

    At the end of their 12th week taking the drug

    More often if problems or questions arise (see other side)

    3. What to Watch Out For in Children or Teens Taking Antidepressants

    If any of the following behaviors appear for the first time, seem worse, or worry the child, parent, or guardian, a medical professional should be contacted right away.

    New or more thoughts of suicide

    Trying to commit suicide

    New or worse depression

    New or worse anxiety

    Feeling very agitated or restless

    Panic attacks

    Difficulty sleeping (insomnia)

    New or worse irritability

    Acting aggressive, being angry, or violent

    Acting on dangerous impulses

    Being extremely hyperactive in actions and talking (hypomania or mania)

    Other unusual changes in behavior

    4. The Benefits and Risks of Antidepressants

    Antidepressants are used to treat people with depression. Depression can lead to suicide. In some people, treatment with an antidepressant causes suicidal thinking or actions or makes them worse. The doctor, the patient, and the patient's parents or guardians should discuss all treatment choices, including the use of antidepressants.

    Of all antidepressants, only fluoxetine (brand name: Prozac) has been FDA approved to treat pediatric depression.

    For obsessive compulsive disorder, FDA considers only fluoxetine (brand name: Prozac), sertraline (brand name: Zoloft), fluvoxamine (no marketed brand name product), and clomipramine (brand name: Anafranil) to be of proven benefit in children and teens.

    The past experiences of the patient with other treatments or antidepressants may lead the doctor to suggest other antidepressants than the ones listed above.

    For some young people, the risks of suicidal behaviors caused by antidepressants may be especially high. These include young people with

    Bipolar illness (sometimes called manic-depressive illness)

    A family history of bipolar illness

    A personal or family history of attempting suicide

    If any of these are present, make sure the doctor knows about them before the doctor prescribes any antidepressant.

    Is this all I need to know about antidepressants?

    No. This is a general warning for all antidepressants about suicidality. Other side effects can occur with antidepressants. Be sure to ask the doctor to explain all the side effects of the particular drug you are taking. Ask your pharmacist where to find additional information.

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