Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Increased incidence of CVA with Atypical antipsychotics
- Gopal S Chinnari, Stephanie Fulton (18 June 2004)
-
Probable underreporting of drug induced parkinsonism
- Joseph H. Friedman (23 June 2004)
-
Atypical antipsychotics should be compared with treatments that work
- Kieran M Walsh (9 July 2004)
-
Do CSM provide further evidence ?
- Anna V Richman (10 July 2004)
-
Controversy over use of risperidone and olanzapine in BPSD
- Ajit K Shah, Guk-Hee Suh (11 July 2004)
-
Drugging demented patients!
- Dr.Naseem A. Qureshi MD, IMAPA, LMIPS (11 July 2004)
-
Do we really have better options?
- Alfonso J. Cruz-Jentoft (28 July 2004)
-
USE OF QUETIAPINE FOR BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA
- Benedetta Santarlasci, and Giulia Burchini (24 August 2004)
-
No excess of stroke with risperidona in a Primary Care area
- Maria J Gonzalez, Dolores Rivero (25 October 2004)
|
|
|||
|
Gopal S Chinnari, SHO in old age psychiatry Burton on trent DE13 ORB, Stephanie Fulton
Send response to journal:
|
Dear sir/madam, Your research shows promising results for treating behavioural and psychotic symptoms in dementia. My concern is, how far we can safely use atypicals as there is increased evidence of cerebrovasculr events in people with dementing illness.It is not recommended to use Resperidone and Olanzapine in dementia. Competing interests: None declared |
|||
|
|
|||
|
Joseph H. Friedman, Professor, Dept of Clinical Neurosciences, Brown University Medical School Memorial Hospital of R.I./111 Brewster ST./Pawtucket,, R.I. 02860
Send response to journal:
|
I applaud the fine article by Lee et al(1) reviewing the double blind placebo controlled data on atypical antipsychotic drugs in the elderly. I would like to suggest that drug induced parkinsonism is likely to have been underreported in each of the trials cited(2). For example, it was noted in this review that olanzapine was associated with "abnormal gait." The article reporting the abnormal gait however reported that "objective EPS were absent with olanzapine." Based on my personal experience (2) it is hard to escape the conclusion that the "abnormal gait" was simply a manifestation of parkinsonism. No other explanation was provided. The literature on the effects of olanzapine in people with Parkinon's disease is very clear in demonstrating worsened motor function (4), and elderly people with dementing diseases, including Alzheimer's disease, dementia with Lewy bodies and vascular dementia, are highly vulnerable to the parkinsonian side effects of medications. I suspect that this underreporting of parkinsonism in the olanzapine study extends to the reporting in the other studies as well. 1. Lee PE, Gill SS, Freedman M, et al. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ doi:10/1136/bmj.38125/465579.55 2. Friedman JH, Trieschmann MM, Fernandez HF. Parkinsonism in a Nursing Home-Underrecognition. J Ger Psychiatry 2004;17:39-41 3. Street JS, Clark WS, Kadam DL, et al. Long term efficacy of olanzapine in the control of psychotic and behavioral symptoms in nursing home patients with Alzheimer's dementia. Int J Geriatr Psychiatry 2001;16:S62- 70. 4.Breier A, Sutton VK, Feldman PD, Kadam DL, Ferchland I, Wright P, Friedman JH. Olanzapine in the treatment of dopamimetic-induced psychosis in patients with Parkinson’s disease. Biol Psychiatry 2002;52:438-45. Competing interests: I have received remuneration for consulting, speaking or clinical research from: Astra-Zeneca, Janssen, Lilly, Bristol Myers Squibb, Pfizer |
|||
|
|
|||
|
Kieran M Walsh, Editorial Registrar, bmjlearning.com BMA House, Tavistock Square, London WC1H 9JR.
