Haloperidol

A post from my liaison psychiatry work, with musings on haloperidol. I'm not a huge fan of haloperidol.

It has been used by different countries as a drug of torture. Even in both low and moderate therapeutic doses it can cause akathisia.

But quite apart from being a drug with rather unpleasant side effects, more than unpleasant symptoms it can be quite harmful. In older adults with dementia, use of haloperidol is associated with increased risk of death, ramping up risk over the 10 weeks or so on average it was used for by about 60% to 70%. That's less than ideal.
It also explains how it triples your risks of strokes. Nice.

It's a drug with unpleasant side effect profile, it's dangerous, but what about practicalities of its use? Unfortunately it's a tricky drug to use correctly.

The Summary of Product Characteristics (SPC) reminds us that, "Cases of sudden death have been reported . . ." and that it has significant risks if you've heart problems. By significant risks, it's not that the drug has cautions and careful considerations to weigh up, no, it's that it's contra-indicated and should not be used. When is it explicitly contra-indicated, in black and white? When you have :
- clinically significant cardiac disorders
- recent acute myocardial infarction (heart attack)
- uncompensated heart failure
- arrhythmias treated with class IA and III antiarrhythmic medicinal products
- QTc interval prolongation
- history of ventricular arrhythmia
- history of torsades de pointes
- clinically significant bradycardia
- second or third degree heart block
- uncorrected hypokalaemia

Quite a list with pretty common problems, like heart attacks and heart failure, precluding the use of haloperidol.

If a physician is going to prescribe, what do they need to evidence in their records? The SPC directs that, "The risk-benefit of haloperidol treatment should be fully assessed before treatment is commenced," detailing how, including heart monitoring with 12 lead ECGs.

ECGs "particularly during the initial phase of treatment."
"Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . . during therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed on an individual basis."

"Periodic electrolyte monitoring is recommended, especially for patients taking diuretics, or during intercurrent illness," so older adults on water tablets or who are ill should have electrolyte monitoring, which by definition is pretty much all patients in acute general hospital beds (because they'll have intercurrent illness).

What does this mean? It means you've a drug with significant side effects, significant risks, marked increase in strokes and death, that shouldn't be used in patients with many common cardiac problems, it needs frequent blood monitoring for electrolytes, an ECG before starting and repeating an ECG on changing dose.

Odd, then, that on medical and surgical wards in the acute Trust it's widely used. Used on acute hospital wards, I can't say it's an intervention I'd wish for myself, or for my nearest and dearest . . .