A descriptive study of aripiprazole, brexpiprazole, and cariprazine exposures in children ages 0 to 5 years reported to United States poison centers

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.

Prolonged QRS Widening After Aripiprazole Overdose

BACKGROUND

Aripiprazole is an atypical antipsychotic with a long half-life. Overdose can result in protracted somnolence and cardiac disturbances, particularly QT interval prolongation.

METHODS

This is a single case report of a 14-year-old boy who took an overdose of aripiprazole and developed QRS widening.

CASE

A 14-year-old boy intentionally ingested 20 tablets of aripiprazole (5 mg). He was brought to the emergency department when his ingestion was discovered. The patient's vital signs were as follows: temperature, 37.7°C; heart rate, 108 beats/min; blood pressure, 138/98 mm Hg; and respirations, 16 breaths/min. Activated charcoal was administered within 90 minutes of ingestion. Initial electrocardiogram (EKG) showed sinus tachycardia, with a QRS of 138 ms and QT interval of 444 ms. QRS duration was 90 ms on an EKG performed 3 months earlier. A bolus of sodium bicarbonate was administered, and the patient was transferred to the pediatric intensive care unit. Repeat EKG demonstrated a QRS of 156 ms, and a sodium bicarbonate infusion was initiated. The patient continued to have QRS prolongation for the next 8 days, reaching a peak of 172 ms 3 days postingestion. Despite aggressive treatment with sodium bicarbonate, there was persistent QRS prolongation; however, the patient did not have any dysrhythmias and remained hemodynamically stable. The patient was discharged 9 days postingestion when the QRS duration normalized to 82 ms. Genetic testing revealed that the patient was a CYP2D6 poor metabolizer.

CONCLUSIONS

This case suggests that aripiprazole toxicity may possibly be associated with QRS prolongation without associated dysrhythmias or cardiovascular compromise. In addition, toxicity may be prolonged in patients who are CYP2D6 poor metabolizers.

Aripiprazole Toxicity With a Biphasic Course of Somnolence

INTRODUCTION

Aripiprazole is an atypical antipsychotic with partial agonism at dopamine and serotonin receptors. In pediatrics, it is approved to treat irritability associated with autistic disorder along with other neuropsychological conditions. Compared with other atypical antipsychotics, it has a favorable side effect profile, but overdose experience is limited.

CASE REPORT

A 3-year-old drug-naive patient accidentally ingested 200 mg of aripiprazole. This ingestion resulted in immediate lethargy with brief improvement 16 hours after ingestion and subsequent decline 2 hours later. Patient returned to baseline 72 hours after ingestion.

DISCUSSION

Unlike previous case reports, this patient displayed a biphasic course of somnolence. Previous reports have described delayed onset and prolonged sedation in response to an aripiprazole overdose. Current recommendations regarding monitoring after ingestion do not account for possible worsening of symptoms after improvement.

CONCLUSION

It is important to recognize the need for a longer observation period after a significant aripiprazole overdose as a variable course of somnolence may be witnessed.

Overdoses with Aripiprazole: Signs, Symptoms and Outcome in 239 Exposures Reported to the Danish Poison Information Centre

The aim of this study was to characterize the clinical signs and symptoms of exposures to aripiprazole overdoses. We retrospectively identified all aripiprazole exposures reported to the Danish Poison Information Centre (DPIC) from June 2007 to May 2015. Information concerning demographics, ingested dose and symptoms was extracted from the DPIC database and medical records. Information on death and admission to hospital was obtained from Danish national registers. We analysed 239 cases, 86 concerning single-drug exposures to aripiprazole, and 153 cases where aripiprazole had been taken with at least one other substance (mixed-drug). The median ingested aripiprazole dose was 105 mg (IQR: 50-1680 mg) in the single-drug exposure group and 120 mg (IQR: 60-225 mg) in the mixed-drug exposure group. The most commonly reported symptom was light sedation, reported in 63% of the single-drug group and 50% of the mixed-drug exposure group. There were no malignant arrhythmias or ECG abnormalities after single-drug exposures. No deaths were recorded in relation to the intake. We found a long-term mortality rate of 13 deaths per 1000 person-years (95% CI: 7; 23 per 1000 person-years), which is significantly higher than in an age- and gender-matched background population. In conclusion, we found that aripiprazole overdoses had few and mild symptoms predominantly related to the sedative properties. We detected a benign cardiovascular safety profile and no new safety concerns. Our findings may support an increased threshold of 300 mg for hospital admission after a single-drug exposure with aripiprazole and symptoms not worse than light sedation.

