Andrew Berry, MD

Background: Delirium is a common disorder in hospitalized adults and is associated with poor outcomes. Antipsychotics are used clinically to treat delirium, but benefits and harms remain unclear.

Study design: A systematic review evaluating treatment of delirium in 16 randomized, controlled trials (RCTs) of antipsychotics vs. placebo or other antipsychotics, as well as 10 prospective observational studies reporting harm.

Setting: Data obtained from PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception to July 2019 without language restrictions.

Synopsis: For 5,607 adult inpatients, treatment of delirium with haloperidol showed no difference in sedation status, duration of delirium, hospital length of stay, or mortality when compared with second-generation antipsychotics or placebo (low and moderate strength of evidence). Regarding second-generation antipsychotics versus haloperidol, no difference was found in delirium severity and cognitive function (low strength of evidence). Direct comparisons between second-generation antipsychotics showed no difference in mortality.

Limitations include heterogeneous use of agents, routes, dose, and measurement tools, which limits generalization of evidence. Multiple RCTs excluded patients with underlying cardiac and neurologic conditions that likely led to underrepresentation of harm in routine use. Insufficient evidence still exists for multiple clinically relevant outcomes including long-term cognitive function.

Bottom line: Evidence from several studies does not support the use of haloperidol or newer antipsychotics to treat delirium.

Citation: Nikooie R et al. Antipsychotics for delirium treatment in adults: A systematic review. Ann Intern Med. 2019 Oct 1;171(7):485-95.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: Delirium is a common disorder in hospitalized adults and is associated with poor outcomes. Antipsychotics are used clinically to treat delirium, but benefits and harms remain unclear.

Study design: A systematic review evaluating treatment of delirium in 16 randomized, controlled trials (RCTs) of antipsychotics vs. placebo or other antipsychotics, as well as 10 prospective observational studies reporting harm.

Setting: Data obtained from PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception to July 2019 without language restrictions.

Synopsis: For 5,607 adult inpatients, treatment of delirium with haloperidol showed no difference in sedation status, duration of delirium, hospital length of stay, or mortality when compared with second-generation antipsychotics or placebo (low and moderate strength of evidence). Regarding second-generation antipsychotics versus haloperidol, no difference was found in delirium severity and cognitive function (low strength of evidence). Direct comparisons between second-generation antipsychotics showed no difference in mortality.

Limitations include heterogeneous use of agents, routes, dose, and measurement tools, which limits generalization of evidence. Multiple RCTs excluded patients with underlying cardiac and neurologic conditions that likely led to underrepresentation of harm in routine use. Insufficient evidence still exists for multiple clinically relevant outcomes including long-term cognitive function.

Bottom line: Evidence from several studies does not support the use of haloperidol or newer antipsychotics to treat delirium.

Citation: Nikooie R et al. Antipsychotics for delirium treatment in adults: A systematic review. Ann Intern Med. 2019 Oct 1;171(7):485-95.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: Delirium is a common disorder in hospitalized adults and is associated with poor outcomes. Antipsychotics are used clinically to treat delirium, but benefits and harms remain unclear.

Study design: A systematic review evaluating treatment of delirium in 16 randomized, controlled trials (RCTs) of antipsychotics vs. placebo or other antipsychotics, as well as 10 prospective observational studies reporting harm.

Setting: Data obtained from PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception to July 2019 without language restrictions.

Synopsis: For 5,607 adult inpatients, treatment of delirium with haloperidol showed no difference in sedation status, duration of delirium, hospital length of stay, or mortality when compared with second-generation antipsychotics or placebo (low and moderate strength of evidence). Regarding second-generation antipsychotics versus haloperidol, no difference was found in delirium severity and cognitive function (low strength of evidence). Direct comparisons between second-generation antipsychotics showed no difference in mortality.

Limitations include heterogeneous use of agents, routes, dose, and measurement tools, which limits generalization of evidence. Multiple RCTs excluded patients with underlying cardiac and neurologic conditions that likely led to underrepresentation of harm in routine use. Insufficient evidence still exists for multiple clinically relevant outcomes including long-term cognitive function.

Bottom line: Evidence from several studies does not support the use of haloperidol or newer antipsychotics to treat delirium.

Citation: Nikooie R et al. Antipsychotics for delirium treatment in adults: A systematic review. Ann Intern Med. 2019 Oct 1;171(7):485-95.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: Resumption of AC or AP therapy for patients following a GIB represents a common clinical challenge. Interruption of these medications following a GIB is associated with increased risk of macrovascular events, thrombosis, morbidity, and death. Prior studies have found inconsistent risk of rebleeding and death with resumption of these therapies following GIB. Little evidence exists for long-term outcomes and optimal timing of AC and AP resumption.

Study design: Retrospective observational cohort study.

Setting: Two general hospitals in Spain.