Send response to journal:
|
Dear Sir, Lee et al looked at trials that compared atypical antipsychotics with placebo and with typical antipsychotics and found limited evidence that they work in patients with behavioural and psychological symptoms of dementia. (1) However neither placebo nor typical antipsychotics have been shown to help patients with behavioural and psychological symptoms of dementia. (2) Trials should always compare new treatments with the best available old treatments. And the treatments that are most likely to be helpful in patients with behavioural and psychological symptoms of dementia are carbamazepine and reality orientation. (3, 4) Lee et al should have drawn greater attention to this in their review and encouraged future researchers to compare new drugs with proven older treatments - carbamazepine and reality orientation. Until this happens patients and their carers will continue to get a raw deal. Yours Sincerely, Dr. Kieran Walsh, Editorial Registrar, bmjlearning.com 1. Lee PE, Gill SS, Freedman M, Bronskill SE, Hillmer MP, Rochon PA. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ. 2004 Jun 11. 2. Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in dementia. In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. 3. Spector A, Orrell M, Davies S, et al. Reality orientation for dementia. In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. 4. Tariot PN, Erb R, Podgorski CA, et al. Efficacy and tolerability of carbamazepine for agitation and aggression in dementia. Am J Psychiatry 1998;155:54–61. Competing interests: None declared |
|||
|
|
|||
|
Anna V Richman, Specialist Registrar in Old Age Psychiatry Mossley Hill Hospital, Park Avenue,Liverpool, L18 8BU
Send response to journal:
|
Dear Sir, In their review article, Lee et al state that "further evidence is required before" atypical antipsychotics "can be endorsed in the management of behavioural and psychological symptoms of dementia"(1). It is of note that of the five randomised trials reviewed, only 3 contained information on adverse events, and only 2 of these reported on the number of serious adverse events. It must be remembered that at present no atypical antipsychotic is licensed for the treatment of behavioural disturbances in dementia. In March 2004, after analysing data from randomised placebo-controlled clinical trials,and finding an approximate three-fold increased risk of cerebrovascular adverse events in patients taking Risperidone or Olanzapine compared to placebo, the Committee on Safety of Medicines advised that Risperidone or Olanzapine should not be used for the treatment of behavioural symptoms of dementia (2). Perhaps this is all the evidence needed, but perhaps not.Let us not forget that all drugs can have serious side effects, and also the importance of non-pharmacological interventions. Anna Richman 1 Lee P E, Gill S S, Freedman M, Bronskill S E,Hillmer M P, Rochon P A .Atypical Antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia :systematic review.BMJ 2004;329:75-78 2.Committee on Safety of Medicines : Atypical Antipsychotic Drugs and stroke CEM/CMO/2004/1 Competing interests: None declared |
|||
|
|
|||
|
Ajit K Shah, Consultant Psychiatrist West London Mental Health NHS Trust, Uxbridge road, Southall, UB1 3EU, Guk-Hee Suh
Send response to journal:
|
We read with great interest the recent systematic review on the use of atypical antipsychotics in the treatment of behavioural and psychological symptoms of dementia (BPSD) (1). The authors referred to new adverse events in the introduction and the conclusions section, but did not specifiy them. We feel it is important that the readers are made explicitly aware of the recent concerns expressed by the Committee of Safety of Medicines (CSM) in the united Kingdom. In March of this year the CSM informed all clinicians that risperidone and olanzapine increase the risk of strokes by three-fold when used to treat BPSD, and olanzapine increases the risk by two-fold for mortality when used to treat BPSD (2). CSM guided clinicians not to use these two drugs in the treatment of BPSD. These findings were based on pooled-analysis of placebo-controlled and randomised studies of risperidone (six) and olanzapine (four) for the treatment of BPSD (Personal communication fron Janssen-Cilag and Lily). Similar concerns have been previously raised in the United States and Canada for risperidone (3), but the concerns for olanzapine are entirely new. Clearly these new concerns have alarmed clinicians as these two drugs have been widely used in the treatment of BPSD because of their percieved efficacy and better side-effect profile. It is indeed a pity that these concerns were not made explicit and the only reference the authors make about cerebrovascular adverse events pertained to one study (4). References 1. Lee PE, Gill SS, Freedman M. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. 2004; 329: 75-78. 2. CSM. Atypical antipsychotic drugs and stroke. http:/medicines.mhca.gov.uk/aboutagency/regframework/csm/csmhome/wlht. Acess 17 May 2004. 3. Smith D, Beier M. Association between risperidone treatment and cerebrovascular adverse events: examining the evidence and postulating hypothesis for an underlying mechanism. Journal of the American Medical Directors Association. 2004; 5: 129-132. 4. Brodaty H, Ames D, Snowdon J. A randomised trial of risperidone in the treatment of aggression, agitation and psychosis in dementia. Journal of Clinical Psychiatry. 2003; 64: 134-143. Competing interests: Both Dr Shah & Professor Suh have received funding from Janssen to attend meetings |
|||
|
|
|||
|
Dr.Naseem A. Qureshi MD, IMAPA, LMIPS, Locum Psychiatrist Postcode:64399, SBAHC, Riyadh, KSA
Send response to journal:
|
Sir: Reportedly, majority of demented patients suffer from multiple medical and neuropsychiatric diseases as compared to age-matched normal population. These diseases mainly include hypertension, coronary heart disease, myocardial infarction, chronic congestive heart failure, hyperlipaedemia, cerebrovascular accidents and associated disabilities, diabetes mellitus, chronic renal failure, musculoskeletal disorders, obesity,liver diseases, dementia, parkinsonism, and other degenerative diseases of the CNS. Most importantly, individual patient with dementia has often additional multiple diseases for which they are frequently prescibed polypharmacy that has more disadvantages than benefits. Reprtedly, elderly patients with dementia do manifest behavioral and psychological manifestations, which are not only distressful to the patient but also to care givers. These behavioral smptoms are caused by biological disturbances as well as by environmental factors. Hence, all patients with dementia may not require psychotropic medications. Only comprehensive assessment of these demented patients guide whether or not they need antipsychotics-atypical or traditional. If yes, these drugs should be given in proper dosages, i.e., 1/3rd to 1/2half adult doses. Secondly, the need of continuation of such medications in elderly population should be assessed more frequently and early discontinuation should be opted. Both atypical and traditional antipsychotics are equally effective in elderly population with dementia and moreover there is no additional advantages of atypical over typical antipsychotics and vise versa. Both types of antipsychotics have their own adverse effects, which more often suggest that elderly patients should be managed by milieu manipulations rather than by being heavily "drugged". Reference: Philip E Lee, Sudeep S Gill, Morris Freedman, Susan E Bronskill, Michael P Hillmer, and Paula A Rochon. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review BMJ 2004; 329: 75-0. Competing interests: None declared |
|||
|
|
|||
|
Alfonso J. Cruz-Jentoft, Jefe de la Unidad de Geriatría Hospital Ramón y Cajal. Ctra. Colmenar km 9,1. 28034 Madrid (Spain)
Send response to journal:
|
Sir, Lee et al have written an excellent review of published trials comparing atypical antipsychotics with placebo and with typical antipsychotics and found limited evidence that they work in patients with behavioural and psychological symptoms of dementia (BPSD)(1). They state that further evidence is required before atypical antipsychotics can be endorsed in the management of behavioural and psychological symptoms of dementia. However, evidence about typical antipsychotics (including haloperidol) is even more limited (2). In fact, legislation to restrict antipsychotic prescription was introduced in the United States before atypical antipsychotics were marketed, as side effects of the former were considered frequent and severe. Typical antipsychotics have not been explicitly licenced in most countries for the treatment of BPSD. Evidence about other drugs is even weaker. Non-pharmacological treatments are widely considered a first step in the treatment of BPSD, but evidence about their use is also very limited (3). Concerns have been raised about the risk of stroke with new antipsychotics, but the mechanism of this association is unknown and data about older antipsychotics are been reviewed to find if this is a group effect or only some antipsychotics increase the risk. As BPSD increase suffering of patients and their carers, increase the risk of nursing home admission and increase cost of care, I believe treatment is needed in severe cases. As good evidence is lacking for every therapeutic intervention available, atypical antipsychotics are still standing as a first line treatment of BPSD. 1. Lee PE, Gill SS, Freedman M, Bronskill SE, Hillmer MP, Rochon PA. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ. 2004 Jun 11. 2. Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in dementia. In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. 3. Cummings JL. Drug therapy: Alzheimer’s disease. N Engl J Med 2004; 351:56-67. Competing interests: The author has received reimbursments by Almirall Prodesfarma, Astra Zeneca, Janssen-Cilag, Novartis and Pfizer (manufacturers of typical and atypical antipsychotic drugs in Spain), for organizing educational programs and speaking; and fees from Janssen-Cilag for consulting. |
|||
|
|
|||
|
Benedetta Santarlasci, consultant pharmacist Azienda Ospedaliera Careggi, Viale Morgagni 85, 50134 Firenze, Italy, and Giulia Burchini
Send response to journal:
|
Sir, Lee et al (1) have reviewed the literature about the use of atypical antipsychotic drugs (AADs) for treating behavioural and psychological symptoms of dementia (BPSD) and have observed that AADs are being used with increasing frequency for this indication. Their conclusion is that typical and atypical antipsychotics have similar effectiveness for this clinical indication with no difference in the respective adverse event profile. In the discussion of adverse events related to AADs, Lee et al. (1) have not mentioned the increased risk of cerebrovascular adverse events (2) that has been found in elderly people with dementia receiving olanzapine or risperidone (3-fold increase). A two-fold increase of mortality in this population has been found too (2). In Italy, there is a widespread off-label use of AADs for BPSD. For this reason, in March 2004 the Italian Ministry of Health has issued a “Dear Doctor letter” to discourage this off-label use and to underscore this risk of cerebrovascular adverse events (3). One controversy regards the use of quetiapine for BPSD. This AAD has less literature than olanzapine or risperidone in terms of both effectiveness and adverse event monitoring. The Italian Ministry of Health admits that this is the reason why quetiapine has not been contraindicated in the Dear Doctor letter. In this scenario, quetiapine could paradoxically benefit from its lack of literature and there could be an unjustified switch towards quetiapine of this off-label prescription of AADs. In our view, the restriction for treating BPSD should have been applied to quetiapine as well, and the entire off-label use of AADs for BPSD should have been banned. REFERENCES 1. Lee PE, Gill SS, Freedman M, Bronskill SE, Hillmer MP, Rochon PA. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ. 2004 Jul 10;329(7457):75. Epub 2004 Jun 11. 2. EMEA website. http://www.emea.eu.int/pdfs/human/press/pus/085604en.pdf accessed on 23 August 2004 3. Italian Ministry of Health website. http://www.ministerosalute.it/imgs/C_17_notaInf_1_listaFile_itemName_1_file.pdf accessed on 23 August 2004 Competing interests: BS has acted as consultant for Eli-Lilly, Italy |
|||
|
|
|||
|
Maria J Gonzalez, General Practitioner. Member of the Catalonian Alzheimer treatment Counsil CAP S Martín Infancia sn. 08020 Barcelona, Dolores Rivero
Send response to journal:
|
In May 2004, the Spanish Committee on Drugs Safety of Medicines advised that risperidone should not be used for long periods in elderly patients suffering from dementia. We conducted a retrospective study of clinical records of demented patients over 64 in an urban area (44.800 people, 181 registered cases of dementia) attached to a Primary Care Centre in Barcelona. We recorded stroke rates, cardiovascular risk factors, type of dementia, and demographic data from the whole181 community dwellers with dementia registered from 1/1/1999 to 15/06/2004. During the 6 years, we found 5 strokes among the 17 patients on haloperidol (29, 4%), and 28 cerebrovascular accident among 87 patients having risperidone (32, 2%). Out of the 61 demented patients untreated 11 (18%) had a stroke. No significant differences were found (p=0, 15). The groups were similar except for an excess of diabetic patients in the risperidone group (33% vs. 5, 9%, p=0.021). The average time running on antipsychotic drugs was 1, 5±1, 6 years without differences within both drugs. (p=0.33) We recognize our population is small but the resemblance of risperidona risk and benefit ratio remains unclear in Primary Care. Competing interests: None declared |
|||