Effects of short- and long-term risperidone treatment on prolactin levels in children with autism

Risperidone: a review of its use in the treatment of irritability associated with autistic disorder in children and adolescents

Risperidone (Risperdal), a psychotropic atypical antipsychotic agent, is thought to act via dopamine D(2) and serotonin (5-HT [5-hydroxytryptamine])(2A) receptor antagonism. The clinical efficacy of oral risperidone in the treatment of bipolar mania and schizophrenia in adult patients is well established. In the US, risperidone is also approved for the treatment of irritability associated with autistic disorder in children and adolescents aged 5-16 years, for the treatment of schizophrenia in adolescents aged 13-17 years and, as monotherapy, for the short-term treatment of acute manic and mixed episodes associated with bipolar I disorder in children and adolescents aged 10-17 years. Oral risperidone treatment was better than placebo treatment in reducing irritability and other behavioral symptoms associated with autistic disorder in children and adolescents in two well designed short-term trials, with these benefits maintained in those receiving risperidone for up to 6 months. The drug had a clinically manageable tolerability profile, with most adverse events being of mild to moderate intensity. There are some aspects of treatment, such as weight gain, somnolence, and hyperglycemia, that require monitoring, and the long-term safety of risperidone in children and adolescents with autistic disorder remains to be fully determined. With these issues in mind, risperidone offers a valuable emerging option for the treatment of irritability associated with autistic disorder in children and adolescents.

Antipsychotics in the treatment of autism

Atypical antipsychotics have become indispensable in the treatment of a variety of symptoms in autism. They are frequently used to treat irritability and associated behaviors including aggression and self injury. They may also be efficacious for hyperactivity and stereotyped behavior. This review presents the rationale for the use of this drug class in autism and reviews the most important studies published on this topic to date. Significant adverse effects, including weight gain and the possibility of tardive dyskinesia, are reviewed. Future research directions are discussed.

Buspirone for autistic disorder in a woman with an intellectual disability

OBJECTIVE

To describe a case of an intellectually disabled patient who was diagnosed with autistic disorder (AD) and responded positively to buspirone, demonstrated by a reduction in target behaviors of self-injury, property destruction, and physical aggression.

CASE SUMMARY

A 33-year-old, white, nonverbal, profoundly intellectually impaired woman (IQ <20-25), residing in a state-run facility, exhibited worsening aggressive behaviors associated with AD. These behaviors were characterized by a history of self-injurious behavior (eg, slapping and scratching herself); property destruction, including breaking windows; and head butting of staff and peers. Additional diagnoses included a seizure disorder, hyperprolactinemia, and osteoporosis. At the time of admission, her drug regimen included 3 atypical antipsychotic agents: risperidone, clozapine, and aripiprazole. Antipsychotic agents have been reported to lower the seizure threshold, and elevated prolactin levels have been associated with risperidone use. Aripiprazole and clozapine were discontinued on admission, and risperidone was discontinued one month later following increased behavioral deterioration. Buspirone was considered an appropriate replacement medication, as it has not been associated with elevated prolactin levels or a lowered seizure threshold, and was initiated at 15 mg/day. Significant reductions in aggression were noted following titration to a total daily dose of 90 mg.

DISCUSSION

Buspirone is approved for treatment of generalized anxiety disorder in adults. Dopaminergic agonist/antagonist actions have been reported with use of higher doses. These receptor effects have been beneficial for aggressive behaviors in the AD population that were exhibited by our patient, but effectiveness for aggression in the intellectually disabled population is uncertain. In our patient, problematic behaviors associated with AD responded positively to buspirone.

CONCLUSIONS

The reduction in target aggressive behaviors achieved with buspirone therapy allowed other treatment interventions to proceed more effectively in our patient. Clinicians may wish to consider use of buspirone in patients with AD who do not respond to or have risk factors for use of other therapy.

Psychopharmacological treatment for very young children: contexts and guidelines

Systematic research and practice guidelines addressing preschool psychopharmacological treatment in very young children are limited, despite evidence of increasing clinical use of medications in this population. The Preschool Psychopharmacology Working Group (PPWG) was developed to review existing literature relevant to preschool psychopharmacology treatment and to develop treatment recommendations to guide clinicians considering psychopharmacological treatment in very young children. This article reviews the developmental considerations related to preschool psychopharmacological treatment, presents current evidence bases for specific disorders in early childhood, and describes the recommended algorithms for medication use. The purpose of this effort is to promote responsible treatment of young children, recognizing that this will sometimes involve the use of medications.

Atypical antipsychotics in children with pervasive developmental disorders

The treatment of pervasive developmental disorders (PDDs) is a challenging task, which should include behavioral therapy modifications as well as pharmacologic therapy. There has been a lack of data on using medications in children with PDDs until recent years. Within the last 10 years, an increase in clinical research has attempted to provide efficacy and safety data to support the use of medications in children with PDDs. Double-blinded and open-label research of atypical antipsychotics has been of particular focus. Evidence shows that atypical antipsychotics (AAs) may be useful in treating certain symptoms associated with PDDs, such as aggression, irritability, and self-injurious behavior. This article reviews the literature regarding the use of AAs in children with PDDs. Of the AAs, risperidone has the largest amount of evidence with five published double-blinded, placebo-controlled trials and nine open-label trials. These risperidone trials have consistently shown improvements in aggression, irritability, self-injurious behavior, temper tantrums, and quickly changing moods associated with autistic disorder and other PDDs. Data for the other AAs are limited, but ziprasidone and aripiprazole appear to be promising treatment options. Based on clinical trials, olanzapine and quetiapine have shown minimal clinical benefit and a high incidence of weight gain and sedation. It should be noted that all AAs do have a risk of metabolic syndrome, and patients should be monitored appropriately while receiving these medications. Overall, AAs can be beneficial in alleviating behavioral symptoms, and should be considered an appropriate therapeutic option, as part of a comprehensive treatment strategy, for children with PDD.

Pharmacogenetics of risperidone response and induced side effects

Risperidone is an atypical antipsychotic that has been effectively used to treat several psychiatric diseases. Atypical antipsychotics present some advantages over conventional antipsychotics, primarily because they offer effective treatment alternatives that are relatively free of extrapyramidal symptoms. However, as with all antipsychotics, there are wide individual differences in response to risperidone, both regarding therapeutic effects and adverse effects, imposing some limitations with respect to the therapeutic use of the drug. Genetic factors are thought to play an important role in determining the variability to drug response. A growing number of studies are investigating how genetic polymorphisms of enzymes involved in drug metabolism or of receptors targeted by antipsychotic agents influence drug treatment of several neuropsychiatric diseases. In this article we will review the genetic variability in both the pharmacokinetics of risperidone action and in pharmacodynamic structures mediating risperidone effects, as well as the pharmacogenetic studies performed for these genes.