Atypical Antipsychotic Drug Atypical Antipsychotic Drug Use in Children and Use in Children and

AdolescentsAdolescents

By: Alicia ShellBy: Alicia ShellSpring 2008Spring 2008

Advisor: Dr. Bill Grimes, PA-CAdvisor: Dr. Bill Grimes, PA-C

Why is this important to us?Why is this important to us? As primary care providers we are going to As primary care providers we are going to

have the opportunity to act as a have the opportunity to act as a psychiatric psychiatric first responderfirst responder

Referral to psychologist/psychiatristReferral to psychologist/psychiatrist Follow-up care (esp. in rural areas)Follow-up care (esp. in rural areas)

BackgroundBackground

Atypical Antipsychotic DrugsAtypical Antipsychotic Drugs: A : A “newer” class of prescription medications “newer” class of prescription medications used to treat psychiatric conditionsused to treat psychiatric conditions

Exact MOA unknown but thought to be Exact MOA unknown but thought to be due to blockade of both the dopamine-2 due to blockade of both the dopamine-2 receptor as well as the serotonin 5-HT2A receptor as well as the serotonin 5-HT2A receptorreceptor

Atypical Antipsychotic DrugsAtypical Antipsychotic Drugs

Clozapine (BN: Clozaril)Clozapine (BN: Clozaril) Risperidone* (Risperdal)Risperidone* (Risperdal) Olanzapine (Zyprexa)Olanzapine (Zyprexa) Quetiapine (Seroquel)Quetiapine (Seroquel) Ziprasidone (Geodon)Ziprasidone (Geodon) Aripiprazole (Abilify)Aripiprazole (Abilify)

Atypical Antipsychotic Drugs cont’d…Atypical Antipsychotic Drugs cont’d…

Used to treat a wide variety of psychiatric Used to treat a wide variety of psychiatric disturbances including:disturbances including: SchizophreniaSchizophrenia Acute maniaAcute mania Bipolar maniaBipolar mania Psychotic agitationPsychotic agitation Bipolar maintenanceBipolar maintenance

Atypical Antipsychotic Drugs cont’d…Atypical Antipsychotic Drugs cont’d…

Their use has supplanted the older Their use has supplanted the older “typical” antipsychotic drugs due to the fact “typical” antipsychotic drugs due to the fact that they are thought to cause less that they are thought to cause less extrapyramidal side effects such as tardive extrapyramidal side effects such as tardive dyskinesiadyskinesia

This has resulted in a substantial increase This has resulted in a substantial increase in the use of antipsychotics for childhood in the use of antipsychotics for childhood behavioral disordersbehavioral disorders

Atypical Antipsychotic Drugs cont’d…Atypical Antipsychotic Drugs cont’d…

Dangerous side effects include: weight Dangerous side effects include: weight gain, diabetes, and hyperlipidemiagain, diabetes, and hyperlipidemia

Few studies have been done to show how Few studies have been done to show how these drugs affect childrenthese drugs affect children

Possibility that children are more likely to Possibility that children are more likely to develop these side effects than adults develop these side effects than adults (Fritz 2006) (Fritz 2006)

Atypical Antipsychotic Drugs cont’d…Atypical Antipsychotic Drugs cont’d…

Recent studies have documented a Recent studies have documented a dramatic increase in prescribing rates for dramatic increase in prescribing rates for all of these medications to children and all of these medications to children and adolescents ranging from 200% to over adolescents ranging from 200% to over 500%500%

(Fritz 2006)(Fritz 2006)

They are being prescribed in the They are being prescribed in the pediatric population to treat:pediatric population to treat:

Oppositional defiant disorder (ODD)Oppositional defiant disorder (ODD) Conduct disorder (CD)Conduct disorder (CD) Mood disorders (i.e. Bipolar disorder)Mood disorders (i.e. Bipolar disorder) Attention deficit/hyperactivity disorder Attention deficit/hyperactivity disorder

(ADHD)(ADHD) Childhood-onset schizophreniaChildhood-onset schizophrenia

Early-onset Bipolar Disorder or Early-onset Bipolar Disorder or Childhood Bipolar DisorderChildhood Bipolar Disorder

Historically under-recognized, now Historically under-recognized, now occasionally over-diagnosed, mood occasionally over-diagnosed, mood disorder affecting approximately 1% of all disorder affecting approximately 1% of all children and adolescents (Faust 2006)children and adolescents (Faust 2006)

Diagnosing this disorder is particularly Diagnosing this disorder is particularly difficult because it can present with a difficult because it can present with a broad spectrum of symptoms of varying broad spectrum of symptoms of varying severityseverity

Initial presentation may involve Initial presentation may involve complaints of:complaints of:

MoodinessMoodiness Frequent or aggressive oppositional Frequent or aggressive oppositional

behaviorsbehaviors Anger that does not resolve within 15 Anger that does not resolve within 15

minutesminutes Sadness and easy cryingSadness and easy crying InattentionInattention ImpulsivenessImpulsiveness

Why is early diagnosis of this Why is early diagnosis of this disorder important?disorder important?

