Download Atypical Antipsychotic Drug Use in Children and Adolescents

Atypical Antipsychotic Drug
Use in Children and
Adolescents
By: Alicia Shell
Spring 2008
Advisor: Dr. Bill Grimes, PA-C
Why is this important to us?
 As
primary care providers we are going to
have the opportunity to act as a psychiatric
first responder
 Referral to psychologist/psychiatrist
 Follow-up care (esp. in rural areas)
Background
Drugs: A “newer”
class of prescription medications used to
treat psychiatric conditions
 Exact MOA unknown but thought to be
due to blockade of both the dopamine-2
receptor as well as the serotonin 5-HT2A
receptor
 Atypical Antipsychotic
Atypical Antipsychotic Drugs
 Clozapine
(BN: Clozaril)
 Risperidone* (Risperdal)
 Olanzapine (Zyprexa)
 Quetiapine (Seroquel)
 Ziprasidone (Geodon)
 Aripiprazole (Abilify)
Atypical Antipsychotic Drugs cont’d…

Used to treat a wide variety of psychiatric
disturbances including:
 Schizophrenia
 Acute mania
 Bipolar mania
 Psychotic agitation
 Bipolar maintenance
Atypical Antipsychotic Drugs cont’d…
 Their
use has supplanted the older
“typical” antipsychotic drugs due to the fact
that they are thought to cause less
extrapyramidal side effects such as tardive
dyskinesia
 This has resulted in a substantial increase
in the use of antipsychotics for childhood
behavioral disorders
Atypical Antipsychotic Drugs cont’d…
 Dangerous
side effects include: weight
gain, diabetes, and hyperlipidemia
 Few studies have been done to show how
these drugs affect children
 Possibility that children are more likely to
develop these side effects than adults
(Fritz 2006)
Atypical Antipsychotic Drugs cont’d…
 Recent
studies have documented a
dramatic increase in prescribing rates for
all of these medications to children and
adolescents ranging from 200% to over
500%
(Fritz 2006)
They are being prescribed in the
pediatric population to treat:
 Oppositional
defiant disorder (ODD)
 Conduct disorder (CD)
 Mood disorders (i.e. Bipolar disorder)
 Attention deficit/hyperactivity disorder
(ADHD)
 Childhood-onset schizophrenia
Early-onset Bipolar Disorder or
Childhood Bipolar Disorder
 Historically
under-recognized, now
occasionally over-diagnosed, mood
disorder affecting approximately 1% of all
children and adolescents (Faust 2006)
 Diagnosing this disorder is particularly
difficult because it can present with a
broad spectrum of symptoms of varying
severity
Initial presentation may involve
complaints of:
 Moodiness
 Frequent
or aggressive oppositional
behaviors
 Anger that does not resolve within 15
minutes
 Sadness and easy crying
 Inattention
 Impulsiveness
Why is early diagnosis of this
disorder important?
 Decrease
the morbidity and mortality that
is associated with it
 Currently estimated that 25-50% of all BD
patients will make a suicide attempt in
their lifetime and approx. 20% will succeed
(Faust 2006)
 Adolescents with BD are at the greatest
risk, particularly those who are rapid
cyclers
How do we treat it?

Unfortunately, there are no specific medications
that are indicated for treating this condition in
children
 Instead, physicians are using antipsychotic
medications designed for adults
 The problem with this is that the usual adult
treatment may not address the needs of young
people with recent-onset psychosis and the
psychological therapies for psychosis need to be
age-specific (Haddock 2006)
Antipsychotic prescribing practices
in children and adolescents:
 Clinical
experience rather than scientific
evidence (Pappadopulos 2002)
 May be the result of social pressure to
use these meds when patient behavior is
particularly disruptive or dangerous
FIND strategy to identify manic
symptoms:

Frequency: symptoms occur most days in a
week
 Intensity: symptoms are severe enough to
cause extreme disturbance in one domain or
moderate disturbance in two or more domains
 Number: symptoms occur three or four times a
day
 Duration: symptoms occur 4 or more hours a
day, total, not necessarily contiguous
(Am. Acad. Child & Adolesc. Psychiatry 2005)
If a psychiatric diagnosis is
confirmed…
 Start



with family-focused psychotherapy
Parent management training
Dyadic (parent-child) psychotherapy
If drugs are deemed necessary, suggest that
that they be used in conjunction with
psychotherapy
(Grimes 2007)
Before initiating treatment with an
atypical antipsychotic:
 A personal
and family history of obesity,
diabetes, dyslipidemia, hypertension, or
cardiovascular disease
 Weight and height so that BMI can be
calculated
 Measurement of waist circumference
 Blood pressure
 Fasting plasma glucose
 Fasting lipid profile

Weight should be reassessed at 4, 8, and 12
weeks after initiating or changing therapy with
an atypical antipsychotic and quarterly thereafter
at the time of routine visits
 If a patient gains more than 5% of his or her
initial weight at any time during therapy, the
patient should be switched to an alternative
agent
 Note: These guidelines were not written for a
pediatric population and the 5% weight gain
threshold may not be sensitive enough for
children and adolescents
(Kowatch 2005)
Conclusions
 Be
very discriminate in regards to who we
give these drugs to
 Proper evaluation of child’s condition
 Monitor, monitor, monitor!


Don’t get complacent
Be vigilant in regards to lab tests, psychiatric
evaluations, weight monitoring, etc.
References
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