CSM warning on atypical psychotics and stroke may be detrimental for dementia
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《英国医生杂志》
EDITOR—On 9 March the Committee on Safety of Medicines (CSM) advised avoiding olanzapine and risperidone for patients with dementia, reflecting concern over the excess risk of stroke.1
Antipsychotic drugs have long been used (off licence) in dementia to treat neuropsychiatric disturbance and are highly effective.2 Atypical antipsychotic drugs have recently been favoured over older preparations to avoid anticholinergic and Parkinsonian side effects, but a recent study of elderly people receiving typical and atypical antipsychotic drugs found no significant difference in risk of stroke between pharmacological groups.3 Stroke, while potentially catastrophic, is a quantifiably rare "excess risk" event in a group already at risk, demanding balanced thinking against real reductions in agitation and aggression.4
We are concerned that antipsychotic treatment will be unnecessarily withheld, and also that general practitioners will now adopt widespread use of conventional antipsychotic drugs. The Adults with Incapacity (Scotland) Act 2000 specifies that informed proxy decisions should be made on the basis of sound generalist and specialist advice, and in conjunction with relatives or carers. We regularly meet such carers in clinical practice who feel well served by drug treatment, are willing to engage in life's realities of assessing and accepting risk, and make those choices in conjunction with informed medical opinion. We believe that the blanket injunction issued by the Committee on Safety of Medicines is oversimplified and may prove detrimental to patient care.
Donald Mowat, consultant in old age psychiatry
donald.mowat@gpct.grampian.scot.nhs.uk
Douglas Fowlie, consultant in old age psychiatry, Tom MacEwan, consultant in old age psychiatry
Royal Cornhill Hospital, Aberdeen AB25 2ZH
Competing interests: TM has received support from Janssen Cilag to attend an international meeting; the authors' department has received limited educational support from various pharmaceutical companies.
References
Committee on Safety of Medicines. Latest news. 9 March 2004. Atypical antipsychotic drugs and stroke. www.mca.gov.uk/aboutagency/regframework/csm/csmhome.htm (accessed 7 May 2004).
Brodaty H, Ames D, Snowdon J, Woodward M, Kirwan J, Clarnette R, et al. A randomised placebo controlled trial of risperidone for the treatment of aggression agitation and psychosis of dementia. J Clin Psychiatry 2003;64: 134-43.
Herrmann N, Mamdami M, Lanctot KL. Atypical antipsychotics and risk of cerebrovascular accidents. Am J Psychiatry (in press).
Schneider L, Dagerman K. Meta-analysis of atypical antipsychotics for dementia patients: balancing efficacy and adverse events. International Psychogeriatrics 2003;15(suppl 2): 164-5.
Antipsychotic drugs have long been used (off licence) in dementia to treat neuropsychiatric disturbance and are highly effective.2 Atypical antipsychotic drugs have recently been favoured over older preparations to avoid anticholinergic and Parkinsonian side effects, but a recent study of elderly people receiving typical and atypical antipsychotic drugs found no significant difference in risk of stroke between pharmacological groups.3 Stroke, while potentially catastrophic, is a quantifiably rare "excess risk" event in a group already at risk, demanding balanced thinking against real reductions in agitation and aggression.4
We are concerned that antipsychotic treatment will be unnecessarily withheld, and also that general practitioners will now adopt widespread use of conventional antipsychotic drugs. The Adults with Incapacity (Scotland) Act 2000 specifies that informed proxy decisions should be made on the basis of sound generalist and specialist advice, and in conjunction with relatives or carers. We regularly meet such carers in clinical practice who feel well served by drug treatment, are willing to engage in life's realities of assessing and accepting risk, and make those choices in conjunction with informed medical opinion. We believe that the blanket injunction issued by the Committee on Safety of Medicines is oversimplified and may prove detrimental to patient care.
Donald Mowat, consultant in old age psychiatry
donald.mowat@gpct.grampian.scot.nhs.uk
Douglas Fowlie, consultant in old age psychiatry, Tom MacEwan, consultant in old age psychiatry
Royal Cornhill Hospital, Aberdeen AB25 2ZH
Competing interests: TM has received support from Janssen Cilag to attend an international meeting; the authors' department has received limited educational support from various pharmaceutical companies.
References
Committee on Safety of Medicines. Latest news. 9 March 2004. Atypical antipsychotic drugs and stroke. www.mca.gov.uk/aboutagency/regframework/csm/csmhome.htm (accessed 7 May 2004).
Brodaty H, Ames D, Snowdon J, Woodward M, Kirwan J, Clarnette R, et al. A randomised placebo controlled trial of risperidone for the treatment of aggression agitation and psychosis of dementia. J Clin Psychiatry 2003;64: 134-43.
Herrmann N, Mamdami M, Lanctot KL. Atypical antipsychotics and risk of cerebrovascular accidents. Am J Psychiatry (in press).
Schneider L, Dagerman K. Meta-analysis of atypical antipsychotics for dementia patients: balancing efficacy and adverse events. International Psychogeriatrics 2003;15(suppl 2): 164-5.