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Akel MB, Condren ME, Passmore SJ. Brexpiprazole toxicity in a paediatric patient. BMJ Case Rep 2024; 17:e258561. [PMID: 38719244 PMCID: PMC11085811 DOI: 10.1136/bcr-2023-258561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024] Open
Abstract
Brexpiprazole is a relatively new drug that has no published research or applications within the paediatric population. Brexpiprazole targets multiple receptors and can manifest as multisystem symptoms when ingested in supratherapeutic quantities. In this report, we discuss the case of a child in early childhood who presented with delayed neurological and cardiac symptoms 24 hours after accidental ingestion of brexpiprazole. Due to delayed onset, this case highlights that a high index of suspicion and prolonged observation are necessary to appropriately manage brexpiprazole overdose or accidental ingestion.
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Affiliation(s)
- Mohamad Bisher Akel
- Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, USA
| | - Michelle E Condren
- Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, USA
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Penugonda AJ, Singh Y, Kattula D, Bhaskar M. Neuroleptic Malignant Syndrome in a 15-Month-Old Child: A Case Report. J Clin Psychopharmacol 2023; 43:455-456. [PMID: 37683235 DOI: 10.1097/jcp.0000000000001749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
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Husak N, Laudone TW, Leonard JB. A descriptive study of aripiprazole, brexpiprazole, and cariprazine exposures in children ages 0 to 5 years reported to United States poison centers. Clin Toxicol (Phila) 2023; 61:110-115. [PMID: 36762866 DOI: 10.1080/15563650.2022.2163901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Increased prescribing of antipsychotics and availability of new antipsychotics has resulted in increased exposures in children. Current data on aripiprazole, brexpiprazole, and cariprazine are limited. METHODS This was a retrospective database study utilizing the National Poison Data System from 2015 through 2021. We included cases of single substance exposures to aripiprazole, brexpiprazole, cariprazine, or lumateperone in children ages 0 to 5 years old with follow-up to a known outcome. Key outcomes were medical outcomes, clinical effects, and level of care if treated in a healthcare facility. RESULTS There were 3,573 aripiprazole, 137 brexpiprazole, 249 cariprazine, and one lumateperone exposure over the period. Primary outcomes were evaluated in 2,655 cases (2,390 aripiprazole, 96 brexpiprazole, and 169 cariprazine). Fifty-one percent were male and 77% were between 0 and 2 years old. Moderate effect was coded in 16.6% of aripiprazole, 23% of brexpiprazole, and 12% of cariprazine exposures. Major effect was coded in 0.6% of aripiprazole, 1% of brexpiprazole, and 2.4% of cariprazine exposures. Duration of symptoms was mostly between 8 and 24 h for 34.6% of aripiprazole, 30% of brexpiprazole, and 32% of cariprazine exposures. Over 60% of the children seen in a health care facility were discharged from the emergency department. The lowest doses resulting in at least a moderate effect and admission to a health care facility was 0.46 mg/kg for aripiprazole, 2.1 mg/kg for brexpiprazole, and 1.9 mg/kg for cariprazine. Important clinical effects included central nervous system depression, tremors, tachycardia, agitation, and vomiting. CONCLUSION Reported ingestions of aripiprazole, brexpiprazole, or cariprazine may result in neurologic symptoms like central nervous system depression or seizures in children. The prolonged duration of symptoms resulted in admission for at least a day for many cases. Further research should address optimal monitoring time and location for these exposures.
