Mortality in patients with Parkinson disease psychosis receiving pimavanserin and quetiapine

Parkinson disease (PD) is a complex neurodegenerative disorder. Cognitive dysfunction and psychosis are leading contributors to nursing home placement.1 Psychosis onset is associated with cognitive decline, levodopa supplementation, and visual dysfunction.2 Treatment of PD psychosis (PDP) centers on levodopa dose adjustment, use of second-generation antipsychotics (SGAs), and cholinesterase inhibitors. SGAs function via serotonergic modulation and dopamine receptors blockade. Quetiapine, a structural analogue to clozapine, is often used to treat PDP, although evidence of its efficacy is mixed in randomized controlled trials.3 Furthermore, there is a concern for increased morbidity and mortality with use of quetiapine and other SGAs in patients with dementia or those with PD, prompting a black box warning by the Food and Drug Administration (FDA).4