Do not use risperidone or olanzapine to treat behavioural problems
associated with dementia
| Prescribing advice
· Patients with dementia currently treated with an atypical antipsychotic
drug should have their treatment reviewed
· Risperidone and olanzapine should not be used for the treatment
of behavioural symptoms associated with dementia
· Risperidone should only be used short-term and under specialist
advice for acute psychotic conditions in elderly patients with
dementia
· Risk of cerebrovascular events should be considered in any patients
with previous history of stroke, transient ischaemic attack and
other risk factors
The MHRA and the Department of Health are developing
new guidelines with the Royal College of Psychiatrists, Alzheimer’s
Society and National Care Standards Commission on alternative
ways of managing
behavioural problems in dementia. |
Risperidone (Risperdal) and olanzapine (Zyprexa) should not be used to treat behavioural problems in older people with dementia, recommends the Committee on Safety of Medicines. However, the new advice is likely to cause problems for health professionals managing this group of patients, a mental health pharmacist has warned.
The CSM guidance comes after a review of safety data revealed a three-fold
increase in stroke risk for older people with dementia who were treated
with risperidone or olanzapine. The Department of health estimates that
if six patients are treated with risperidone for one year, one cerebrovascular
adverse event would be attributable to the drug.
Atypical antipsychotics are not licensed for treatment of behavioural
problems associated with dementia but are used widely in this patient
population.
Approximately 30,000 patients aged 65 years and over were treated with
risperidone for behavioural problems associated with dementia last year.
A further 9,000 received olanzapine for this indication.
The CSM believes many patients who suffer from dementia can be managed
without medicines. “For those who do need drug treatment, there
are a variety of alternatives available,” said Sir Alasdair Breckenbridge,
chairman of the Medicines and Healthcare products Regulatory Agency.
Stephen Bazire, director of pharmacy services, Norfolk Mental Health
Care NHS Trust, warned that problems could arise because of the advice. “We
have been using low-dose risperidone — 0.25mg to 2mg daily — without
apparent problems,” he said. Many people currently managed with
low doses of these drugs in nursing homes will have to be cared for in
other establishments, he added. The advice would mean reverting to older
drugs, such as the phenothiazines and haloperidol, which were not without
their own problems.
Mr Bazire suggested pericyazine (Neu-lactil) could be used as an alternative
treatment for behavioural problems associated with dementia. However,
the dearth of information published on QT prolongation for phenothiazines
(other than thioridazine) means that it is difficult to assess their
safety. He added that the anticholinergic effects of these drugs would
not be helpful in patients already suffering with impaired cognitive
function. Use of other atypical antipsychotics without a proven stroke
problem would also be an option. Newer dementia drugs, such as the anticholinesterases
and memantine, would not be appropriate since they are not effective
for calming patients down, he added. |
The
Pharmaceutical Journal