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Use of haloperidol versus atypical antipsychotics and risk of in-hospital death in patients with acute myocardial infarction: cohort study

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1218 (Published 28 March 2018) Cite this as: BMJ 2018;360:k1218

Re: Use of haloperidol versus atypical antipsychotics and risk of in-hospital death in patients with acute myocardial infarction: cohort study

Delirium, once developed in physically critical conditions, is frequently challenging to treat pharmacologically but antipsychotics are frequently utilised in reality, despite their side effect burden and equivocal efficacy, either as a remedy (1) or as prophylaxis (2). Given a paucity of data, the study by Park et al. in the BMJ (3) is very important to potentially inform clinical management of delirium in a high risk population (i.e., post acute myocardial infarction). The authors carefully ruled out patients managed with intravascular haloperidol (in light of substantially different bioavailability of the drug).

Readers may want to know if intramuscular forms of medications were excluded as well. Readers will also be interested in knowing the relative dose of each respective antipsychotic since this is a critical consideration in any typical antipsychotic versus atypical antipsychotic comparison (as has been exemplified in the studies on schizophrenia (4).) Alternatively they may want to make sure that a shorter treatment duration with haloperidol by an average of 1.5 days could not have been due to its higher relative dose and that such a higher dose could not have been the very basis of the primary finding of higher mortality with this antipsychotic.

1 Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005594.
2 van den Boogaard M, Slooter AJC, Brüggemann RJM, Schoonhoven L, Beishuizen A, Vermeijden JW, Pretorius D, de Koning J, Simons KS, Dennesen PJW, Van der Voort PHJ, Houterman S, van der Hoeven JG, Pickkers P; REDUCE Study Investigators. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial. JAMA. 2018 Feb 20;319(7):680-690. doi: 10.1001/jama.2018.0160.
3 Park Y, Bateman BT, Kim DH, Hernandez-Diaz S, Patorno E, Glynn RJ, Mogun H, Huybrechts KF. Use of haloperidol versus atypical antipsychotics and risk of in-hospital death in patients with acute myocardial infarction: cohort study. BMJ. 2018 Mar 28;360:k1218. doi: 10.1136/bmj.k1218.
4 Geddes J, Freemantle N, Harrison P, Bebbington P. Atypical antipsychotics in the treatment of schizophrenia: systematic overview and meta-regression analysis. BMJ. 2000 Dec 2;321(7273):1371-6.

Competing interests: No competing interests

16 April 2018
Takefumi Suzuki
Professor
Department of Neuropsychiatry and Clinical Ethics, Faculty of Medicine, University of Yamanashi, Japan
1110, Shimokato, Chuo-city, Yamanashi, 409-3898, Japan