Comparison of pediatric atypical antipsychotic exposures reported to U.S. poison centers

CONTEXT

The rise in atypical antipsychotic prescribing increases the risk of pediatric exposures. Published studies in children are limited.

OBJECTIVE

The objectives are to evaluate national poison center data on atypical antipsychotic exposures in young children and compare toxicity amongst selected agents.

MATERIALS AND METHODS

A retrospective study of U.S. National Poison Data System single substance exposures, from 2005 to 2013, of five atypical antipsychotics in children <6 years old, followed to known outcome was performed. Data were evaluated for reason, clinical effects, management site and outcome.

RESULTS

There were 16,935 exposures included: 5018 aripiprazole, 1735 olanzapine, 3904 quetiapine, 4778 risperidone and 1500 ziprasidone. Median age was two years. Most common reason was unintentional-general (90.6%). Therapeutic error occurred more often with risperidone (19.9%). Clinical effects occurred in 59.4% of aripiprazole, 57.9% of olanzapine, 56.6% of ziprasidone, 40.1% of risperidone, and 29.3% of quetiapine. The most frequent were drowsiness/lethargy (35.6%), tachycardia (6.9%), agitation (4.0%), and ataxia (3.3%). Drowsiness/lethargy occurred most with aripiprazole (47.6%), ziprasidone (46.5%) and olanzapine (45.1%) and least with quetiapine (20.5%) and risperidone (28.6%). Tachycardia and agitation both occurred most often with olanzapine (11.4% and 12.7%, respectively). Management sites were non-health care facility (28.0%), treated/discharged from emergency department (48.9%), admitted - noncritical care (11.4%), critical care (9.5%), and other/unknown (2.2%). Admission was lowest for risperidone (13.9%) and quetiapine (11.9%) and highest for olanzapine (32.9%). Coded outcomes were no effect (53.3%), minor (33.7%), moderate (12.1%), major (0.9%) and no deaths. Moderate/major outcomes occurred most often with ziprasidone (20.5%) and olanzapine (19.0%) and least often with quetiapine (5.3%) and risperidone (10.9%).

DISCUSSION AND CONCLUSION

Overall outcomes were favorable, with major toxicity in <1% of exposures. Risperidone and quetiapine exposures resulted in less toxicity. This finding may be attributed to higher frequency of therapeutic errors for risperidone but the reason for less toxicity with quetiapine is unclear.

[Aripiprazole use in children and adolescent psychiatric patients]

Aripiprazole inaugurates a new generation of antipsychotics called dopamine-serotonin system stabilizers. Its mechanism of action is different as aripiprazole is a partial dopamine D(2) and serotonin 5-HT(1A) receptor agonist and 5-HT(2A) receptor antagonist. Therefore, aripiprazole is thought to have an antagonistic action in the mesolimbic pathway but an agonistic action in the mesocortical pathway, tending to normalize the dopaminergic transmission regardless of the type of imbalance. Clinical trials involving children and adolescents have demonstrated the efficacy of aripiprazole in bipolar disorders, schizophrenia, mood disorders associated with pervasive developmental disorders, in tics and Tourette's. The most frequent side effects are extrapyramidal symptoms and sleepiness and are dose-dependent. Nevertheless, contrary to other second-generation antipsychotics available in France, it induces little weight gain, does not modify lipid and glucidic profiles, does not increase prolactin levels, or induce QTc lengthening. The main advantage of aripiprazole is its good safety profile, with different toxicity targets to other second-generation antipsychotics available in France. Aripiprazole appears to be an alternative for children and adolescents who are vulnerable to these side effects and are having trouble coping with them.