Decrease the morbidity and mortality that Decrease the morbidity and mortality that is associated with itis associated with it

Currently estimated that 25-50% of all BD Currently estimated that 25-50% of all BD patients will make a suicide attempt in patients will make a suicide attempt in their lifetime and approx. 20% will succeed their lifetime and approx. 20% will succeed (Faust 2006)(Faust 2006)

Adolescents with BD are at the greatest Adolescents with BD are at the greatest risk, particularly those who are rapid risk, particularly those who are rapid cyclerscyclers

How do we treat it?How do we treat it? Unfortunately, there are no specific medications Unfortunately, there are no specific medications

that are indicated for treating this condition in that are indicated for treating this condition in childrenchildren

Instead, physicians are using antipsychotic Instead, physicians are using antipsychotic medications designed for adults medications designed for adults

The problem with this is that the usual adult The problem with this is that the usual adult treatment may not address the needs of young treatment may not address the needs of young people with recent-onset psychosis and the people with recent-onset psychosis and the psychological therapies for psychosis need to be psychological therapies for psychosis need to be age-specific (Haddock 2006)age-specific (Haddock 2006)

Antipsychotic prescribing practices Antipsychotic prescribing practices in children and adolescents:in children and adolescents:

Clinical experience rather than scientific Clinical experience rather than scientific evidence (Pappadopulos 2002)evidence (Pappadopulos 2002)

May be the result of social pressure to May be the result of social pressure to use these meds when patient behavior is use these meds when patient behavior is particularly disruptive or dangerousparticularly disruptive or dangerous

FIND strategy to identify manic FIND strategy to identify manic symptoms:symptoms:

Frequency: symptoms occur most days in a weekFrequency: symptoms occur most days in a week Intensity: symptoms are severe enough to cause Intensity: symptoms are severe enough to cause

extreme disturbance in one domain or moderate extreme disturbance in one domain or moderate disturbance in two or more domainsdisturbance in two or more domains

Number: symptoms occur three or four times a dayNumber: symptoms occur three or four times a day Duration: symptoms occur 4 or more hours a day, Duration: symptoms occur 4 or more hours a day,

total, not necessarily contiguoustotal, not necessarily contiguous(Am. Acad. Child & Adolesc. Psychiatry 2005)(Am. Acad. Child & Adolesc. Psychiatry 2005)

If a psychiatric diagnosis is If a psychiatric diagnosis is confirmed…confirmed…

Start with family-focused psychotherapyStart with family-focused psychotherapy Parent management trainingParent management training Dyadic (parent-child) psychotherapyDyadic (parent-child) psychotherapy If drugs are deemed necessary, suggest that If drugs are deemed necessary, suggest that

that they be used in conjunction with that they be used in conjunction with psychotherapypsychotherapy

(Grimes 2007)(Grimes 2007)

Before initiating treatment with an Before initiating treatment with an atypical antipsychotic:atypical antipsychotic:

A personal and family history of obesity, A personal and family history of obesity, diabetes, dyslipidemia, hypertension, or diabetes, dyslipidemia, hypertension, or cardiovascular diseasecardiovascular disease

Weight and height so that BMI can be Weight and height so that BMI can be calculatedcalculated

Measurement of waist circumferenceMeasurement of waist circumference Blood pressureBlood pressure Fasting plasma glucoseFasting plasma glucose Fasting lipid profileFasting lipid profile

Weight should be reassessed at 4, 8, and 12 Weight should be reassessed at 4, 8, and 12 weeks after initiating or changing therapy with an weeks after initiating or changing therapy with an atypical antipsychotic and quarterly thereafter at atypical antipsychotic and quarterly thereafter at the time of routine visitsthe time of routine visits

If a patient gains more than 5% of his or her initial If a patient gains more than 5% of his or her initial weight at any time during therapy, the patient weight at any time during therapy, the patient should be switched to an alternative agentshould be switched to an alternative agent

Note: These guidelines were not written for a Note: These guidelines were not written for a pediatric population and the 5% weight gain pediatric population and the 5% weight gain threshold may not be sensitive enough for threshold may not be sensitive enough for children and adolescentschildren and adolescents

(Kowatch 2005)(Kowatch 2005)

ConclusionsConclusions

Be very discriminate in regards to who we Be very discriminate in regards to who we give these drugs togive these drugs to

Proper evaluation of child’s conditionProper evaluation of child’s condition Monitor, monitor, monitor!Monitor, monitor, monitor!

Don’t get complacentDon’t get complacent Be vigilant in regards to lab tests, psychiatric Be vigilant in regards to lab tests, psychiatric

evaluations, weight monitoring, etc.evaluations, weight monitoring, etc.

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