Thanks for @emcrit for pointing their followers to our recent @NEJM publication on antipsychotics for @ICU_delirium: nejm.org/doi/full/10.10…
I appreciate their thoughtful and thorough commentary, especially the description of when to consider using an antipsychotic. But a number of points should be clarified. emcrit.org/pulmcrit/antip…
"89% of these patients had hypoactive delirium" - True at randomization but the percent with hypoactive delirium fluctuated during the trial; 209 (37%) experienced 1 or more days of hyperactive (agitated) delirium.
"Open-label antipsychotics were allowed in all arms of the trial, with 21% of patients receiving them." Half of the 21% received <5 mg of open-label haloperidol total; 75% received <10 mg total.
"The use of antipsychotics across all arms of the trial will minimize observed differences between groups." 79% of participants received 0 mg open-label antipsychotic. The other 21% received cumulative doses that were 1/10 or less what they received as double-blind study drug.
"Intravenous haloperidol has traditionally been used for the management of delirious patients with profound agitation." Not unreasonable, but one (small) RCT compared haloperidol with dexmedetomidine for agitation and found the latter was better. ncbi.nlm.nih.gov/pubmed/19454032
"Evidence obtained from haloperidol or ziprasidone doesn’t necessarily apply to other antipsychotics." This point--often used to justify the use of other antipsychotics--doesn't change the fact that we have no high-quality evidence supporting the use of any antipsychotic.
"Before publication of this study was anyone using antipsychotics for hypoactive delirium?" Yes, there's plenty of published data showing this to be the case. This is just one of many examples where what doctors believe they do differs from what they actually do.
In fact, multiple studies have found that 25% of antipsychotic-naive patients who were started on an antipsychotic for @ICU_delirium end up being discharged from the hospital on the drug. ncbi.nlm.nih.gov/pubmed/27881149