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Affiliation(s)
- Nicholas Husak
- Department of Pharmacy, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Thomas W Laudone
- Deparment of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Hunter K, Poel K, Pennington S, Bindseil I, Banerji S, Leonard J, Wang GS. Trends of prescription psychotropic medication exposures in pediatric patients, 2009-2018. Clin Toxicol (Phila) 2021; 60:243-251. [PMID: 34196239 DOI: 10.1080/15563650.2021.1946556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mental health disorders and related suicide attempts are increasing in both the adult and pediatric patient populations. Because of the increasing prevalence of mental health disorders, there is increased use of psychotropic medications in adult and pediatric patients, which can pose a risk for potentially adverse pediatric ingestions. The objective was to determine trends and outcomes for pediatric psychotropic medication ingestions reported to the American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS). METHODS This was a retrospective review of pediatric (≤18 years of age) exposures reported to AAPCC NPDS between January 1, 2009 and December 31, 2018. Single psychotropic medication ingestions of atypical antipsychotics, bupropion, buspirone, clonidine, lithium, methylphenidate, mirtazapine, monoamine oxidase inhibitors (MAOIs), selective norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), trazodone, and tricyclic antidepressants (TCAs) were examined. RESULTS Over the 10-year study period, 356,548 pediatric psychotropic medication ingestions were reported to NPDS. SSRI ingestions were the most frequently reported (34%), followed by atypical antipsychotics (17%), and methylphenidate (15%). Unintentional ingestions were most prominent in patients 0-12 years of age (79%), whereas, in patients age 13-18 years, 76% were intentional. SSRI ingestions were asymptomatic in 68% of cases. Clonidine and bupropion ingestions had the highest proportion of moderate and major clinical effects (29 and 25%, respectively). There were 29 deaths: atypical antipsychotics (n = 4), bupropion (n = 10), lithium (n = 1), SNRI (n = 1), SSRIs (n = 7), and TCAs (n = 6); 19 (65%) were in adolescent patients. CONCLUSIONS SSRIs were the most frequently reported ingestion, while bupropion and clonidine were associated with a high percentage of moderate and major clinical effects. This study demonstrates opportunities for targeted prevention strategies to prevent potentially adverse pediatric ingestions to psychotropic medications.
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Affiliation(s)
- Kiley Hunter
- Department of Pharmacy, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Kevin Poel
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Stephanie Pennington
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Isabelle Bindseil
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Shireen Banerji
- Rocky Mountain Poison and Drug Safety, Denver Health Hospitals, Denver, CO, USA
| | - Jan Leonard
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - George Sam Wang
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
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Bravo M, Lim R, Poonai N, Chen B. Clinical Suspicion and Language Translation in the Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:e272-e274. [PMID: 30130342 DOI: 10.1097/pec.0000000000001606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
ABSTRACT Elucidating a medical history and gaining patient consent and buy-in are difficult in any teenager presenting to a North American pediatric emergency department, but especially so when they present with limited English fluency. Translators can make this process easier, but both limited availability and impreciseness in translation can reduce their utility. We describe 2 teenage females who presented to our pediatric emergency department within 48 hours with similar presentations but no obvious organic cause or examination findings to suggest a specific diagnosis. We demonstrate how complex language translation issues in these adolescents contributed to prolonged diagnoses and advocate for independent interpreters to be available on first presentation to hospital.
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Affiliation(s)
| | - Rodrick Lim
- Pediatrics and Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Naveen Poonai
- Pediatrics and Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Abstract
Objective: To review the use of aripiprazole in children and adolescents. Methods: Medline and Embase databases were systematically searched using the keywords aripiprazole and child or adolescent over the period from 2000 to 2019. The initial screen yielded 163 publications, from which 99 studies were reviewed. Results: Aripiprazole is one of the most widely prescribed atypical antipsychotics. Like others, its use in children and adolescents is becoming commonplace and occurs in off-label indications. Aripiprazole has proven efficacy for several indications in children and adolescents, including schizophrenia, bipolar disorder, Tourette's syndrome, and behavioral impairments associated with autism and intellectual disability. Adverse effects are more important in children and adolescents than adults, particularly weight gain, drowsiness, extrapyramidal effects, and metabolic effects, even though the latter may appear less important than with other atypical antipsychotics. Severe adverse effects often occur in multiple-prescription settings. At present, postprescription monitoring is very poor. Conclusion: Aripiprazole has proven efficacy for several indications in children and adolescents. However, its use requires clinical and paraclinical monitoring to assess the occurrence of adverse events that may challenge the benefit/risk ratio. In addition, off-label prescriptions should be limited, as they appear to account for a significant proportion of aripiprazole use worldwide.