Increased aripiprazole concentrations in an HIV-positive male concurrently taking duloxetine, darunavir, and ritonavir

OBJECTIVE

To report a case of increased aripiprazole concentrations during coadministration with darunavir, ritonavir, and duloxetine.

CASE SUMMARY

A 43-year-old HIV-positive Hispanic man received darunavir/ritonavir-based antiretroviral therapy (ART) in addition to aripiprazole and duloxetine for depression and anxiety. A month after the aripiprazole dosage was increased to 50 mg daily, the patient developed confusion and loss of coordination. Weeks later, he presented to the emergency department with fever, cough, headache, neck stiffness, back pain, and blurred vision and was admitted for possible meningitis. Because symptoms improved with pain control and intravenous fluids during hospitalization, he was discharged within a couple days after admission. One month later he was readmitted for worsening symptoms, and the resulting diagnostic workup showed unremarkable findings except for lymphadenopathy (LAD). This finding was attributed to discontinuing ARTs after his first admission. He was discharged on aripiprazole 50 mg daily, darunavir 800 mg daily, ritonavir 100 mg daily, and duloxetine 60 mg daily. A random steady-state concentration of aripiprazole was 1100 ng/mL (therapeutic concentration 100-200 ng/mL) obtained 49 days after discharge.

DISCUSSION

The Horn Drug Interaction Probability Scale demonstrated a possible relationship between the increased aripiprazole concentration and coadministration of darunavir/ritonavir and duloxetine, which inhibit CYP3A4 and 2D6. Potential confounders to the increased concentration include duloxetine inhibition of CYP2D6 polymorphism, possible 2D6 polymorphism, and exceeding aripiprazole's maximum dose. The initial presentation of confusion and loss of coordination may have been early signs of aripiprazole toxicity, which relapsed as shown by his symptoms prior to admission.

CONCLUSIONS

The interaction between aripiprazole and darunavir, ritonavir, and duloxetine may be significant. Clinicians should be cognizant of increased risk of aripiprazole toxicity in HIV-positive patients concurrently taking ritonavir-boosted ART and other cytochrome P450 inhibitors like duloxetine. Dose adjustments or monitoring parameters should be an area of research and discussion.

Risk assessment of isolated aripiprazole exposures and toxicities: a retrospective study

STUDY OBJECTIVE

To characterize the clinical effects of acute isolated aripiprazole poisonings and to assess the toxic dose of this drug.

METHODS

All isolated acute aripiprazole exposures reported to a poison control system from January 2002 through September 2006 were retrospectively reviewed. Patients with incomplete information or those lost to follow-up were excluded.

RESULTS

A total of 286 cases were identified. Mean age was 18.9 years (SD 15.7), with a range of 6 months-70 years. Seventy-seven patients (27%) were <or=6 years, 80 patients (28%) were 7-17 years, and 129 patients (45%) were >or=18 years. Doses were known in 255 patients (89%). Symptoms occurred in 158 patients (55%): somnolence 89 (56%), tachycardia 32 (20%, heart rate 102-186), nausea/vomiting 29 (18%), dystonic reactions 21 (13%), tremor 9 (6%), agitation 3 (2%), dizziness 3 (2%), paresthesia 2 (1%), headache 2 (1%), dysphagia 1 (<1%), syncope 1 (<1%), minor facial swelling 1 (<1%), and hypotension 1 (<1%). None of the patients required intubation, and there were no deaths or EKG abnormalities. Median dose for symptomatic and asymptomatic groups were 25 and 15 mg, respectively, for <or=6 years (p = 0.02); 60 and 30 mg for 7-17 years (p = 0.01); and 100 and 75 mg for >or=18 (p = 0.25). In comparison of drug groups (Group 1, <or=20 mg; Group 2, 21-90 mg; Group 3, >or=91 mg), symptoms were more likely to occur in Group 2 versus Group 1 (OR 2.29, 95% CI 0.79-6.61) in patients <or=6 years; in Group 3 versus Group 1 (OR 3.39, 95% CI 1.07-10.73) followed by Group 2 versus Group 1 (OR 1.14, 95% CI 0.36-3.56) in patients 7-17 years; and in Group 3 versus Group 1 (OR 1.36, 95% CI 0.54-3.42) but not any more likely in Group 2 versus Group 1 (OR 0.92, 95% CI 0.33-2.52) in patients >or=18 years.

