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What’s New in the
Patient Safety World
April 2020
More on
Inappropriate Medications in Parkinson’s
Most of our prior
columns on medication errors in patients with Parkinson’s Disease (PD) have
focused on the difficulties hospitals have meeting the
necessary timing of medication doses for inpatients. But we’ve also noted that
many patients with PD get prescribed medications that may worsen symptoms of PD
or be otherwise contraindicated. Most often those are medications having
significant anti-dopaminergic activity, such as butyrophenones and
phenothiazines.
But patients with PD
also have a high incidence of psychosis. Symptoms may include visual
hallucinations, delusions, and systemized hallucinations that are often severe
enough to merit treatment. Patients with PD also have a high incidence of
dementia and depression, which may put them further at risk for psychosis.
In our November 27,
2018 Patient Safety Tip of the Week “Focus
on Deprescribing” we noted a study (Mantri 2018)
which looked at patterns of dementia treatment and frank prescribing errors in
older adults with Parkinson Disease. 27.2% were given a prescription for at
least 1 antidementia medication. Of those receiving an acetylcholinesterase
inhibitor (ACHEI), 44.5% experienced at least 1 high-potency
anticholinergic–ACHEI event. They did find variation in such prescribing by
race/ethnicity, sex, and geography.
In our March 19, 2019 Patient Safety Tip of the Week “Updated Beers Criteria” we noted the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults (AGS 2019) specifically commented on Parkinson’s Disease. After reviewing and discussing the evidence on antipsychotics to treat psychosis in patients with Parkinson disease, the panel decided to remove aripiprazole as preferred and add pimavanserin. Thus, the 2019 Beers Criteria recognize quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson disease. Note that the Beers Criteria also recommend avoiding the anticholinergic drugs benztropine and trihexyphenidyl for prevention or treatment of Parkinson’s, since more effective agents are available.
A new study of patients with PD and comorbid depression
living in nursing homes (Chekani
2020) examined incidence of inappropriate atypical antipsychotics,
namely asenapine, brexpiprazole,
iloperidone, lurasidone, olanzapine, paliperidone, risperidone, or ziprasidone
as specified in the 2015 AGS Beers criteria. Appropriate atypical antipsychotic
included aripiprazole, clozapine, or quetiapine. (Note that they used the 2015
AGS Beers criteria rather than the updated 2019 criteria, which would have
considered aripiprazole to be inappropriate. It also did not note the use of pimavanserin.) The incidence of atypical antipsychotic use
was 17.50% among PD patients over a 2-year follow-up. The percentage of
inappropriate use among atypical antipsychotic users was 36.32%. The likelihood
of inappropriate antipsychotic use was higher for patients who had dementia or
COPD. However, patients who were taking levodopa, dopamine agonists,
Catechol-O-methyltransferase (COMT) inhibitors, Monoamine Oxidase (MAO)
inhibitors type B, or amantadine were less likely to receive inappropriate
antipsychotics.
There is a point we
are trying to emphasize with all of this. Parkinson’s Disease, probably more so
than any other condition, is frequently associated with features that call for
medications that are often contraindicated because of other features. We find
it hard to believe that anyone could conceivably remember all the ramifications
without assistance. This is a situation desperately calling for a sophisticated
clinical decision support system to help guide appropriate medication
management whether the patient is an outpatient, inpatient, or LTC patient.
Our prior columns on problems related to Parkinson’s Disease patients as inpatients:
- August 2011 “Problems Managing Medications in Parkinson’s Disease”
- December 2012 “More on Hospitalized Parkinson’s Disease Patients”
- June 2015 “More Risks for Parkinson Inpatients”
- November 27, 2018 “Focus
on Deprescribing”
- November 2019 “Protocol
Helps Parkinson’s Inpatients”
References:
Mantri S, Fullard M, Gray SL, et al. Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease. JAMA Neurol 2018; Published online October 1, 2018
https://jamanetwork.com/journals/jamaneurology/article-abstract/2704469
2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriatr Soc 2019; First published: 29 January 2019
https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767
Chekani F, Holmes HM, Johnson ML, Chen H, Sherer JT, Aparasu RR. Use of Atypical Antipsychotics in Long-Term Care Residents with Parkinson’s Disease and Comorbid Depression. Drug Healthc Patient Saf 2020; 12: 23-30
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