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Affiliation(s)
- Nicolas Coustals
- Department of Child and Adolescent Psychiatry, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Marie-Line Ménard
- Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France.,CoBTek, EA7276, University of Côte d'Azur, Nice, France
| | - David Cohen
- Department of Child and Adolescent Psychiatry, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France.,Institut des Systèmes Intelligents et Robotiques, CNRS UMR 7222, Université Sorbonne, Paris, France
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Rodriguez SA, Moss MJ. Pediatric brexpiprazole toxicity. Clin Toxicol (Phila) 2020; 58:1354-1355. [DOI: 10.1080/15563650.2020.1743303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Simon A. Rodriguez
- Utah Poison Control Center, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Michael J. Moss
- Utah Poison Control Center, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
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Weiss SJ, Cueto-Vilorio VA, Dharmaraj R, Barolia D, Nashat A, Walsh SJ, Simpson SE. Characterization of intentional lurasidone ingestions using the United States National Poison Data System. Clin Toxicol (Phila) 2020; 58:1342-1346. [PMID: 32167797 DOI: 10.1080/15563650.2020.1737102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: The ziprasidone analogue lurasidone is approved for the treatment of schizophrenia and bipolar disorder for adults and children older than 10 years. Small studies and case reports suggest lurasidone overdose is not generally associated with major adverse effects, but no large sample has been published.Objective: To describe intentional lurasidone overdoses reported to poison centers.Methods: Retrospective analysis of single-substance intentional lurasidone ingestions from the National Poison Data System (NPDS) from 2011 to 2018.Results: There were 1753 single-substance intentional overdoses. Average age was 28.6 years (SD = 13.3 years) and 1199 (68.4%) of patients were female. Most cases (86.6%) were coded as suspected suicide. Regarding final management site, 1143 (65.2%) were discharged or admitted to psychiatric facilities; 328 (18.8%) were admitted, half of whom were admitted to critical care units (CCUs). Major effect was coded in 12 (0.7%), moderate effect in 259 (14.8%), minor effect in 531 (30%), and no effect in 614 (35%). There were no deaths. For cases for which dose information was available, there was not a statistically significant difference between median doses when analyzed by clinical effect. Most common adverse effects were drowsiness (449, 25.6%), tachycardia (254, 14.5%), vomiting (121, 6.9%), and hypertension (115, 6.6%). Most cases had either no therapy reported, or therapy was recommended by the poison center but confirmed not to have been administered (1010, 57.6%). Of the 164 patients admitted to CCUs, 80 (48.8%) received either no therapy or intravenous fluids alone.Discussion: These data suggest major effects are uncommon from lurasidone overdose. Despite a high rate of admission to CCUs, a substantial proportion received no critical therapies.Conclusions: This report demonstrates intentional lurasidone overdoses reported to poison centers generally have a favorable clinical course.
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Affiliation(s)
- S J Weiss
- Albert Einstein Medical Center, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - V A Cueto-Vilorio
- Albert Einstein Medical Center, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - R Dharmaraj
- Albert Einstein Medical Center, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - D Barolia
- Albert Einstein Medical Center, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - A Nashat
- Albert Einstein Medical Center, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - S J Walsh
- Albert Einstein Medical Center, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - S E Simpson
- Albert Einstein Medical Center, Albert Einstein Healthcare Network, Philadelphia, PA, USA
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Liu XI, Schuette P, Burckart GJ, Green DJ, La J, Burnham JM, Rakhmanina N, Robb A, Huang SM, van den Anker JN. A Comparison of Pediatric and Adult Safety Studies for Antipsychotic and Antidepressant Drugs Submitted to the United States Food and Drug Administration. J Pediatr 2019; 208:236-242.e3. [PMID: 30679050 PMCID: PMC7171692 DOI: 10.1016/j.jpeds.2018.12.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/08/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine the differences in the adverse drug reaction (ADR) profile of antipsychotic and antidepressant agents between pediatric and adult patients in studies submitted to the Food and Drug Administration (FDA) during the drug development process. STUDY DESIGN Clinical trials in adult and pediatric patients were conducted by sponsors as part of the drug development programs for antipsychotic and antidepressant agents, and ADR information was collected as part of those trials and submitted to the FDA. Data collection was conducted by reviewing publicly available FDA-authored reviews and FDA-approved product labels for 10 drugs with an antipsychotic or an antidepressant indication from 2007 to 2017. RESULTS There were 308 drug and ADR combinations for the 10 drugs and drug combinations with 113 (36.7%) having a significantly different incidence in pediatric patients compared with adults. Sixty-eight (60.2%) of these ADRs had a significantly higher incidence in pediatric patients than in adults. Sedation was higher in 6 of the 10 drugs and drug combinations with risk differences ranging from 9.6 to 36.6%. CONCLUSIONS This analysis indicates that there were significant differences between the pediatric and adult safety profiles of antipsychotic and antidepressant drugs. Sedation was the major ADR associated with the use of atypical antipsychotic drugs in pediatric patients. Clinicians caring for children should consider the ADR profile when prescribing antipsychotics and antidepressants in pediatric patients.