CONCLUSIONS

Acute aripiprazole poisonings most commonly result in sedation, sinus tachycardia, nausea/vomiting, or dystonic reactions. Symptoms are more likely with doses above 90 mg, although pediatric patients can be affected at a lower dose.

Clinical implications of antipsychotic-induced hyperprolactinemia in patients with schizophrenia spectrum or bipolar spectrum disorders: recent developments and current perspectives

Hyperprolactinemia is increasingly studied as a frequent and potentially important consequence of antipsychotic medication treatment. Some individuals presenting with hyperprolactinemia remain asymptomatic, but others may exhibit a wide range of clinical symptoms resulting from either the direct effects of prolactin on body tissues (galactorrhea, gynecomastia) or endocrine-related secondary effects (sexual and reproductive dysfunction in the short term, and possibly the risk of tumorigenesis and osteoporosis in the longer term). Short-term side effects may negatively impact medication compliance, and long-term effects have the potential for serious health consequences. Antipsychotic medications have differing propensities to cause prolactin elevation. The first-generation antipsychotics, as well as the second-generation antipsychotic risperidone and its active metabolite paliperidone, have been shown to cause marked and sustained elevations in prolactin levels, whereas others of the second-generation antipsychotics appear to have little or no effect on prolactin levels or may decrease prolactin. A comprehensive overview of antipsychotics and hyperprolactinemia is presented together with a review of emerging evidence about the short- and long-term health risks of hyperprolactinemia.

Antipsychotic poisoning in young children: a systematic review

The aim of this review was to determine the spectrum and severity of effects of unintentional antipsychotic poisoning in children. A computerised literature search of MEDLINE (1966 to February 2005) and EMBASE (1980 to February 2005) was undertaken. The Internet was searched using URL: www.google.com. The proceedings of the North American Congress of Clinical Toxicology (NACCT) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) were hand searched. All cases of unintentional antipsychotic (all classes) poisoning in children aged 0-6 years were included. The data extracted included the age, weight, antipsychotic, dose, clinical effects, treatment and outcomes. The toxic dose was estimated as the lowest dose causing objective adverse effects.Sixty-eight reports were identified. Few contained all of the required information. Most of the case series included multiple antipsychotics with limited information on individual drugs or all ages with limited paediatric information. For most antipsychotics the ingestion of one tablet caused symptoms that were sometimes severe and usually lasted from 1 to 3 days. Extrapyramidal symptoms (EPS) were often delayed for up to 12-24 hours. Chlorpromazine caused CNS depression, hypotension and miosis; EPS and cardiac effects were rare, and the toxic dose was estimated to be 15 mg/kg. Haloperidol caused drowsiness (rarely coma) and over one-half of patients had neuromuscular effects (mainly EPS), with a toxic dose estimated at 0.15 mg/kg. Thioridazine caused CNS depression and potentially cardiac effects, with a toxic dose of 1.4 mg/kg. Atypical antipsychotics caused significant CNS depression (except risperidone); EPS were less common. Toxic doses were clozapine 2.5 mg/kg, olanzapine 0.5 mg/kg and aripiprazole 3 mg/kg. EPS responded to anticholinergic drug treatment. In summary, unintentional antipsychotic ingestion in children can cause severe effects that last 1-3 days, often with one tablet. Children potentially ingesting a toxic dose or who are symptomatic should be considered for assessment in hospital. Most cases resolve with good supportive care. Toxic doses are only estimates that are based on limited data and should be used with caution until prospective studies are undertaken.