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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
Limitations
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

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