Dopamine D2 receptor antagonism of antipsychotics and the risk of death due to choking

•Here, we examined rates of death due to choking (i.e. death by asphyxiation, defined according to ICD-10 codes) in schizophrenia.•Schizophrenia was associated with a 20-fold increase in risk of death by asphyxiation relative to the general population.•Death by asphyxiation risks were relatively high during use of strong dopamine-2 receptor antagonist antipsychotics.•Relative to nonuse, death by asphyxiation risk was not elevated during use of weak or moderate dopamine-2 receptor antagonists.•Clinical implications of these results include the need to address eating habits and try and prevent infections in at-risk patients. The risk of fatal choking for people with schizophrenia and associations with antipsychotic medication are largely unknown. Therefore, we calculated the choking-related standardized mortality ratio for schizophrenia relative to the general population (SMRchoking). We also computed adjusted hazard ratios (aHR) of choking-related mortality for antipsychotics in a nationwide cohort of patients with schizophrenia (N = 59,916). SMRchoking was 20.5 (95 % confidence interval (CI)=17.1–23.9). The aHR was 1.74 (95 %CI=1.19–2.55) for strong dopamine 2-antagonists. For other antipsychotics, CIs included 1. Importantly, aHRs were particularly high for high dose categories of strong dopamine D2 receptor (D2R) antagonists. In conclusion, a schizophrenia diagnosis is associated with a 20-fold risk of death due to choking. This risk is elevated during use of strong D2R antagonist antipsychotics, particularly when prescribed in high dosages.