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Lee TC, Desforges P, Murray J, Saleh RR, McDonald EG. Off-label Use of Quetiapine in Medical Inpatients and Postdischarge. JAMA Intern Med. 2016;176(9):1390–1391. doi:10.1001/jamainternmed.2016.3309
Off-label use of antipsychotic medication is increasing, particularly the use of quetiapine for sleep, owing to its sedating properties.1 This is a cause for concern given important adverse effects, including drug-induced diabetes and parkinsonism, weight gain, neuroleptic malignant syndrome, oversedation, and risk of arrhythmia.2 We describe quetiapine use in a prospective cohort of medical inpatients and the proportion of in-hospital use that is perpetuated on discharge.
In our 52-bed medical clinical teaching unit (CTU) (Royal Victoria Hospital; 417 beds, Montreal, Quebec, Canada), we prospectively enrolled all consecutive inpatients 60 years or older between December 2013 and April 2015. There were no exclusion criteria. Patient data were abstracted from medical records at discharge or death, and were analyzed in March 2016. One of us (P.D.) retrospectively reviewed all medical records for quetiapine dose and indication. In the absence of a documented comorbid psychiatric condition (eg, schizophrenia, major depressive, or bipolar affective disorder) or evidence of delirium it was inferred that once-nightly quetiapine was being given for sleep. Categorical variables were compared using χ2 and continuous variables using Wilcoxon rank-sum or the Kruskal-Wallis test as appropriate. The study was approved by the McGill University Health Centre research ethics board.
Our CTU admits acutely ill patients who do not require surgery, chemotherapy, or immediate critical care. Top admitting diagnoses are pneumonia, congestive heart failure, and acute kidney injury. Approximately 45% and 10% of patients older than 65 years receive more than 10 or 20 medications, respectively. Of the 1001 consecutive patients, 125 (13.0%) received quetiapine during hospitalization. The Table compares demographics and comorbidities between users and nonusers. Eighty users (64.0%) received the medication at bedtime for sleep, of whom 73.0% (58 of 80) were newly initiated in hospital. Overall, 59 of 1001 (5.9%) were discharged with a prescription for quetiapine, 29 of whom (49.2%) received the medication for sleep. One in 7 patients who first received quetiapine for sleep in the hospital was discharged home with at least a 1-month prescription.
In our single-center study of 1001 older medical inpatients, quetiapine was given to 1 in 8 patients (13.0%) with nearly two-thirds of the use being for sleep. About half of this use was continued at discharge (5.9%) including 1 in 7 patients who were first introduced to the medication as a sleep aid while in hospital. The proportion of patients who received quetiapine off-label for sleep was similar to that in a recent study of outpatients who received quetiapine for any off-label indication (66% vs 67%; P = .41).3 There is a limited number of studies examining off-label quetiapine use and adverse drug events,2 but associations with anticholinergic events and urinary tract symptoms are described in older adults with dementia, and sedation, fatigue, weight gain, and extrapyramidal symptoms in users irrespective of age.4 Hospitalized and acutely ill older adults may be particularly susceptible to the neurocognitive adverse effects.
Our study has limitations; first, our single academic center experience may not be generalizable to nonacademic centers or outside of Quebec. Second, use for sleep may have been misclassified if delirium was not adequately recorded in the medical record; however, the separation of the doses suggests that we excluded much of the nonsleep use. Third, we were able to obtain prescribing but not dispensing information; therefore, some patients may not have received the drug.
These limitations aside, it is important to highlight the overall prevalence of quetiapine use, the frequency of off-label use for sleep, and the continuation of the drug postdischarge given that off-label medication use is associated with higher adverse drug event rates.5 In the absence of quality randomized clinical trials demonstrating efficacy and safety, we suggest limiting off-label quetiapine use, particularly in elderly hospitalized patients.
Corresponding Author: Emily G. McDonald, MD, MSc, Royal Victoria Hospital, 1001 Decarie Blvd, D5.5843, Montreal, QC H4A3J1, Canada (firstname.lastname@example.org).
Published Online: July 11, 2016. doi:10.1001/jamainternmed.2016.3309.
Author Contributions: Dr Lee had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Lee and Desforges are co–first author.
Study concept and design: Lee, Murray, Saleh, McDonald.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Lee, Desforges, Murray, McDonald.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Lee, Desforges, Murray.
Administrative, technical, or material support: Desforges, Murray, Saleh.
Study supervision: Lee, Desforges, McDonald.
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