Association of Delirium Response and Safety of Pharmacological Interventions for the Management and Prevention of Delirium: A Network Meta-analysis. 藥物干預預防處理譫妄療效和安全性聯繫的網狀Meta分析
譫妄很常見，且常被誤診。它在住院的老年患者中尤其普遍。一些藥物被認為在治療或預防譫妄方面有作用。但是，仍不確定哪些藥物能提供最佳的緩解率，最低的譫妄發生率和最佳的耐受性。為了找到這些問題的答案，Wu等人回顧了評估各種譫妄藥物的研究。
研究設計
研究人員對隨機對照試驗(RCT)進行了系統回顧和網絡薈萃分析，研究了用於治療或預防譫妄的各種藥物。
分析包括58個隨機對照試驗。在這些研究中，20個RCT共1435名參與者比較了譫妄治療的治療效果，38個RCT共8168名參與者檢查了預防措施。
進行網絡薈萃分析，以確定一種或多種藥物組合是否優於安慰劑或廣泛使用的藥物。
結果
與安慰劑/對照組相比，氟哌啶醇聯合勞拉西泮治療譫妄的有效率最佳。
在譫妄預防方面，接受雷美替胺、奧氮平、利培酮或右美託咪定治療的患者，其譫妄發生率明顯低於接受安慰劑/對照治療的患者。
與安慰劑/對照組相比，沒有任何一種藥物治療與全因死亡風險顯著相關。
結論
氟哌啶醇聯合勞拉西泮可能是治療譫妄的最佳方法，雷美替胺可能是預防譫妄的最佳藥物。用於治療或預防的任何藥物干預措施均不會增加全因死亡率。
然而，網絡薈萃分析涉及無法直接進行的治療比較推斷。正如Blazer所指出的，這項研究的兩項發現(氟哌啶醇+勞拉西泮是治療試驗中一個獨特的干預手段，而雷美替胺是一種獨特的預防干預手段)，似乎都是由Wu等人審查的58項研究中的兩項驅動的。Wu等人還警示說，這兩種干預手段的有效性需要進一步研究。
Association of Delirium Response and Safety of Pharmacological Interventions for the Management and Prevention of Delirium: A Network Meta-analysis.
Wu YC
Abstract
Importance:
Although several pharmacological interventions for delirium have been investigated, their overall benefit and safety remain unclear.
Objective:
To evaluate evidence regarding pharmacological interventions for delirium treatment and prevention.
Data Sources:
PubMed, Embase, ProQuest, ScienceDirect, Cochrane Central, Web of Science, ClinicalKey, and ClinicalTrials.gov from inception to May 17, 2018.
Study Selection:
Randomized clinical trials (RCTs) examining pharmacological interventions for delirium treatment and prevention.
Data Extraction and Synthesis:
To extract data according to a predetermined list of interests, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were applied, and all meta-analytic procedures were conducted using a random-effects model.
Main Outcomes and Measures:
The primary outcomes were treatment response in patients with delirium and the incidence of delirium in patients at risk of delirium.
Results:
A total of 58 RCTs were included, in which 20 RCTs with 1435 participants (mean age, 63.5 years; 65.1% male) compared the outcomes of treatment and 38 RCTs with 8168 participants (mean age, 70.2 years; 53.4% male) examined the prevention of delirium. A network meta-analysis demonstrated that haloperidol plus lorazepam provided the best response rate for delirium treatment (odds ratio [OR], 28.13; 95% CI, 2.38-333.08) compared with placebo/control. For delirium prevention, the ramelteon, olanzapine, risperidone, and dexmedetomidine hydrochloride groups had significantly lower delirium occurrence rates than placebo/control (OR, 0.07; 95% CI, 0.01-0.66 for ramelteon; OR, 0.25; 95% CI, 0.09-0.69 for olanzapine; OR, 0.27; 95% CI, 0.07-0.99 for risperidone; and OR, 0.50; 95% CI, 0.31-0.80 for dexmedetomidine hydrochloride). None of the pharmacological treatments were significantly associated with a higher risk of all-cause mortality compared with placebo/control.
Conclusions and Relevance:
This network meta-analysis demonstrated that haloperidol plus lorazepam might be the best treatment and ramelteon the best preventive medicine for delirium. None of the pharmacological interventions for treatment or prophylaxis increased the all-cause mortality.
PMID: 30810723
PMCID: PMC6495351
DOI: 10.1001/jamapsychiatry.2018.4365
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