Lacasse Hélène, Perreault Marc M, Williamson David R
Pharmaprix Jean-François Guévin, Montréal, Québec, Canada.
Ann Pharmacother. 2006 Nov;40(11):1966-73. doi: 10.1345/aph.1H241. Epub 2006 Oct 17.
To determine which antipsychotic is associated with the greatest efficacy and safety when used for the pharmacotherapeutic management of delirium in medically or surgically ill patients.
MEDLINE, Current Contents, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Biological Abstracts, Cochrane Central Register of Controlled Trials, and EMBASE databases (all to July 2006) were searched for trials evaluating the pharmacologic treatment of delirium in medically or surgically ill patients. The key terms used included delirium, agitation, or acute confusion, and antipsychotics, phenothiazine, butyrophenone, perphenazine, fluphenazine, clozapine, trifluorophenazine, loxapine, thioridazine, pimozide, molindone, haloperidol, methotrimeprazine, chlorpromazine, prochlorperazine, droperidol, risperidone, quetiapine, ziprasidone, amisulpride, or olanzapine.
Prospective, randomized, controlled trials comparing the clinical effects of antipsychotic therapy with placebo or comparing 2 antipsychotic treatments in an acute care setting were selected. Studies involving dementia-associated delirium, Alzheimer's disease-associated delirium, emergency department-associated acute agitation, acute brain trauma-associated agitation, or agitation secondary to underlying psychiatric afflictions such as depression or schizophrenia were excluded. All studies were evaluated independently by the 3 authors using a validated evaluation tool. Outcomes related to both efficacy and safety were collected. Four prospective trials were included in this systematic review.
Antipsychotic agents, either atypical or typical, were effective compared with baseline for the treatment of delirium in medically or surgically ill patients without underlying cognitive disorders. Oral haloperidol was associated with more frequent extrapyramidal side effects, but overall, all agents were well tolerated. Interpretation of the published evidence is limited by the small sample sizes, varied patient populations, and comparative agents of the studies reviewed.
The comparative studies evaluated here suggest that antipsychotic drugs are efficacious, when compared with baseline, and safe for the treatment of delirium. Haloperidol remains the most studied agent. Recommendation of one antipsychotic over another as a first-line pharmacologic intervention in the treatment of hospital-associated delirium is limited by the quality and quantity of data available. Better designed and larger studies evaluating the addition of antipsychotic agents to nonpharmacologic treatments are needed to measure the true effect of pharmacologic treatment.
确定在对内科或外科疾病患者谵妄进行药物治疗管理时，哪种抗精神病药物具有最大的疗效和安全性。
检索了MEDLINE、《现刊目次》、《护理及相关健康文献累积索引》、PsycINFO、《生物学文摘》、Cochrane对照试验中心注册库和EMBASE数据库（均至2006年7月），以查找评估内科或外科疾病患者谵妄药物治疗的试验。使用的关键词包括谵妄、激越或急性意识模糊，以及抗精神病药物、吩噻嗪、丁酰苯类、奋乃静、氟奋乃静、氯氮平、三氟拉嗪、洛沙平、硫利达嗪、匹莫齐特、吗茚酮、氟哌啶醇、甲氧异丁嗪、氯丙嗪、丙氯拉嗪、氟哌利多、利培酮、喹硫平、齐拉西酮、氨磺必利或奥氮平。
选择前瞻性、随机、对照试验，比较抗精神病药物治疗与安慰剂的临床效果，或在急性护理环境中比较两种抗精神病药物治疗。排除涉及痴呆相关性谵妄、阿尔茨海默病相关性谵妄、急诊科相关性急性激越、急性脑外伤相关性激越或继发于潜在精神疾病如抑郁症或精神分裂症的激越的研究。所有研究均由3位作者使用经过验证的评估工具独立评估。收集与疗效和安全性相关的结果。本系统评价纳入了4项前瞻性试验。
与基线相比，非典型或典型抗精神病药物对无潜在认知障碍的内科或外科疾病患者的谵妄治疗有效。口服氟哌啶醇与更多的锥体外系副作用相关，但总体而言，所有药物耐受性良好。所审查研究的小样本量、多样的患者群体和对照药物限制了对已发表证据的解读。
此处评估的比较研究表明，与基线相比，抗精神病药物对谵妄治疗有效且安全。氟哌啶醇仍然是研究最多的药物。由于现有数据的质量和数量有限，在推荐一种抗精神病药物优于另一种作为医院相关性谵妄治疗的一线药物干预方面受到限制。需要设计更好、规模更大的研究来评估在非药物治疗中添加抗精神病药物的效果，以衡量药物治疗的真正效果。