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Affiliation(s)
| | - Paul Schuette
- Office of Biostatistics, United States Food and Drug Administration, Silver Spring, MD
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, United States Food and Drug Administration, Silver Spring, MD
| | - Dionna J. Green
- Office of Pediatric Therapeutics, United States Food and Drug Administration, Silver Spring, MD
| | - Julie La
- Loma Linda School of Pharmacy, Loma Linda, CA
| | - Janelle M. Burnham
- Office of Clinical Pharmacology, United States Food and Drug Administration, Silver Spring, MD
| | | | | | - Shiew Mei Huang
- Office of Clinical Pharmacology, United States Food and Drug Administration, Silver Spring, MD
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Vial T, Patat AM, Paret N, Boels D, Torrents R, Nisse P, Villa A, Kassai B. Risperidone medication errors in children: an analysis of French poison centres data. Clin Toxicol (Phila) 2018; 57:362-367. [PMID: 30449187 DOI: 10.1080/15563650.2018.1523424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To describe clinical consequences of risperidone medication errors in children of less than 13 years and to estimate a clinically relevant toxic dose. METHODS All cases of risperidone medication errors managed by French Poison Centres from 2001 to 2012 were analyzed. Inclusion criteria were a delay of at least 2 hours between ingestion and request to the FPC in asymptomatic children, an ingested dose above two-fold the maximal daily dose for children above 5 years or any symptomatic patient at the time of first contact. RESULTS One hundred and sixty cases met our criteria. Median age was 8 years (range 0.9-12) and 28.1% were aged 5 years or less. Causes of the error were an incorrect dose in treated children (84.2%) or a dose given to a wrong child (15.8%). The median ingested dose was 0.1 mg/kg or 3.3-fold the maximum recommended dose. Overall, 59 children had no symptoms, 95 experienced minor symptoms and six moderate symptoms. Somnolence/sedation was the most common (73.3%). Of the 17 children who developed extrapyramidal disorders, all had minor or moderate symptoms and only five required a symptomatic treatment. CONCLUSIONS Risperidone medication errors in children cause minimal effects. Somnolence and mild to moderate extrapyramidal reactions were the main features of toxicity, and significant cardiac or other neurological features were not observed. No case with severe toxicity was noted. At home surveillance can be proposed for children exposed to a dose ≤0.15 mg/kg.
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Affiliation(s)
- Thierry Vial
- a Department of Pharmacotoxicology , Lyon University Hospital, Hospices Civils de Lyon , France
| | - Anne-Marie Patat
- a Department of Pharmacotoxicology , Lyon University Hospital, Hospices Civils de Lyon , France
| | - Nathalie Paret
- a Department of Pharmacotoxicology , Lyon University Hospital, Hospices Civils de Lyon , France
| | - David Boels
- b Poison Control Center , Angers University Hospital , France
| | - Romain Torrents
- c Poison Control Center, Marseille University Hospital, Assistance Publique Hôpitaux de Marseille , France
| | - Patrick Nisse
- d Poison Control Center, Lille University Hospital , France
| | - Antoine Villa
- e Poison Control Center, Paris University Hospital, Assitance Publique Hôpitaux de Paris , France
| | - Behrouz Kassai
- f Department of Pharmacotoxicology and UMR 5588-CNRS, Lyon University Hospital , France
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Abstract
Pharmaceutical ingestions comprise an important part of pediatric toxicology. Based on the 2015 Annual Report of the American Association of Poison Control Centers' National Poison Data System, coupled with recent epidemiology articles on the topic of pediatric toxicology, it is apparent that poison prevention education has not been completely successful in decreasing exposures to toxic drugs. From the unintentional ingestion in a toddler due to unsafe storage to the intentional adolescent ingestion for misuse and abuse, pharmaceutical medications continue to cause harm. Access to adult prescription drugs in the home accounted for most of the exposures in children age ≤5 years as well as adolescents age 13 to 19 years. Ingestions resulting from more common pharmaceutical exposures are discussed with the hope of increasing awareness about the need for added vigilance. [Pediatr Ann. 2017;46(12):e459-e465.].
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