title: Frequency and Outcome of Neuroleptic Rotation in the Management of Delirium in Patients with Advanced Cancer.
abstract: OBJECTIVE
  The response to haloperidol as a first-line neuroleptic and the pattern of neuroleptic rotation after haloperidol failure have not been well defined in palliative care. The purpose of this study was to determine the efficacy of haloperidol as a first-line neuroleptic and the predictors associated with the need to rotate to a second neuroleptic.
  
  
  METHODS
  We conducted a retrospective review of the charts of advanced cancer patients admitted to our acute palliative care unit between January 2012 and March 2013. Inclusion criteria were a diagnosis of delirium and first-line treatment with haloperidol.
  
  
  RESULTS
  Among 167 patients with delirium, 128 (77%) received only haloperidol and 39 (23%) received a second neuroleptic. Ninety-one patients (71%) who received haloperidol alone improved and were discharged alive. The median initial haloperidol dose was 5 mg (interquartile ranges [IQR], 3 to 7 mg) and the median duration was 5 days (IQR, 3 to 7 days). The median final haloperidol dose was 6 mg (IQR, 5 to 7 mg). A lack of treatment efficacy was the most common reason for neuroleptic rotation (87%). Significant factors associated with neuroleptic rotation were inpatient mortality (59% vs. 29%, p=0.001), and being Caucasian (87% vs. 62%, p=0.014). Chlorpromazine was administered to 37 patients (95%) who were not treated successfully by haloperidol. The median initial chlorpromazine dose was 150 mg (IQR, 100 to 150 mg) and the median duration was 3 days (IQR, 2 to 6 days). Thirteen patients (33%) showed reduced symptoms after the second neuroleptic.
  
  
  CONCLUSIONS
  Neuroleptic rotation from haloperidol was only required in 23% of patients with delirium and was associated with inpatient mortality and white race.
authors: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA ; Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.
authors: Seong Hoon
authors: SH
authors: Shin
authors: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors: David
authors: D
authors: Hui
authors: Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors: Gary
authors: G
authors: Chisholm
authors: Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, Korea.
authors: Jung Hun
authors: JH
authors: Kang
authors: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors: Julio
authors: J
authors: Allo
authors: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors: Janet
authors: J
authors: Williams
authors: Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors: Eduardo
authors: E
authors: Bruera
keywords: Acute palliative care unit; Delirium; Haloperidol; Neuroleptic rotation
references: J Clin Oncol. 2012 Apr 10;30(11):1206-14
references: 22412123
references: J Palliat Med. 2013 Aug;16(8):908-14
references: 23758527
references: Support Care Cancer. 2010 Jan;18(1):67-76
references: 19350282
references: J Palliat Med. 2012 Aug;15(8):902-9
references: 22663175
references: Am J Hosp Palliat Care. 2011 Feb;28(1):44-51
references: 21057140
references: Am J Hosp Palliat Care. 2012 Jun;29(4):295-301
references: 21998445
references: Palliat Support Care. 2011 Dec;9(4):351-7
references: 22104410
references: Hematol Oncol Clin North Am. 2002 Jun;16(3):701-14
references: 12170576
references: Palliat Med. 2004 Apr;18(3):184-94
references: 15198131
references: Cancer Treat Rev. 2013 Feb;39(1):105-12
references: 22959227
references: Aust N Z J Psychiatry. 2011 Jun;45(6):477-82
references: 21563866
references: J Palliat Care. 1991 Summer;7(2):6-9
references: 1714502
references: Jpn J Clin Oncol. 2008 Jan;38(1):56-63
references: 18238881
references: J Clin Psychopharmacol. 2003 Dec;23(6):657-9
references: 14624195
references: J Palliat Care. 2011 Summer;27(2):141-7
references: 21805949
references: Am J Hosp Palliat Care. 2011 Nov;28(7):501-10
references: 21454319
references: J Pain Symptom Manage. 2010 Feb;39(2):186-96
references: 20152585
references: Intensive Care Med. 2004 Mar;30(3):444-9
references: 14685663
references: Psychiatry Clin Neurosci. 2013 Jul;67(5):323-31
references: 23859663
references: Neurocrit Care. 2012 Feb;16(1):170-83
references: 22038577
references: Support Care Cancer. 2011 Jun;19(6):765-70
references: 20429015
references: Cochrane Database Syst Rev. 2012 Nov 14;11:CD004770
references: 23152226
references: Clin Geriatr Med. 2000 May;16(2):357-72
references: 10783433
references: Drugs. 2012 Jul 30;72(11):1457-71
references: 22804788
references: Gen Hosp Psychiatry. 2013 Mar-Apr;35(2):105-11
references: 23218845