Microsoft word - pico mélanie délirium version 1997

ANTI-PSYCHOTIQUES ATYPIQUES OU HALDOL DANS
LE DÉLIRIUM ?
QUESTION : Laquelle de ces deux option est plus sécuritaire ?
AUTEUR : Mélanie Lecault (OCTOBRE 2007)
population gériatrique nécessitant un contrôle rapide des signes de CONTEXTE : J’ai noté, au cours de mes stages (notamment en CHSLD),
l’utilisation importante des anti-psychotiques atypiques pour contrôler les
comportements d’agitation et d’agressivité des patients à profil gériatrique.
RECHERCHE :
Cochrane : antipsychotics AND delirium (16 résultats; 3 pertinents) RÉSULTATS:
1) Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics for delirium.
Cochrane Database of Systematic Reviews 2007, Issue 2.
Background : Delirium occurs in up to 30% of hospitalised patients and is associated with prolonged hospital stay and increased morbidity and mortality. Recently published reports have suggested that the standard drug for delirium, haloperidol, a typical antipsychotic that may cause adverse extrapyramidal symptoms among patients, may be replaced by atypical antipsychotics such as risperidone, olanzapine or quetiapine, that are as effective as haloperidol in controlling delirium, but that have a lower incidence of extrapyramidal adverse effects. Objectives : To compare the efficacy and incidence of adverse effects of haloperidol with risperidone, olanzapine, and quetiapine in the treatment of delirium. Main results : Three studies were found that satisfied selection criteria. These studies compared haloperidol with risperidone, olanzapine, and placebo in the management of delirium and in the incidence of adverse drug reactions. Decrease in delirium scores were not significantly different comparing the effect of low dose haloperidol (< 3.0 mg per day) with the atypical antipsychotics olanzapine and risperidone (Odds ratio 0.63 (95% CI 0.29 - 1.38; p = 0.25). Low dose haloperidol did not have a higher incidence of adverse effects than the atypical antipsychotics. High dose haloperidol (> 4.5 mg per day) in one study was associated with an increased incidence of extrapyramidal adverse effects, compared with olanzapine. Low dose haloperidol decreased the severity and duration of delirium in post-operative patients, although not the incidence of delirium, compared to placebo controls in one study. There were no controlled trials comparing quetiapine with haloperidol. Authors' conclusions : There is no evidence that haloperidol in low dosage has different efficacy in comparison with the atypical antipsychotics olanzapine and risperidone in the management of delirium or has a greater frequency of adverse drug effects than these drugs. High dose haloperidol was associated with a greater incidence of side effects, mainly parkinsonism, than the atypical antipsychotics. Low dose haloperidol may be effective in decreasing the degree and duration of delirium in post-operative patients, compared with placebo. These conclusions must be tempered by the observation that they are based on small studies of limited scope, and therefore will require further corroborating evidence before they can be translated into specific recommendation for the treatment of delirium. 2) Lonergan E, Luxenberg J, Colford J, Birks J. Haloperidol for agitation in
dementia. Cochrane Database of Systematic Reviews 2002, Issue 2.
Background : Agitation occurs in up to 70% of demented patients. Haloperidol has been used for decades to control agitation in dementia, but its effectiveness remains unclear. Previous meta-analyses examined only English language publications or compared haloperidol with other drugs rather than with placebo. To study the effectiveness of haloperidol a more widely based review was performed. Objectives : To determine whether evidence supported the use of haloperidol in agitated dementia. Main results : The five included trials led to the following results: 1. There was no significant improvement in agitation among haloperidol treated patients, compared with controls. 2. Aggression decreased among patients with agitated dementia treated with haloperidol; other aspects of agitation were not affected significantly in treated patients compared with controls 3. Although two studies showed increased drop-outs due to adverse effects among haloperidol patients, there was no significant difference in drop-out rates, comparing all haloperidol treated patients with controls. 4. The data were insufficient to examine response to treatment in relation to length of treatment, degree of dementia, age or sex of patients, and cause of dementia. Authors' conclusions : 1. Evidence suggests that haloperidol was useful in reducing aggression, but was associated with adverse effects; there was no evidence to support the routine use of this drug for other manifestations of agitation in dementia. 2. Similar drop-out rates among haloperidol and placebo treated patients suggested that poorly controlled symptoms, or other factors, may be important in causing treatment discontinuation. 3. Variations in degree of dementia, dosage and length of haloperidol treatment, and in ways of assessing response to treatment suggested caution in the interpretation of reported effects of haloperidol in the management of agitation in dementia. 4. The present study confirmed that haloperidol should not be used routinely to treat patients with agitated dementia. Treatment of agitated dementia with haloperidol should be individualized and patients should be monitored for adverse effects of therapy. 3) Ballard C, Waite J, Birks J. Atypical antipsychotics for aggression and
psychosis in Alzheimer's disease. Cochrane Database of Systematic Reviews
2006, Issue 1.