Synopsis: Overall 871 patients (mean age, 79 years) presenting with GIB on AC or AP therapy were followed for a median of 25 months. A total of 63% of patients experienced one of the following: thrombotic events, recurrent bleeding, or death during follow-up. Resumption of therapy was associated with a twofold risk of rebleeding, but lower rates of ischemic events (hazard ratio, 0.62; 95% confidence interval, 0.4-0.9) and death (HR, 0.60; 95% CI, 0.45-0.80). Early resumption (7 days or less) was associated with more rebleeding (30.6% vs. 23.1%; P = .04), fewer ischemic events (13.6% vs. 20.4%; P = .02%), and no difference in death. Bleeding was more frequent with AC agents, compared with AP agents.

Although resumption of AC or AP following a GIB increased bleeding risk, this may be outweighed by reductions in ischemic events and death if these agents are continued. For hospitalist clinicians, this remains a nuanced and patient-centered decision.

Interpretation is limited by variability in GIB location, agents used, and timing of resumption. Also, the study population included a limited number of elderly patients with multiple comorbidities and high overall death rate.

Bottom line: Resuming AC and AP medications following gastrointestinal bleeding doubled the rebleeding risk but lowered the risk of ischemic events and death, compared with the discontinuation of these medications.

Citation: Sostres C et al. Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users. Aliment Pharmcol Ther. 2019 Oct;50:919-29.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: Resumption of AC or AP therapy for patients following a GIB represents a common clinical challenge. Interruption of these medications following a GIB is associated with increased risk of macrovascular events, thrombosis, morbidity, and death. Prior studies have found inconsistent risk of rebleeding and death with resumption of these therapies following GIB. Little evidence exists for long-term outcomes and optimal timing of AC and AP resumption.

Study design: Retrospective observational cohort study.

Setting: Two general hospitals in Spain.

Synopsis: Overall 871 patients (mean age, 79 years) presenting with GIB on AC or AP therapy were followed for a median of 25 months. A total of 63% of patients experienced one of the following: thrombotic events, recurrent bleeding, or death during follow-up. Resumption of therapy was associated with a twofold risk of rebleeding, but lower rates of ischemic events (hazard ratio, 0.62; 95% confidence interval, 0.4-0.9) and death (HR, 0.60; 95% CI, 0.45-0.80). Early resumption (7 days or less) was associated with more rebleeding (30.6% vs. 23.1%; P = .04), fewer ischemic events (13.6% vs. 20.4%; P = .02%), and no difference in death. Bleeding was more frequent with AC agents, compared with AP agents.

Although resumption of AC or AP following a GIB increased bleeding risk, this may be outweighed by reductions in ischemic events and death if these agents are continued. For hospitalist clinicians, this remains a nuanced and patient-centered decision.

Interpretation is limited by variability in GIB location, agents used, and timing of resumption. Also, the study population included a limited number of elderly patients with multiple comorbidities and high overall death rate.

Bottom line: Resuming AC and AP medications following gastrointestinal bleeding doubled the rebleeding risk but lowered the risk of ischemic events and death, compared with the discontinuation of these medications.

Citation: Sostres C et al. Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users. Aliment Pharmcol Ther. 2019 Oct;50:919-29.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: Resumption of AC or AP therapy for patients following a GIB represents a common clinical challenge. Interruption of these medications following a GIB is associated with increased risk of macrovascular events, thrombosis, morbidity, and death. Prior studies have found inconsistent risk of rebleeding and death with resumption of these therapies following GIB. Little evidence exists for long-term outcomes and optimal timing of AC and AP resumption.

Study design: Retrospective observational cohort study.

Setting: Two general hospitals in Spain.

Synopsis: Overall 871 patients (mean age, 79 years) presenting with GIB on AC or AP therapy were followed for a median of 25 months. A total of 63% of patients experienced one of the following: thrombotic events, recurrent bleeding, or death during follow-up. Resumption of therapy was associated with a twofold risk of rebleeding, but lower rates of ischemic events (hazard ratio, 0.62; 95% confidence interval, 0.4-0.9) and death (HR, 0.60; 95% CI, 0.45-0.80). Early resumption (7 days or less) was associated with more rebleeding (30.6% vs. 23.1%; P = .04), fewer ischemic events (13.6% vs. 20.4%; P = .02%), and no difference in death. Bleeding was more frequent with AC agents, compared with AP agents.

Although resumption of AC or AP following a GIB increased bleeding risk, this may be outweighed by reductions in ischemic events and death if these agents are continued. For hospitalist clinicians, this remains a nuanced and patient-centered decision.

Interpretation is limited by variability in GIB location, agents used, and timing of resumption. Also, the study population included a limited number of elderly patients with multiple comorbidities and high overall death rate.

Bottom line: Resuming AC and AP medications following gastrointestinal bleeding doubled the rebleeding risk but lowered the risk of ischemic events and death, compared with the discontinuation of these medications.

Citation: Sostres C et al. Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users. Aliment Pharmcol Ther. 2019 Oct;50:919-29.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.