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Unsafe Use of Intravenous Haloperidol Pervasive in Hospitalized Elderly University of Colorado Hospital and University of Colorado Denver at Anschutz Medical Campus, Aurora, Colorado Background
Delirium is present in 11-24% of elderly patients on hospital 556 patients received IV haloperidol during the study period. admission while another 6-56% will develop it during their Median size of the first dose of haloperidol given is 2 mg (range Only the first haloperidol doses were recorded so events associated with prolonged or cumulative doses of haloperidol Off-label intravenous (IV) administration of haloperidol is often 20% received ≥ 5 mg of haloperidol for their first dose. may be missed which may underestimate unsafe use. used due to its rapid onset and ease of administration.4 80% had an ECG within 7 days of their first dose. (Measure 1) We did not account for transient factors (i.e. electrolyte Numerous case reports of QT prolongation, Torsades de Pointes 16% received IV haloperidol despite having a baseline QTc ≥ 500 disturbances) that may have affected QTc. (TdP), and sudden death is associated with IV haloperidol. In 2007, FDA issued a black box warning for IV haloperidol due Only 21% of patients with a baseline QTc ≥ 450 ms had a repeat the risk of adverse outcomes from QT prolongation.5 ECG measured within 24 hrs after the first dose. (Measure 3) Conclusion
Table 1: Characteristics of Study Population
Off-label IV haloperidol use is common among hospitalized 58% of patients in this analysis did not receive care concordant To determine whether hospitalized elderly patients who are prescribed IV haloperidol receive expert recommendation-concordant More than 1 in 10 elderly patients received IV haloperidol despite care to minimize adverse events related to QT prolongation. a QTc ≥ 500 ms even after the FDA black box warning was An adverse outcome in a patient receiving IV haloperidol with known prolonged QTc may have significant medico legal Retrospective study of patients ≥ 65 years who received ≥ 1 dose Interventions to improve physician prescribing and assure proper of IV haloperidol at the University of Colorado Hospital (UCH) monitoring for this medication should be implemented. Concomittant QT Prolonging Drugs - no. (%) Patient demographics, co-morbid conditions, and QTc from References
electrocardiogram (ECG) were collected from electronic medical Inouye SK. Delirium in older persons. NEJM 2006; 354(11):1156-65. Date of first dose of haloperidol administered, amount given, and Saxena S, Lawley D. Delirium in the elderly: a clinical review. Postgrad Med concomitant QT prolonging drugs were obtained from electronic Expert Recommendation Non-Adherence
Fong TG, Tulebae SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention, and treatment. Nat Rev Neurol 2009;5:210-20. Adherence to expert recommendations defined as meeting the Haloperidol Injection USP (for immediate release) Package Insert. Bedford, Information for Healthcare Professionals: Haloperidol. Available at: ECG performed within 7 days before administration of http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPat ientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm0852 IV haloperidol administration avoided if QTc ≥ 500 ms Crouch MA, Limon L, Cassano AT. Clinical relevance and management of ECG performed to reevaluate QTc within 24 hours after drug-related QT interval prolongation. Pharmacotherapy 2003;23(7):881-908. first dose of haloperidol if prior QTc ≥ 450 ms Li EC, Esterly JS, Pohl S, et al. Drug-induced QT-interval prolongation: considerations for the clinicians. Pharmacotherapy 2010;30(7):684-701. Measures

Source: http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/GIM/Research/Documents/Cumbler%20IV%20Haldol%20Poster%20RMHMS%202011-final.pdf

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