Andrade Chittaranjan
Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences, Bangalore, India (
J Clin Psychiatry. 2023 Jan 30;84(1):23f14790. doi: 10.4088/JCP.23f14790.
Patients who require antipsychotic drug treatment are at increased risk of fractures, including osteoporosis-related fragility fractures, for reasons related to demographics, illness-related factors, and treatment-related factors. As examples, patients with dementia may be vulnerable to falls due to cognitive and psychomotor impairment, patients with schizophrenia may be vulnerable to injury related to physical restlessness or physical aggression, and patients receiving antipsychotics may suffer falls related to sedation, psychomotor impairment, bradykinesia, or postural hypotension. Antipsychotics may also increase the risk of fracture through long-term hyperprolactinemia and resultant osteoporosis. A meta-analysis of 36 observational studies conducted in mostly elderly samples found that antipsychotic exposure was associated with an increased risk of hip fracture as well as increased risk of any fracture; the findings were consistent in almost all subgroup analyses. An observational study that controlled for confounding by indication and illness severity found that fragility fractures in patients with schizophrenia were associated with higher daily doses, higher cumulative doses, longer duration of treatment, and prolactin-raising rather than prolactin-sparing antipsychotics; in patients receiving prolactin-raising antipsychotics, the concurrent use of aripiprazole appeared protective. The absolute risks of fracture are unknown and could vary depending on patient age, patient sex, indication for antipsychotic use, nature of the antipsychotic (and associated risk of sedation, psychomotor impairment, bradykinesia, and postural hypotension), daily dose prescribed, duration of antipsychotic exposure, baseline risk of fracture, and other risk factors. Patients should therefore be individually evaluated for risk factors for falls and fractures related to sociodemographic, clinical, and treatment-related risk factors. Patients identified to be at risk should be advised about risk-mitigating strategies. If prolactin-raising antipsychotics are required in the long term, prolactin levels should be monitored and prolactin-lowering strategies should be considered. Osteoporosis should be investigated and managed, if identified, to prevent fragility fractures.
由于人口统计学、疾病相关因素和治疗相关因素，需要抗精神病药物治疗的患者发生骨折的风险增加，包括与骨质疏松症相关的脆性骨折。例如，痴呆症患者可能因认知和精神运动障碍而容易跌倒，精神分裂症患者可能因身体躁动或身体攻击而容易受伤，接受抗精神病药物治疗的患者可能因镇静、精神运动障碍、运动迟缓或体位性低血压而跌倒。抗精神病药物还可能通过长期高催乳素血症和由此导致的骨质疏松症增加骨折风险。一项对主要为老年样本的36项观察性研究的荟萃分析发现，接触抗精神病药物与髋部骨折风险增加以及任何骨折风险增加相关；几乎所有亚组分析的结果都是一致的。一项控制了适应症和疾病严重程度混杂因素的观察性研究发现，精神分裂症患者的脆性骨折与每日剂量较高、累积剂量较高、治疗持续时间较长以及升高催乳素而非保留催乳素的抗精神病药物有关；在接受升高催乳素的抗精神病药物治疗的患者中，同时使用阿立哌唑似乎具有保护作用。骨折的绝对风险尚不清楚，可能因患者年龄、患者性别、抗精神病药物使用适应症、抗精神病药物的性质（以及相关的镇静、精神运动障碍、运动迟缓、体位性低血压风险）、规定的每日剂量、抗精神病药物接触持续时间、骨折基线风险和其他风险因素而异。因此，应针对与社会人口统计学、临床和治疗相关风险因素相关的跌倒和骨折风险因素对患者进行个体评估。应向确定有风险的患者建议风险缓解策略。如果长期需要使用升高催乳素的抗精神病药物，应监测催乳素水平，并应考虑降低催乳素的策略。如果发现骨质疏松症，应进行调查和管理，以预防脆性骨折。
