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Editorials

Antiemetics, stroke, and the limits of observational epidemiology

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o924 (Published 08 April 2022) Cite this as: BMJ 2022;377:o924
  1. David N Juurlink, division head
  1. Clinical Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
  1. david.juurlink{at}ices.on.ca

This association should prompt research, not influence practice

Over the past two decades, dozens of studies have explored the association between antipsychotics—drugs that antagonise dopamine receptors in the central nervous system—and stroke.12 In a linked paper, Bénard-Laribière and colleagues (doi:10.1136/bmj-2021-066192) extend this question to the dopamine-blocking antiemetics domperidone, metoclopramide, and metopimazine.3 Using five years of French prescription claims and hospital records, they found that the three drugs were associated with an increased risk of incident ischaemic stroke. The study’s design, conclusions, and implications bear examination.

When most of us think of observational studies, cohort and case-control designs are what first come to mind. Indeed, these constitute the bulk of research linking antipsychotics with stroke. In their simplest construction, cohort studies compare people with an exposure to people with no such exposure, observing them over time for the development of outcomes. Case-control studies, in contrast, start by identifying people with and without an outcome—cases and controls, respectively—and then …

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