Assistant Professor in the Department of Family Medicine and in the School of Epidemiology and Public Health at the University of Ottawa in Ontario, Scientist in the C.T. Lamont Primary Health Care Research Centre of the Bruyère Research Institute, and Adjunct Scientist at the Institute for Clinical Evaluative Sciences (ICES).
Assistant Professor in the Department of Family Medicine at the University of Ottawa, Adjunct Assistant Professor in the School of Pharmacy at the University of Waterloo in Ontario, and Scientist at the Bruyère Research Institute at the University of Ottawa.
Can Fam Physician. 2018 Jan;64(1):17-27.
To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop antipsychotics; to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes.
The overall team comprised 9 clinicians (1 family physician, 1 family physician specializing in long-term care, 1 geriatric psychiatrist, 2 geriatricians, 4 pharmacists) and a methodologist; members disclosed conflicts of interest. For guideline development, a systematic process was used, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence was generated from a Cochrane systematic review of antipsychotic deprescribing trials for the behavioural and psychological symptoms of dementia, and a systematic review was conducted to assess the evidence behind the benefits of using antipsychotics for insomnia. A review of reviews of the harms of continued antipsychotic use was performed, as well as narrative syntheses of patient preferences and resource implications. This evidence and GRADE quality-of-evidence ratings were used to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage.
We recommend deprescribing antipsychotics for adults with behavioural and psychological symptoms of dementia treated for at least 3 months (symptoms stabilized or no response to an adequate trial) and for adults with primary insomnia treated for any duration or secondary insomnia in which underlying comorbidities are managed. A decision-support algorithm was developed to accompany the guideline.
Antipsychotics are associated with harms and can be safely tapered. Patients and caregivers might be more amenable to deprescribing if they understand the rationale (potential for harm), are involved in developing the tapering plan, and are offered behavioural advice or management. This guideline provides recommendations for making decisions about when and how to reduce the dose of or stop antipsychotics. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients and families.
制定循证指南，帮助临床医生决定何时以及如何安全地逐渐减少和停止使用抗精神病药物；重点关注现有最高级别的证据，并在指南制定、审查和认可过程中征求初级保健专业人员的意见。
整个团队由 9 名临床医生（1 名家庭医生、1 名专门从事长期护理的家庭医生、1 名老年精神病医生、2 名老年病学家、4 名药剂师）和一名方法学家组成；成员披露了利益冲突。为了制定指南，使用了系统的过程，包括 GRADE（推荐评估、制定和评估分级）方法。证据来自 Cochrane 对用于治疗痴呆的行为和心理症状的抗精神病药停药试验的系统评价，以及对使用抗精神病药治疗失眠的益处背后证据的系统评价。还对继续使用抗精神病药的危害进行了综述，并对患者偏好和资源影响进行了叙述性综合分析。这些证据和 GRADE 证据质量评级用于生成建议。团队通过共识完善了指南内容和建议措辞，并综合了临床考虑因素，以解决一线临床医生常见的问题。该指南草案分发给临床医生和利益相关者进行审查，并在每个阶段进行修订。
我们建议对至少接受 3 个月（症状稳定或对充分的试验无反应）治疗的有行为和心理症状的痴呆成人和任何时间治疗的原发性失眠成人或继发于潜在合并症的失眠成人逐渐减少抗精神病药物的剂量。为配合该指南制定了决策支持算法。
抗精神病药物会产生危害，并且可以安全地逐渐减少剂量。如果患者和照护者了解（潜在危害）的基本原理、参与制定逐渐减少剂量的计划、并提供行为建议或管理，则他们可能更愿意逐渐减少剂量。本指南提供了关于何时以及如何减少或停止抗精神病药物剂量的建议。这些建议旨在协助而非决定与患者及其家属共同做出决策。
