Antipsychotic drug use and pneumonia: Systematic review and meta-analysis.

OBJECTIVES: The purpose of this study was to investigate the association of antipsychotic exposure to the incidence and mortality of pneumonia. METHODS: The design of this study involved meta-analysis of observational studies identified from electronic databases. RESULTS: In total, 19 studies were included in the systematic review and 14 in the meta-analysis. Risk of pneumonia was increased by first-generation antipsychotics (risk ratio 1.69, 95% confidence interval 1.34-2.15; five studies), second-generation antipsychotics (risk ratio 1.93, 95% confidence interval 1.55-2.41; six studies) and all antipsychotics (risk ratio 1.83, 95% confidence interval 1.60-2.10; seven studies) compared with no antipsychotic use. Pneumonia risk did not differ in seven studies comparing first-generation antipsychotics with second-generation antipsychotics (risk ratio 1.07, 95% confidence interval 0.85-1.35). Case fatality rate was not different in pneumonia cases associated with antipsychotic exposure versus cases without exposure (risk ratio 1.50; 95% confidence interval 0.76-2.96; two studies). All antipsychotics with data from ⩾2 studies allowing meta-analysis, were associated with a significantly increased pneumonia risk (i.e. haloperidol, olanzapine, clozapine, risperidone, quetiapine, zotepine). CONCLUSION: Exposure to both first-generation antipsychotics and second-generation antipsychotics is associated with an increased pneumonia risk. Clinicians need to be vigilant for the occurrence of pneumonia in patients commencing antipsychotics, especially those with other risk factors for pneumonia including older age, chronic respiratory disease, cerebrovascular disease, dysphagia and smoking.

Effect of paliperidone palmitate on hospitalisation in a naturalistic cohort - a four-year mirror image study.

BACKGROUND: Clinical trial outcomes are heavily influenced by the non-naturalistic clinical trial process. Observations of outcomes in clinical practice are a valuable adjunct to clinical trial results. HYPOTHESIS: Our null hypothesis was that clinically indicated switching to paliperidone palmitate had no effect on hospital admissions or hospital bed days. METHOD: This was a part-prospective mirror image study examining outcomes 2years before starting paliperidone palmitate and 2years after. Sensitivity analyses examined the effect of different placings of the mirror in the mirror image design. RESULTS: We prospectively followed-up 225 patients prescribed paliperidone palmitate in clinical practice. At 2years, 41.8% of patients were still receiving paliperidone palmitate. In the primary analysis, the mean number of admissions fell from 1.80 in the two years before starting paliperidone palmitate to 0.81 in two years following the drug's initiation (outpatients) or two years following hospital discharge (inpatients) (P<0.001). More than half of patients were not admitted to hospital during two years follow-up. Mean total bed days was reduced from 79.6 in the two years before to 46.2 in the two years after paliperidone palmitate initiation or discharge (P<0.001). Sensitivity analyses gave broadly similar outcomes. Continuers demonstrated better outcomes than discontinuers in sensitivity analyses but not in the primary analysis. CONCLUSION: Paliperidone palmitate initiation is associated with a substantial reduction in hospital admissions and days spent in hospital. The reduction in costs associated with reduced use of health care facilities is likely to exceed the purchase and administration costs of the drug.

Antipsychotic use and unexpected death: a hospital-based case-control study.

OBJECTIVE: To examine the risk of unexpected death in patients prescribed an antipsychotic. Unexpected death was defined as death occurring within 7 days of the onset of acute symptoms. METHOD: A case-control study conducted on events occurring between July 2009 and January 2011 in a UK mental health trust providing in-patient and out-patient services. RESULTS: The study included 100 cases (deaths) and 436 unmatched controls. Current users of antipsychotics had a lower risk of unexpected death than non-users--adjusted odds ratio (OR) 0.48 (95% CI 0.24-0.94, P = 0.033). A significant reduction in risk was seen for second-generation [adjusted OR 0.42 (95% CI 0.21-0.86, P = 0.018)], but not first-generation agents [adjusted OR 0.83 (95% CI 0.31-2.20, P = 0.706)]. Treatment with antipsychotics for any duration was associated with reduced risk. Dose and route of administration did not affect risk. In a planned secondary analysis not adjusting for cardiovascular disease, prescription of an antipsychotic was not associated with increased risk of unexpected death [adjusted OR 0.56 (95% CI 0.28-1.08, P = 0.084)]. CONCLUSION: Our findings do not support an association between current antipsychotic use and increased risk of unexpected death.