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Safety of Oral Antipsychotics in Older Adults After Major Surgery

Second-generation antipsychotic agents and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium, according to a study of people receiving an oral low-to-moderate dose antipsychotic drug. “We recommend reducing antipsychotic use altogether as there is no safer antipsychotic drug option and focusing concerted clinical and health policy efforts and investment in nonpharmacologic interventions for delirium prevention and management,” the authors conclude.

The retrospective cohort study included 17,115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018 at U.S. hospitals in the Premier Healthcare Database. Drugs and doses analyzed were haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg). The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting.

“The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%,” the investigators found. “Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group.”

Source: Annals of Internal Medicine