Background : Aggression, agitation or psychosis occur in the majority of people with dementia at some point in the illness. There have been a number of trials of atypical antipsychotics to treat these symptoms over the last five years, and a systematic review is needed to evaluate the evidence in a balanced way. Objectives : To determine whether evidence supports the use of atypical antipsychotics for the treatment of aggression, agitation and psychosis in people with Alzheimer's disease. Main results : Sixteen placebo controlled trials have been completed with atypical antipsychotics although only nine had sufficient data to contribute to a meta-analysis and only five have been published in full in peer reviewed journals. No trials of amisulpiride, sertindole or zotepine were identified which met the criteria for inclusion. The included trials led to the following results: 1. There was a significant improvement in aggression with risperidone and olanzapine treatment compared to placebo. 2. There was a significant improvement in psychosis amongst risperidone treated patients. 3. Risperidone and olanzapine treated patients had a significantly higher incidence of serious adverse cerebrovascular events (including stroke), extrapyramidal side effects and other important adverse outcomes. 4. There was a significant increase in drop-outs in risperidone (2 mg) and olanzapine (5-10 mg) treated patients. 5. The data were insufficient to examine impact upon cognitive function. Authors' conclusions : Evidence suggests that risperidone and olanzapine are useful in reducing aggression and risperidone reduces psychosis, but both are associated with serious adverse cerebrovascular events and extrapyramidal symptoms. Despite the modest efficacy, the significant increase in adverse events confirms that neither risperidone nor olanzapine should be used routinely to treat dementia patients with aggression or psychosis unless there is severe distress or risk of physical harm to those living and working with the patient. Although insufficient data were available from the considered trials, a meta-analysis of seventeen placebo controlled trials of atypical neuroleptics for the treatment of behavioural symptoms in people with dementia conducted by the Food and Drug Administration suggested a significant increase in mortality (OR 1.7)**. A peer-reviewed meta-analysis (Schneider 2005) of 15 placebo controlled studies (nine unpublished) found similarly increased risk in mortality (OR=1.54, 95% CI 1.06 to 2.23, p=0.02) for the atypical neuroleptics. The risk difference was 0.01(95% 0.0044 to 0.02) ** sur le site de la FDA on lit : “Analyses of seventeen placebo controlled trials that enrolled 5106 elderly patients with dementia related behavioral disorders revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients. Clinical trials were performed with Zyprexa (olanzapine), Abilify (aripiprazole), Risperdal (risperidone), and Seroquel (quetiapine). Over the course of these trials averaging about 10 weeks in duration, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. » (Alerte du 4/11/2005) CONCLUSION:
La première étude répond plus précisément à la question, et est la plus récente. Trois études seulement ont été comprises dans l’analyse, comparant l’halopéridol avec le rispéridone, l’olanzapine et un placebo. La quetiapine n’a pas été étudiée. Une des études s’applique aux patients en post-opératoire, donc ne correspond pas à la population ciblée, et les antipsychotiques ont été utilisés en prophylaxie, et non pas comme traitement d’un delirium établi. Dans une des études, l’halopéridol est administré IM, alors que l’olanzapine et le placebo le sont PO. Les deux études pertinentes étaient à petite échelle : N=24, N=185. L’halopéridol était aussi efficace que l’olanzapine ou le rispéridone pour réduire les effets du délirium. L’halopéridol à petite dose ne cause pas plus d’effets secondaires que le rispéridone ou l’olanzapine. Cependant, il semble que l’halopéridol administré à haute dose et pour une durée prolongée (4.5 mg et plus pour plus de 7 jours) provoque plus d’effets extra-pyramidaux que l’olanzapine. Compte tenu de la taille et du nombre des études, il serait intéressant d’avoir encore plus de preuves pour supporter l’utilisation de l’halopéridol dans un contexte de délirium. En attendant, je crois qu’il est tout de même indiqué d’utiliser l’halopéridol en première ligne pour traiter les manifestations d’un délirium chez la population gériatrique quand les interventions non-pharmacologiques ont échoué. Cependant, si le besoin d’un antipsychotique devient chronique, je crois qu’il est indiqué de le changer pour un antipsychotique atypique, comme, la rispéridone. Toutefois, il faut être conscient des effets potentiellement graves associés à ce type de médication (ACV, augmentation de la mortalité). Il serait intéressant de réviser la littérature à ce sujet mais tel n’était pas le but de cette question-ci.

Source: http://medecinefamiliale.com/umf/pico/atypiques_delirium.pdf