PharmacoEconomics & Outcomes News 595 - 23 Jan 20101. Dorsey ER, et al. Impact of FDA black box advisory on antipsychoticThe impact of safety concerns on medication use. Archives of Internal Medicine 170: 96-103, No. 1, 11 Jan 2010.2. Hoffmann F, et al. Eight-year prescription trends of memantine andantipsychotic use

cholinesterase inhibitors among persons 65 years and older in Germany.International Clinical Psychopharmacology 25: 29-36, No. 1, Jan 2010.

In March 2004, the UK Committee on Safety of 3. Trifiro G, et al. Prescribing pattern of antipsychotic drugs in the Italian generalpopulation 2000-2005: a focus on elderly with dementia. International ClinicalMedicines issued a recommendation to healthcarePsychopharmacology 25: 22-28, No. 1, Jan 2010.professionals to avoid the use of atypical antipsychotics 4. Chen Y, et al. Unexplained variation across US nursing homes in antipsychotic

in elderly with dementia due to a three-fold increase in prescribing rates. Archives of Internal Medicine 170: 89-95, No. 1, 11 Jan 2010.801140312the risk of cerebrovascular events. This was followed by

a black box warning from the US FDA in April 2005,alerting physicians of an increased risk of mortalityassociated with atypical antipsychotics in these samepatients. Several recent studies have evaluated theimpact of these safety concerns on the prescribingpatterns of antipsychotics.

According to an audit of office-based physiciansconducted in the US,1 atypical antipsychotic use fell 2%overall - 19% among patients with dementia - in the yearfollowing the FDA’s advisory. Prior to this, total atypicalantipsychotic drug use was increasing at a rate of 34%per year.

At their peak (in 2004), atypical antipsychoticsaccounted for up to 19% of prescriptions for elderlypatients with dementia in the US. The rate fell to 9% by2008. Despite this, atypical antipsychotics remain thesecond most common drug class for the treatment ofdementia in the elderly, after acetylcholinesteraseinhibitors.1 Interestingly, a German study showed thatthe prescription prevalence for acetylcholinesteraseinhibitors has more than doubled in both elderly malesand females since the year 2000 (0.27%–0.85% inelderly males and 0.36%–1.07% in elderly females, from2000 to 2007).2

A study conducted in Italy indicates a shift towardsusing typical antipsychotics rather than atypicalantipsychotics to treat elderly patients with dementia.3

The use of atypical agents to treat dementia increasedsubstantially from 2000 to 2004 (from 0.2 to 9.7 usersper 10 000 elderly persons), but the increase tapered offthereafter, following the safety warnings. Conversely,the use of typical antipsychotics was decreasing from2001 to 2004 (from 15.7 to 10.7 per 10 000 elderlypersons), but then increased between 2004 and the endof 2005 (12.1 per 10 000 elderly in December 2005).

Despite the general decline in atypical antipsychoticuse, an analysis of pharmacy claims from newlyadmitted nursing home residents in the US reveals thatthere is still some cause for concern.4 In 2006, morethan 29% of nursing home residents were prescribed anantipsychotic. Over 16% of residents received anantipsychotic despite having no clinical indication forsuch therapy (no psychoses or dementia). There wasalso significant amounts of unexplained variation in therates of antipsychotic prescribing between nursinghomes. After adjusting for potential clinical indications,residents of facilities with the highest prescribing rateswere 37% more likely to be prescribed an antipsychoticthan residents of facilities with the lowest prescribingrates (risk ratio 1.37; 95% CI 1.24, 1.51). Theresearchers suggest that the nursing homes’ culturetowards antipsychotic prescribing may play animportant component in explaining the amount ofvariation. They conclude that "safety concerns continueto persist in the use of antipsychotic medications in NH[nursing home] residents whose benefits from theseagents are unclear".

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PharmacoEconomics & Outcomes News 23 Jan 2010 No. 5951173-5503/10/0595-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved