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Jiménez-Fernández S, Gurpegui M, Correll CU, de Leon J, Schoretsanitis G. A Systematic Review of Clozapine Concentration-Dose Ratio from Therapeutic Drug Monitoring Studies in Children and Adolescents Treated with Clozapine for Mental Disorders. Ther Drug Monit 2024; 46:170-180. [PMID: 38018845 PMCID: PMC10930379 DOI: 10.1097/ftd.0000000000001154] [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] [Received: 07/31/2023] [Accepted: 09/14/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Therapeutic drug monitoring of clozapine in children and adolescents has received insufficient attention. Calculation of concentration-to-dose (C/D) ratios from trough steady-state concentrations estimate drug clearance. METHODS A systematic electronic literature search was conducted in 3 article databases from inception until January 10, 2023, and articles reporting clozapine concentrations in children and adolescents were retrieved. The pharmacokinetic quality of the studies was assessed, and clozapine C/D ratios were calculated using the sample mean clozapine dose and concentration. RESULTS Of the 37 articles of potential interest, only 7 reported clozapine trough and steady-state concentrations. After excluding case reports and a study confounded by fluvoxamine, 4 studies on psychosis from Europe and the United States were included. The clozapine C/D ratios were similar to published adult values and ranged from 0.82 to 1.24 with a weighted mean of 1.08 ng/mL per mg/d. The weighted means were 334 mg/d for the dose and 380 ng/mL for the concentration. The stratified analysis of the weighted mean clozapine C/D ratios from 2 studies showed lower values in 52 male (1.05 ng/mL per mg/d) than in 46 female (1.46 ng/mL per mg/d) children and adolescents, with values similar to those reported for European adult nonsmokers. Two female adolescents had high clozapine C/D ratios (2.54 ng/mL per mg/d), an Asian American patient with borderline obesity and a patient with intellectual disability with low dosage (mean = 102 mg/d) and concentration (mean = 55 ng/mL). CONCLUSIONS Reports on clozapine therapeutic drug monitoring in children and adolescents are limited in number and quality. Future studies should focus on basic pharmacokinetic issues, such as stratification by sex, smoking, and relevant comedications with inductive or inhibitory properties.
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Affiliation(s)
- Sara Jiménez-Fernández
- Child and Adolescent Mental Health Unit, Virgen de Las Nieves University Hospital, Granada, Spain
- CTS-549 Research Group (Psychiatry and Neurosciences), Junta de Andalucía, Spain
| | - Manuel Gurpegui
- CTS-549 Research Group (Psychiatry and Neurosciences), Junta de Andalucía, Spain
- Granada Center for Psychiatric Studies, Granada, Spain
| | - Christoph U. Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain; and
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
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2
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Hadjoudj J, Konecki C, Feliu C, Djerada Z. Association between olanzapine plasma concentrations and treatment response: A systematic review, meta-analysis and individual participant data meta-analysis. Biomed Pharmacother 2024; 172:116236. [PMID: 38325263 DOI: 10.1016/j.biopha.2024.116236] [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] [Received: 10/11/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
AIMS By meta-analysing pooled studies and available individual participant data, we aim to provide new insight on olanzapine therapeutic drug monitoring in schizophrenia. METHOD We conducted a computerized search of bibliographic databases (Pubmed, Cochrane library, Web of Science and PsycINFO) to identify studies that assessed the relationship between olanzapine plasma concentration and the change in patients' clinical scores. We investigated this relationship with olanzapine plasma level 12h00 post-intake using a random-effects model. RESULTS 7 studies were included in the pooled data analysis (781 patients). We found no difference in oral dose between responders and non-responders but a significantly higher concentration of 4.50 µg/L in responders (p < 0.01). Olanzapine concentration above the thresholds identified in each study was associated with response (odd ratio = 3.50, p = 0.0007). We identified that non-responder patients showed greater inter-individual variability than responders. In the individual data analysis (159 patients), we found no relationship between dose and clinical response but an association between plasma level and response in the shape of a parabolic curve. The Receiver Operating Characteristic curve found a threshold of 22.07 µg/L to identify responders (96% sensitivity, 86% specificity) and a threshold of 56.47 µg/L to identify a decreased probability of response. CONCLUSION In contrast to oral dose, our work confirmed that plasma olanzapine levels are associated with clinical response and should therefore be used to optimise treatment. We determined a treatment response threshold of 22.07 µg/L and suggest that a concentration above the therapeutic window may result in a decreased response.
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Affiliation(s)
- Jed Hadjoudj
- Department of Psychiatry, Marne Public Mental Health Institution & Reims University Hospital, Reims, France; Department of Pharmacology, EA3801, SFR CAP-Sante´, Reims University Hospital, 51 rue Cognac-Jay, 51095 Reims, France
| | - Céline Konecki
- Department of Pharmacology, Université Reims Champagne-Ardenne, EA3801, SFR CAP-Sante´, Reims University Hospital, 51 rue Cognac-Jay, 51095 Reims, France
| | - Catherine Feliu
- Department of Pharmacology, Université Reims Champagne-Ardenne, EA3801, SFR CAP-Sante´, Reims University Hospital, 51 rue Cognac-Jay, 51095 Reims, France
| | - Zoubir Djerada
- Department of Pharmacology, Université Reims Champagne-Ardenne, EA3801, SFR CAP-Sante´, Reims University Hospital, 51 rue Cognac-Jay, 51095 Reims, France.
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3
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Liang J, Ringeling LT, Hermans RA, Bayraktar I, Bosch TM, Egberts KM, Kloosterboer SM, de Winter B, Dierckx B, Koch BCP. Clinical pharmacokinetics of antipsychotics in pediatric populations: a scoping review focusing on dosing regimen. Expert Opin Drug Metab Toxicol 2023; 19:501-509. [PMID: 37668177 DOI: 10.1080/17425255.2023.2252340] [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] [Received: 06/07/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Achieving optimal clinical responses and minimizing side effects through precision dosing of antipsychotics in children and adolescents with psychiatric disorders remains a challenge. Identifying patient characteristics (covariates) that affect pharmacokinetics can inform more effective dosing strategies and ultimately improve patient outcomes. This review aims to provide greater insight into the impact of covariates on the clinical pharmacokinetics of antipsychotics in pediatric populations. AREAS COVERED A comprehensive literature search was conducted, and the main findings regarding the effects of the covariates on the pharmacokinetics of antipsychotics in children and adolescents are presented. EXPERT OPINION Our study highlights significant covariates, including age, sex, weight, CYP2D6 phenotype, co-medication, and smoking habits, which affect the pharmacokinetics of antipsychotics. However, the findings were generally limited by the small sample sizes of naturalistic, open-label, observational studies, and the homogeneous subgroups. Dosing based on weight and preemptive genotyping could prove beneficial for optimizing the dosing regimen in pediatric populations. Future research is needed to refine dosing recommendations and establish therapeutic reference ranges critical for precision dosing and Therapeutic Drug Monitoring (TDM). The integration of individual patient characteristics with TDM can further optimize the efficacy and safety of antipsychotics for each patient.
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Affiliation(s)
- Jiayi Liang
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Maasstad Hospital, Rotterdam, the Netherlands
| | - Lisa T Ringeling
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rebecca A Hermans
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Izgi Bayraktar
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tessa M Bosch
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Maasstad Hospital, Rotterdam, the Netherlands
- Department of Clinical Pharmacology & Toxicology, Maasstad Lab, Maasstad Hospital, Rotterdam, the Netherlands
| | - Karin M Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany
| | - Sanne M Kloosterboer
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Brenda de Winter
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bram Dierckx
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Birgit C P Koch
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
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Ilzarbe L, Ilzarbe D, Gutiérrez-Arango F, Baeza I. Sex Differences in Serum Prolactin Levels in Children and Adolescents on Antipsychotics: A Systematic Review and Meta-Analysis. Curr Neuropharmacol 2023; 21:1319-1328. [PMID: 36305138 PMCID: PMC10324329 DOI: 10.2174/1570159x21666221027143920] [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] [Received: 12/31/2021] [Revised: 08/21/2022] [Accepted: 09/02/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Serum prolactin levels are influenced by sex, physical development and medications among other factors. Antipsychotics usually increase serum prolactin levels in both adults and younger patients, but no study has reviewed the potential association between sex and vulnerability for developing hyperprolactinemia among children and adolescents. OBJECTIVE Systematic review and meta-analysis of serum prolactin levels in children and adolescents on antipsychotic treatment for any psychiatric diagnosis to determine the effect of sex. METHODS A systematic search was performed in MEDLINE/PubMed/Web of Science and Cochrane databases for randomized controlled trials of antipsychotics in children and adolescents reporting serum prolactin levels by sex. RESULTS Of 1278 identified records, seven studies were included, comparing different single antipsychotics to placebo (risperidone N=4; lurasidone N=1; olanzapine N=1; queriapine N=1). Both male and female children and adolescents on antipsychotics presented a significant increase in prolactin levels relative to subjects receiving a placebo. (Male: 16.53 with 95% CI: 6.15-26.92; Female: 26.97 with 95% CI: 9.18-44.75). The four studies using risperidone had similar findings (Male: 26.49 with 95% CI: 17.55-35.43; Female: 37.72 with 95% CI: 9.41-66.03). In the direct comparison between sexes, females showed greater increases in prolactin, but the differences were not statistically significant. CONCLUSION Serum prolactin levels are increased in children and adolescents of both sexes on antipsychotics, with females showing a slightly greater increase than males. Further research is needed to clarify the influence of sex and pubertal status on prolactin levels in children and adolescents taking antipsychotics.
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Affiliation(s)
- Lidia Ilzarbe
- Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic de Barcelona, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Daniel Ilzarbe
- Department of Child and Adolescent Psychiatry and Psychology, Institut Clinic of Neurosciences, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Felipe Gutiérrez-Arango
- Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Inmaculada Baeza
- Department of Child and Adolescent Psychiatry and Psychology, Institut Clinic of Neurosciences, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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5
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Fekete S, Güntzel T, Egberts K, Geissler J, Neubert A, Gerlach M, Romanos M, Taurines R. Serious Adverse Drug Reactions to Antipsychotics in Minors with Multiple Disabilities: Preventability and Potential Cost Savings by Therapeutic Drug Monitoring. PHARMACOPSYCHIATRY 2022; 56:32-39. [PMID: 36332618 PMCID: PMC9811527 DOI: 10.1055/a-1963-7631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Children and adolescents with multiple disabilities and mental disorders (CAMD) are frequently treated with antipsychotic drugs. However, CAMD are particularly susceptible to serious adverse drug reactions (sADRs). This retrospective study examined the frequency of sADRs to antipsychotics in CAMD. Further, the potential preventability of these sADRs through therapeutic drug monitoring (TDM) and the potential socio-economic benefits of TDM were explored. METHODS Routine clinical data of all patients treated at a specialized psychiatric clinic for CAMD between January 2017 and December 2018 were retrospectively examined. Data on the occurrence of sADRs (definition according to the European Medicines Agency), their causality with antipsychotics, as well as their preventability (Schumock criteria) were extracted from patient files. The prolongation of the hospital stay due to sADRs was calculated, and the cost savings were estimated if TDM had been applied. The data were based on a subsample of the KiDSafe project, supported by the Innovation Fund of the Joint Federal Committee, grant number 01NVF16021. RESULTS One hundred two CAMD who were administered at least one antipsychotic drug during inpatient treatment were identified. Of these patients, 22 (21.6%) sADRs with a possible causal relationship with the antipsychotic treatment were documented. Eleven sADRs (50%) could potentially have been prevented through TDM. Mitigating sADRs through TDM likely would have prevented prolonged hospital stays and thus conferred considerable savings for health insurance companies. DISCUSSION The routine implementation of TDM is urgently recommended for antipsychotic treatment in CAMD to increase drug therapy safety.
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Affiliation(s)
- Stefanie Fekete
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,Correspondence Dr. Stefanie
Fekete University hospital of
WürzburgDepartment of Child and Adolescent
Psychiatry, Psychosomatics and Psychotherapy, Margarete-Höppel-Platz
197080
WurzburgGermany
| | - Tim Güntzel
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany
| | - Karin Egberts
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring,Competence network for Therapeutic Drug Monitoring in child and
adolescent psychiatry
| | - Julia Geissler
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, University Hospital
Erlangen, Erlangen, Germany
| | - Manfred Gerlach
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring,Competence network for Therapeutic Drug Monitoring in child and
adolescent psychiatry
| | - Marcel Romanos
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring
| | - Regina Taurines
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group Therapeutic Drug Monitoring
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Krøigaard SM, Clemmensen L, Tarp S, Pagsberg AK. A Meta-Analysis of Antipsychotic-Induced Hypo- and Hyperprolactinemia in Children and Adolescents. J Child Adolesc Psychopharmacol 2022; 32:374-389. [PMID: 36074098 DOI: 10.1089/cap.2021.0140] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: Antipsychotic-related prolactin changes may expose children and adolescents to severe adverse reactions (ARs) related to pubertal development and growth. We therefore aimed to assess the effects of antipsychotics on prolactin levels and associated somatic ARs in children and adolescents. Methods: We systematically searched PubMed and CENTRAL for placebo-controlled randomized trials of antipsychotics in children and adolescents aged ≤18 years, reporting prolactin levels and related ARs. We conducted a random-effect meta-analysis and assessed risk of bias version 2 (ROB2). Results: Thirty-two randomized controlled trials with an average trial duration of 6 weeks, covering 4643 participants with an average age of 13 years and a male majority of 65.3%. Risk of bias across domains was low or unclear. The following antipsychotic compounds: aripiprazole (n = 810), asenapine (n = 506), lurasidone (n = 314), olanzapine (n = 179), paliperidone (n = 149), quetiapine (n = 381), risperidone (n = 609), and ziprasidone (n = 16) were compared with placebo (n = 1658). Compared with placebo, statistically significant higher prolactin increase occurred with risperidone (mean difference [MD] = 28.24 ng/mL), paliperidone (20.98 ng/mL), and olanzapine (11.34 ng/mL). Aripiprazole significantly decreased prolactin (MD = -4.91 ng/mL), whereas quetiapine, lurasidone, and asenapine were not associated with significantly different prolactin levels than placebo. Our results on ziprasidone are based on a single study, making it insufficient to draw strong conclusions. On average, 20.8% of patients treated with antipsychotic developed levels of prolactin that were too high (hyperprolactinemia), whereas only 1.03% of patients reported prolactin-related ARs. Data were highly limited for long-term effects. Conclusions: In children and adolescents, risperidone, paliperidone, and olanzapine are associated with significant prolactin increase, whereas aripiprazole is associated with significant decrease. Despite the significant changes in prolactin level, few ARs were reported. Study protocol on PROSPERO: CRD42018116451.
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Affiliation(s)
- Sabrina Meyer Krøigaard
- Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark
| | - Lars Clemmensen
- VIRTU Research Group, Copenhagen Research Center for Mental Health-CORE, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Copenhagen University Hospital, Hellerup, Denmark
| | - Simon Tarp
- The Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Egberts K, Fekete S, Häge A, Hiemke C, Scherf-Clavel M, Taurines R, Unterecker S, Gerlach M, Romanos M. [Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2022; 50:133-152. [PMID: 35274573 DOI: 10.1024/1422-4917/a000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice Abstract. Despite the improved evidence base, many uncertainties remain in child and adolescent psychiatric pharmacotherapy about the efficacy and tolerability of drugs, which are often prescribed off-label or in combination therapy in this age group. Because medium- to long-term use is unavoidable in many cases, clinicians should minimize adverse drug reactions as far as possible and tailor an effective dosage to the individual characteristics of the patient. Not only are children and adolescents particularly vulnerable to certain adverse drug effects, they are also exposed to iatrogenic risks from dosing or application errors, which can lead to under- or overdosing with correspondingly negative effects on the success of the therapy. In addition to determining a strict indication, it is therefore essential to establish precise dosage and systematic monitoring of the safety of the psychopharmacotherapy. This article introduces therapeutic drug monitoring as a useful clinical tool and describes how its correct application in practice can improve the efficacy as well as the safety and tolerability of psychotropic therapy in children and adolescents for the immediate benefit of patients. Keywords: Psychopharmacotherapy, adverse drug reactions, pharmacovigilance, therapeutic drug monitoring, quality assurance.
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Affiliation(s)
- Karin Egberts
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefanie Fekete
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V
| | - Alexander Häge
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Christoph Hiemke
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Mainz.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Maike Scherf-Clavel
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Regina Taurines
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefan Unterecker
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Manfred Gerlach
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Marcel Romanos
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
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8
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Metabolic Effects of Clozapine Administration Based on Sex Differences and the Relationships Between Dosage and Prolactin Levels: An Observational Study. Clin Neuropharmacol 2021; 44:205-209. [PMID: 34581701 DOI: 10.1097/wnf.0000000000000482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Clozapine is the second-generation antipsychotic that induces the largest metabolic disorders. However, evidence is limited to the liabilities based on sex differences. This study aimed to investigate the effects of clozapine treatment on metabolic and neuroendocrine parameters, and the relationships between prescribed clozapine dosage and prolactin levels that may be associated with plasma clozapine concentrations, in 24 female and 24 male Japanese schizophrenia inpatients switched to clozapine. METHODS Within female and male subjects, sequential changes in 7 items of metabolic parameters, including anthropometric measurements, fasting serum lipid components and glucose levels, and estimated insulin resistance at 2 months were evaluated and analyzed against clozapine dosages and prolactin levels at 2 months. RESULTS Triglyceride levels, triglyceride to high-density lipoprotein ratios reflecting insulin resistance and glucose levels increased in female and male subjects. High-density lipoprotein cholesterol levels decreased in female and male subjects. High-density lipoprotein cholesterol levels were negatively correlated with prolactin levels in female subjects, and glucose levels were positively correlated with prolactin levels in male subjects, although clozapine doses showed no such correlations. CONCLUSIONS Clozapine administration developed sex-neutral metabolic disorders in the study subjects. Higher prolactin levels seemed to increase the risk of dyslipidemia and hyperglycemia with sex differences, which suggested that serum prolactin levels other than clozapine doses might be useful to predict sex-specific metabolic disorders. Further prospective studies, combining measurement of metabolic hormones and plasma concentrations of clozapine and its metabolites, will help to confirm our findings.
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9
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Kloosterboer SM, Vierhout D, Stojanova J, Egberts KM, Gerlach M, Dieleman GC, Hillegers MHJ, Passe KM, Gelder TV, Dierckx B, Koch BCP. Psychotropic drug concentrations and clinical outcomes in children and adolescents: a systematic review. Expert Opin Drug Saf 2020; 19:873-890. [PMID: 32421365 DOI: 10.1080/14740338.2020.1770224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The use of psychotropic drugs in children and adolescents is widespread but associated with suboptimal treatment effects. Therapeutic drug monitoring (TDM) can improve safety of psychotropic drugs in children and adolescents but is not routinely performed. A major reason is that the relationship between drug concentrations and effects is not well known. AREAS COVERED This systematic review evaluated studies assessing the relationship between psychotropic drug concentrations and clinical outcomes in children and adolescents, including antipsychotics, psychostimulants, alpha-agonists, antidepressants, and mood-stabilizers. PRISMA guidelines were used and a quality assessment of the retrieved studies was performed. Sixty-seven eligible studies involving 24 psychotropic drugs were identified from 9,298 records. The findings were generally heterogeneous and the majority of all retrieved studies were not of sufficient quality. For 11 psychotropic drugs, a relationship between drug concentrations and side-effects and/or effectiveness was evidenced in reasonably reported and executed studies, but these findings were barely replicated. EXPERT OPINION In order to better support routine TDM in child- and adolescent psychiatry, future work must improve in aspects of study design, execution and reporting to demonstrate drug concentration-effect relationships. The quality criteria proposed in this work can guide future TDM research. Systematic review protocol and registration PROSPERO CRD42018084159.
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Affiliation(s)
- Sanne M Kloosterboer
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands.,Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Denise Vierhout
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Jana Stojanova
- Interdisciplinary Center for Health Studies (CIESAL), Universidad de Valparaíso , Valparaíso, Chile
| | - Karin M Egberts
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg , Würzburg, Germany
| | - Manfred Gerlach
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg , Würzburg, Germany
| | - Gwen C Dieleman
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Manon H J Hillegers
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Kimberly M Passe
- Department of Psychiatry, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Bram Dierckx
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus Medical Center , Rotterdam, The Netherlands
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10
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Beauchemin M, Geguchadze R, Guntur AR, Nevola K, Le PT, Barlow D, Rue M, Vary CPH, Lary CW, Motyl KJ, Houseknecht KL. Exploring mechanisms of increased cardiovascular disease risk with antipsychotic medications: Risperidone alters the cardiac proteomic signature in mice. Pharmacol Res 2019; 152:104589. [PMID: 31874253 DOI: 10.1016/j.phrs.2019.104589] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/29/2019] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
Atypical antipsychotic (AA) medications including risperidone (RIS) and olanzapine (OLAN) are FDA approved for the treatment of psychiatric disorders including schizophrenia, bipolar disorder and depression. Clinical side effects of AA medications include obesity, insulin resistance, dyslipidemia, hypertension and increased cardiovascular disease risk. Despite the known pharmacology of these AA medications, the mechanisms contributing to adverse metabolic side-effects are not well understood. To evaluate drug-associated effects on the heart, we assessed changes in the cardiac proteomic signature in mice administered for 4 weeks with clinically relevant exposure of RIS or OLAN. Using proteomic and gene enrichment analysis, we identified differentially expressed (DE) proteins in both RIS- and OLAN-treated mouse hearts (p < 0.05), including proteins comprising mitochondrial respiratory complex I and pathways involved in mitochondrial function and oxidative phosphorylation. A subset of DE proteins identified were further validated by both western blotting and quantitative real-time PCR. Histological evaluation of hearts indicated that AA-associated aberrant cardiac gene expression occurs prior to the onset of gross pathomorphological changes. Additionally, RIS treatment altered cardiac mitochondrial oxygen consumption and whole body energy expenditure. Our study provides insight into the mechanisms underlying increased patient risk for adverse cardiac outcomes with chronic treatment of AA medications.
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Affiliation(s)
- Megan Beauchemin
- College of Osteopathic Medicine, University of New England, Biddeford, ME, United States
| | - Ramaz Geguchadze
- College of Osteopathic Medicine, University of New England, Biddeford, ME, United States
| | - Anyonya R Guntur
- Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough, ME, United States
| | - Kathleen Nevola
- Center for Molecular Medicine, Maine Medical Center Research Institute, Scarborough, ME, United States; Sackler School for Graduate Biomedical Research, Tufts University, Boston, MA, United States; Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, United States
| | - Phuong T Le
- Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough, ME, United States
| | - Deborah Barlow
- College of Osteopathic Medicine, University of New England, Biddeford, ME, United States
| | - Megan Rue
- Center for Molecular Medicine, Maine Medical Center Research Institute, Scarborough, ME, United States
| | - Calvin P H Vary
- Center for Molecular Medicine, Maine Medical Center Research Institute, Scarborough, ME, United States
| | - Christine W Lary
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, United States
| | - Katherine J Motyl
- Center for Molecular Medicine, Maine Medical Center Research Institute, Scarborough, ME, United States
| | - Karen L Houseknecht
- College of Osteopathic Medicine, University of New England, Biddeford, ME, United States.
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11
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Raffin M, Bonnot O, Giannitelli M, Xavier J, Bodeau N, Bibrac B, Leban M, Fautrel B, Menard ML, Consoli A, Cohen D. Hormonal Risk Factors for Osteoporosis: Different Profile Among Antipsychotics. J Child Adolesc Psychopharmacol 2018; 28:719-726. [PMID: 30421978 DOI: 10.1089/cap.2017.0158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives: Osteoporosis is a major risk factor for fracture and treatment is mainly preventive. Patients with severe psychiatric condition and treated with antipsychotics are at risk for vitamin D deficiency and iatrogenic hyperprolactinemia, two serious risk factors of osteoporosis. We aim to determine whether all antipsychotics are similar regarding the risk of osteoporosis in young patients. Methods: From January 2009 to March 2015, we determined the vitamin D blood level (VDBL) among 484 inpatients and from January 2012 to March 2015, we determined the prolactin blood level (PBL) among 205 inpatients. We systematically recorded well-documented risk factors (e.g., age, gender, ethnic origin, body mass index, or season) and suspected risk factors (e.g., disease type or antipsychotic treatment). Results: Up to 89% of the inpatients had a VDBL under the recommended threshold. Up to 60% of the inpatients had hyperprolactinemia. The multivariate model found a significant effect on VDBL for seasonality (higher VDBL in summer), ethnicity (lower VDBL in Black individuals), and treatment exposure. The multivariate model found a significant effect on PBL for gender and treatment exposure. In both models, aripiprazole had a safer profile compared with other antipsychotics. Conclusion: Because adolescence is a period of bone construction and a critical window of opportunity for maximizing bone mass, we recommend vitamin D supplementation in young patients with severe mental condition. It could be interesting to reconsider to regularly monitor PBL among youth patients treated with antipsychotic, with the exception of aripiprazole.
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Affiliation(s)
- Marie Raffin
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | - Olivier Bonnot
- Department of Child and Adolescent Psychiatry, Nantes University Hospital, Nantes, France
| | - Marianna Giannitelli
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | - Jean Xavier
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France.,CNRS UMR 7222, Institut des Systèmes Intelligents et Robotiques, UPMC, Paris, France
| | - Nicolas Bodeau
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France
| | - Barbara Bibrac
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France
| | - Monique Leban
- Pierre Louis Institute for Epidemiology and Public Health, Assistance Publique-Hôpitaux de Paris, UPMC-GRC 08, Paris, France
| | - Bruno Fautrel
- Department of Rheumatology, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France
| | - Marie-Line Menard
- Department of Child and Adolescent Psychiatry, Nice Children's Hospitals CHU-Lenval, Nice, France
| | - Angele Consoli
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | - David Cohen
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France.,CNRS UMR 7222, Institut des Systèmes Intelligents et Robotiques, UPMC, Paris, France
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12
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Gopal S, Lane R, Nuamah I, Copenhaver M, Singh J, Hough D, Bach M, Savitz A. Evaluation of Potentially Prolactin-Related Adverse Events and Sexual Maturation in Adolescents with Schizophrenia Treated with Paliperidone Extended-Release (ER) for 2 Years: A Post Hoc Analysis of an Open-Label Multicenter Study. CNS Drugs 2017; 31:797-808. [PMID: 28660406 DOI: 10.1007/s40263-017-0437-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Elevated prolactin levels (hyperprolactinemia) are a frequent adverse effect of antipsychotic medications, especially in young populations. Prolonged hyperprolactinemia may affect sexual functioning and the onset and progression of puberty. OBJECTIVE This study assessed potentially prolactin-related treatment-emergent adverse events (PPRL-TEAEs) and sexual maturation during long-term treatment of adolescents with paliperidone extended-release (ER). METHODS This post hoc analysis of a 2-year open-label multicenter study (NCT00488319) included patients of either sex aged 12-17 years at study enrollment, diagnosed with schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV]) for ≥1 year, who had received one or more adequate antipsychotic treatment prior to enrollment but had not responded sufficiently. Patients were initially treated with 6 mg/day paliperidone ER and further titrated between 1.5 and 12 mg/day based on clinical response and tolerability. The primary objective was to determine the relationship between characteristics (including sex, age at study entry, ethnicity, geographic region, age at diagnosis, duration of illness, number of prior hospitalizations, serum prolactin, and baseline Tanner stages) and onset or risk of PPRL-TEAEs. The secondary objective was to assess sexual maturation during long-term treatment with paliperidone ER. RESULTS In total, 400 patients were enrolled in the study and 184 patients completed the 2-year study; the majority were boys (61%), White (66%), and aged >14 years at study enrolment (73%) with mean (standard deviation [SD]) body mass index (BMI) of 21.96 (4.375) kg/m2 at baseline. Girls (18.5%) had a higher incidence of PPRL-TEAEs than did boys (3.3%). Most of these events were mild to moderate in severity, and none were serious; four patients discontinued the study due to PPRL-TEAEs. Mean prolactin levels in the total population of boys and girls increased early during treatment then stabilized with time. Mean ± SD maximum changes in prolactin levels from baseline were higher in girls and boys with PPRL-TEAEs than in those without (Girls: 74.7 ± 32.3 ng/ml [n = 28] vs. 50.5 ± 44.9 ng/ml [n = 114]; p = 0.008. Boys: 33.6 ± 23.7 ng/ml [n = 8] vs. 31.0 ± 24.5 ng/ml [n = 205]; p = 0.77). No clinically significant mean changes from baseline in growth-adjusted z-score for weight, height, or BMI were observed. Overall, ~90% of the patients who completed the 2-year study achieved Tanner stages 4-5 by study endpoint. Female sex, age at diagnosis (13-14 years), girls of Hispanic ethnicity, and region (EU and North America) were associated with a greater risk for PPRL-TEAEs; higher baseline Tanner stages for pubic hair (boys and girls) and breast development (stage 3 vs. 4 or 5) also seemed to be associated with a higher incidence of PPRL-TEAEs. CONCLUSIONS Female sex appeared to be associated with an increased risk for PPRL-TEAEs. Other potential predictors, such as ethnicity, region, age at diagnosis, and Tanner stage 4 or 5, all seemed to be related to sex. Evidence from this study was insufficient to definitively conclude that prolactin values at baseline and change during treatment were predictive of PPRL-TEAEs, although there is a signal that this may be the case in girls. These results are exploratory in nature, and confirmatory studies are needed to confirm these observations. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00488319.
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Affiliation(s)
- Srihari Gopal
- Neurosciences, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA.
| | - Rosanne Lane
- Neurosciences, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Isaac Nuamah
- Neurosciences, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Margaret Copenhaver
- Neurosciences, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | | | - David Hough
- Neurosciences, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Mark Bach
- Janssen Pharmaceutical KK, Tokyo, Japan
| | - Adam Savitz
- Neurosciences, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
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13
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Therapeutic Drug Monitoring in Children and Adolescents Under Pharmacotherapy With Olanzapine in Daily Clinical Practice. Ther Drug Monit 2017; 39:273-281. [DOI: 10.1097/ftd.0000000000000398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Savitz A, Lane R, Nuamah I, Singh J, Hough D, Gopal S. Long-Term Safety of Paliperidone Extended Release in Adolescents with Schizophrenia: An Open-Label, Flexible Dose Study. J Child Adolesc Psychopharmacol 2015. [PMID: 26218669 DOI: 10.1089/cap.2014.0130] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the long-term safety and tolerability of paliperidone extended-release (ER) in adolescents with schizophrenia. METHODS This was a 2 year open-label, multicenter study in adolescents (12-17 years of age, inclusive) with schizophrenia. Eligible patients were initially treated with 6 mg/day paliperidone ER, and the dose could be adjusted between 1.5 and 12 mg/day based on clinical need. Safety parameters were treatment-emergent adverse events (TEAEs), weight, Tanner staging, blood chemistry (including prolactin, glucose, insulin, and lipid levels), and extrapyramidal symptom (EPS) scales. The main efficacy end-point was change from baseline to endpoint in Positive and Negative Syndrome Scale for Schizophrenia (PANSS) total score. RESULTS Of 400 enrolled patients (mean age, 15.4 years; boys, 61%), 220 were completers. Median (range) exposure was 604.5 (2-765) days. TEAEs were reported in 85.3% of patients; most frequently reported TEAEs included somnolence, increased weight, headache, insomnia, nasopharyngitis, akathisia, schizophrenia exacerbation, and tremor. No deaths were reported. There were no clinically significant mean changes in growth-adjusted z score for change in weight, height, or body mass index (BMI). Tanner ratings showed normal maturation. Most frequently occurring EPS-related events were related to Parkinsonism (15.5%) and hyperkinesia (13.8%). No cases of tardive dyskinesia were reported. Hyperprolactinemia (based on laboratory values) was noted in 56% of patients and 9.3% of patients had prolactin-related TEAEs. A low percentage of patients (4.3%, n=14) had a shift from normal or impaired fasting glucose to high levels. Mean (SD) decrease (improvement) in PANSS total score from baseline to end-point was -19.1 (21.89). The majority of patients had a ≥20% improvement in PANSS total score (responders) from initial treatment with paliperidone ER. Overall, 41.7% of patients achieved remission during the study. CONCLUSIONS Paliperidone ER was generally tolerable, and exhibited efficacy in the maintenance treatment of schizophrenia in adolescents in this large 2 year study.
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Affiliation(s)
- Adam Savitz
- Janssen Research & Development, LLC , Titusville, New Jersey
| | - Rosanne Lane
- Janssen Research & Development, LLC , Titusville, New Jersey
| | - Isaac Nuamah
- Janssen Research & Development, LLC , Titusville, New Jersey
| | - Jaskaran Singh
- Janssen Research & Development, LLC , Titusville, New Jersey
| | - David Hough
- Janssen Research & Development, LLC , Titusville, New Jersey
| | - Srihari Gopal
- Janssen Research & Development, LLC , Titusville, New Jersey
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15
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Park EJ, Park YM. The short-term effects of risperidone-induced hyperprolactinemia on lipid metabolism in drug-naïve children and adolescents. Psychiatry Investig 2015; 12:55-60. [PMID: 25670946 PMCID: PMC4310921 DOI: 10.4306/pi.2015.12.1.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 10/27/2013] [Accepted: 10/28/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The present cross-sectional study was designed to assess the risk of elevated prolactin levels and other hormonal or metabolic changes in children and adolescents taking risperidone. METHODS Twenty-five children and adolescents [aged 7-18 years, 12.1±3.3 years (mean±SD); 19 boys and 6 girls] who had been taking risperidone for at least 3 months were enrolled. The following blood parameters were measured: serum levels of prolactin, thyroid hormones, alanine transaminase (ALT), sex hormones, lipids. RESULTS The median risperidone dosage was 1.55 mg/day (SD 1.14 mg/day, range 0.25-4.00 mg/day). The prolactin level (33.65±16.71 ng/mL, range 5.8-68.3 ng/mL) was higher than normal, and was elevated (≥15 ng/mL in male, ≥23.3 ng/mL in female) in about 84% of the patients. The dosage of risperidone was positively correlated with serum prolactin level (r=0.767, p<0.001). The TG/HDL ratio was higher in the group with higher prolactin levels (i.e., ≥30 ng/mL), and hence might be a useful marker of insulin resistance. CONCLUSION In young patients taking risperidone, a high serum prolactin level may influence lipid metabolism, even when cholesterol levels are within the normal range. Further investigation is needed around this issue. Serum prolactin assessment is recommended for children and adolescents taking risperidone.
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Affiliation(s)
- Eun Jin Park
- Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Young-Min Park
- Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
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Raffin M, Gianitelli M, Consoli A, Bonnot O, Menard ML, Askenazy F, Laurent C, Cohen D. Management of Adverse Effects of Second-generation Antipsychotics in Youth. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s40501-013-0007-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Kent JM, Hough D, Singh J, Karcher K, Pandina G. An open-label extension study of the safety and efficacy of risperidone in children and adolescents with autistic disorder. J Child Adolesc Psychopharmacol 2013; 23:676-86. [PMID: 24350813 PMCID: PMC3870601 DOI: 10.1089/cap.2012.0058] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the long-term safety and efficacy of risperidone in treating irritability and related behaviors in children and adolescents with autistic disorders. METHODS In this 6 month (26 week) open-label extension (OLE) study, patients (5-17 years of age, who completed the previous fixed-dose, 6 week, double-blind [DB] phase) were flexibly dosed with risperidone based on body weight. The maximum allowed dose was 1.25 mg/day for those weighing 20 to <45 kg, and 1.75 mg/day for those weighing ≥ 45 kg. The study primarily assessed risperidone's safety; efficacy was assessed as a secondary end-point. RESULTS Fifty-six (71%) out of 79 enrolled patients completed the OLE; the most common discontinuations were for insufficient response (7 [9%]) or adverse events (AE) (5 [6%]). The most common (≥ 5% frequency in the total group) AEs were increased appetite (11% [n=9]); increased weight and vomiting (9% [n=7] each); sedation, pyrexia, and upper respiratory tract infection (8% [n=6] each); nasopharyngitis (6% [n=5]); and somnolence and fatigue (5% [n=4] each). Extrapyramidal AEs were reported in 6 (8%) patients. Increase in mean weight (11-15%) and body mass index (5-10%) occurred; one patient discontinued because of weight increase. One potentially prolactin-related AE (irregular menstruation) was reported. The risperidone high-dose group had the greatest mean improvement in sleep visual analog scale (24.6). All groups showed additional improvement in efficacy scale scores during the OLE. CONCLUSIONS During this OLE, safety findings with risperidone treatment (maximum weight-based dose of 1.25 mg/day or 1.75 mg/day) were consistent with those observed in the DB phase, and with the current safety information for risperidone in autistic, psychiatric, and behavioral disorders. Patients experienced some additional improvement in irritability and related behaviors. CLINICAL TRIALS REGISTRY This phase-4 study is registered at ClinicalTrials.gov (NCT00576732).
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Affiliation(s)
| | - David Hough
- Janssen Research & Development, LLC, Titusville, New Jersey
| | - Jaskaran Singh
- Janssen Research & Development, LLC, Titusville, New Jersey
| | - Keith Karcher
- Janssen Research & Development, LLC, Titusville, New Jersey
| | - Gahan Pandina
- Janssen Research & Development, LLC, Titusville, New Jersey
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18
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Schneider C, Corrigall R, Hayes D, Kyriakopoulos M, Frangou S. Systematic review of the efficacy and tolerability of clozapine in the treatment of youth with early onset schizophrenia. Eur Psychiatry 2013; 29:1-10. [PMID: 24119631 DOI: 10.1016/j.eurpsy.2013.08.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/20/2013] [Accepted: 08/11/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The use of clozapine (CLZ) for treatment-resistant schizophrenia is well established in adults. However, it is seldom used in youth with early onset schizophrenia (EOS) largely because of lack of clarity about its risk benefit ratio. This review synthesises and evaluates available evidence regarding the efficacy and tolerability of CLZ in EOS with the aim to assist clinical decision-making. METHODS We conducted a systematic review of the primary literature on the clinical efficacy and adverse drug reactions (ADRs) observed during CLZ treatment in EOS. We also identified relevant practice guidelines and summarised current guidance. RESULTS CLZ showed superior efficacy than other antipsychotics in treating refractory EOS patients; short-term clinical trials suggest an average improvement of 69% on the Brief Psychiatric Rating Scale that was sustained during long-term follow-up (up to 9 years). No fatalities linked to CLZ treatment were reported. Sedation and hypersalivation were the most common complaints, reported by over 90% of patients. Other common ADRs (reported in 10-60% of patients) were enuresis, constipation, weight gain, and non-specific EEG changes. Less common ADRs (reported in 10-30% of patients) were akathisia, tachycardia and changes in blood pressure. Neutropenia was reported in 6-15% of cases but was usually transient while agranulocytosis was rare (<0.1%). Seizures were also uncommon (<3%). Metabolic changes were relatively common (8-22%) but emergent diabetes was not frequently observed (<6%). Overall the rate of discontinuation was low (3-6%). Current guidelines recommend the use of CLZ in EOS patients who have failed to respond to two adequate trials with different antipsychotics and provide detailed schedules of assessments to evaluate and assess potential ADRs both prior to initiation and throughout CLZ treatment. CONCLUSION Available data although limited in terms of number of studies are consistent in demonstrating that CLZ is effective and generally safe in the treatment of refractory EOS provided patients are regularly monitored.
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Affiliation(s)
- C Schneider
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London, UK
| | - R Corrigall
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London, UK
| | - D Hayes
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London, UK
| | - M Kyriakopoulos
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London, UK
| | - S Frangou
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, Box 1230, 1425, Madison Avenue, New York, NY 10029, USA.
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Maranghi F, Tassinari R, Mantovani A. Toxicological assessment of drugs that affect the endocrine system in puberty-related disorders. Expert Opin Drug Metab Toxicol 2013; 9:1309-16. [PMID: 23790205 DOI: 10.1517/17425255.2013.811488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Toxicologists must ensure that clinical risk-to-benefit analysis should be made both for genders and age groups, with any treatment. Puberty concerns physiological changes leading to organism's maturation. Pubertal growth disorders are increasing in last decades: besides causing physical and psychological distress, they may signal underlying endocrine-metabolic abnormalities with serious health consequences later on. Therapeutic approaches for some health conditions in childhood and adolescence are considered. AREAS COVERED The authors discuss how some diseases and treatments can impact pubertal growth. The authors look at particular immunological disorders such as asthma and how both the disease and treatment affects pubertal growth. They also discuss how the provision of available data can help to assess the dose-response of the drug, in these cases, and minimize the chance of side effects. The authors also discuss pediatric inflammatory bowel disease and how both the disease and treatment can mitigate the growth delay. Last, but not least, the authors discuss how the effects of the drugs used in the treatment of psychiatric disorders may accentuate endocrine issues in juvenile patients. Hyperprolactinemia induction by some antipsychotics is highlighted as an example. EXPERT OPINION Appropriate risk-benefit analysis of drugs prescribed during childhood and adolescence and intended to be used in the long term is required. Furthermore, future treatment strategies and safer compounds development should be supported by the knowledge of mechanisms underlying adverse side effects in pubertal growth and development.
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Affiliation(s)
- Francesca Maranghi
- Food and Veterinary Toxicology Unit, Department of Veterinary Public Health and Food Safety, Istituto Superiore di Sanità , Viale Regina Elena, 299, 00161 Rome , Italy +39 06 49902527 ; +39 06 4990 2363 ;
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Abstract
Pediatric behavioral and affective disorders often require antipsychotic therapy, in combination with psychotherapeutic interventions, for their treatment and stabilization. Although pharmacotherapy can include either typical or atypical antipsychotics, the latter are generally preferred because of their apparently lower risk of adverse effects. Recent controlled trials have demonstrated the efficacy of some of these agents (including aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone) in adolescent schizophrenia and children or adolescent bipolar mania, or to treat severe aggression and self-injury in the context of autism in children and adolescents. Although few studies have systematically monitored their short- and, more importantly, long-term safety, current evidence indicates that sedation, hyperprolactinemia, and metabolic abnormalities such as excess weight gain, diabetes, and related cardiovascular effects were clinically relevant adverse effects in young patients, with the individual agents differing in their propensity to induce these effects. When prescribing antipsychotics for children and adolescents, physicians should therefore be aware of the specific adverse effect profiles and patients should be closely monitored for the short- and long-term development of adverse events. In pediatric patients, the starting dose, titration plan, and maintenance dose of antipsychotics must be based on their pharmacokinetics and metabolism, as in adults. Because there are significant individual differences in drug and active metabolite(s) pharmacokinetics and metabolism, which may be further affected by a number of confounding factors (including demographic variables, phenotype and drug interactions), therapeutic drug monitoring may be a valid tool for individualizing dosage, but its interpretation should also take account of changes in pharmacodynamic sensitivity with the development during childhood and adolescence.
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Affiliation(s)
- Silvio Caccia
- Istituto di Ricerche Farmacologiche IRCCS-Mario Negri, via Giuseppe La Masa 19, 20156 Milan, Italy.
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Safer DJ, Calarge CA, Safer AM. Prolactin serum concentrations during aripiprazole treatment in youth. J Child Adolesc Psychopharmacol 2013; 23:282-9. [PMID: 23647135 PMCID: PMC3657283 DOI: 10.1089/cap.2012.0062] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE This study aimed to: document the extent of the reduction of serum prolactin (PRL) levels induced by aripiprazole (ARI) treatment in children and adolescents, compare this effect by age group, and shed light on this phenomenon. METHODS PRL serum levels in unmedicated subjects were compared to those in subjects treated with aripiprazole to calculate the rate of subnormal PRL levels during aripiprazole treatment. Next, a literature search was performed to better understand the effects of dopaminergic drugs on PRL levels by age group. RESULTS Sixty percent of those treated with aripiprazole exhibited subnormal PRL serum levels versus 8% of unmedicated subjects. The rate of PRL subnormality in response to aripiprazole was half as frequent in adolescents and was minimal in adults. The drug-induced reduction of PRL serum levels became more prominent with increasing doses of aripiprazole and with an increased treatment duration. CONCLUSIONS With the increasing use of aripiprazole in the United States population, it is important that future research be conducted to explore the potential sequelae of subnormal PRL serum levels in children and adolescents.
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Affiliation(s)
- Daniel J Safer
- Departments of Psychiatry and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Couchman L, Bowskill SVJ, Handley S, Patel MX, Flanagan RJ. Plasma clozapine and norclozapine in relation to prescribed dose and other factors in patients aged <18 years: data from a therapeutic drug monitoring service, 1994-2010. Early Interv Psychiatry 2013; 7:122-30. [PMID: 22747759 DOI: 10.1111/j.1751-7893.2012.00374.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 04/07/2012] [Indexed: 11/26/2022]
Abstract
AIM Clozapine is used in children and adolescents to treat early onset schizophrenia, but data on efficacy and on the plasma clozapine concentrations attained are limited. METHODS We studied data from a clozapine therapeutic drug monitoring (TDM) service, patients in the UK and Eire aged <18 years, 1994-2010. Multiple linear regression analysis was performed to investigate the relationship between plasma clozapine concentration and dose, age, sex, body weight, plasma clozapine:norclozapine ratio (clozapine metabolic ratio (MR)) and smoking habit. RESULTS There were 1408 samples from 454 patients, 267 (59%) males aged at time of first sample (median = 17; range = 8-17 years) and 187 (41%) females aged 16 (10-17) years. The plasma clozapine concentration was <0.35 mg L(-1) in 36%, and ≥0.60 mg L(-1) in 31% of samples (6.4% samples ≥1.0 mg L(-1) ). Although plasma clozapine was broadly related to prescribed dose, there was much variation: 10% of samples had plasma clozapine >0.60 mg L(-1) at prescribed clozapine doses of 50-150 mg d(-1) (66% <0.35 mg L(-1) ), while 12% of samples had plasma clozapine <0.35 mg L(-1) at doses ≥650 mg d(-1) (62% >0.6 mg L(-1) ). The covariates studied in the 16-17-year-olds had proportionately similar influences to those observed in adults. Together they explained 48% of the variance observed in plasma clozapine, with dose, smoking habit, MR and sex being major influences. In the younger patients, there were very few smokers, and the influence of sex did not reach statistical significance. CONCLUSIONS As in adults, clozapine TDM may help in assessing adherence and in dose adjustment, for example if smoking habit changes.
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Affiliation(s)
- Lewis Couchman
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust
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Talib HJ, Alderman EM. Gynecologic and reproductive health concerns of adolescents using selected psychotropic medications. J Pediatr Adolesc Gynecol 2013; 26:7-15. [PMID: 22929762 DOI: 10.1016/j.jpag.2012.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 05/16/2012] [Accepted: 05/17/2012] [Indexed: 11/28/2022]
Abstract
Psychiatric disorders are common in adolescent girls and may require chronic therapies with psychotropic medications. Antipsychotic medications and mood stabilizers have been increasingly prescribed to and widely used by adolescents for a variety of both "on" an "off" label indications. Studies on the safety and monitoring of these medications in adolescent girls have shown important potential for gynecologic and reproductive adverse effects. The objective of this article is to review the mechanisms for and management of menstrual disorders mediated by hyperprolactinemia associated with antipsychotic medications, hypothyroidism associated with lithium and quetiapine, and the independent association of polycystic ovary syndrome (PCOS) in girls using valproic acid. Beyond their susceptibility to these disruptions in the menstrual cycle, adolescent girls with psychiatric illness also have increased sexual risk behaviors. These behaviors makes it all the more important to review teratogenicity and clinically relevant contraceptive drug interactions in adolescent girls using these psychotropic medications.
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Affiliation(s)
- Hina J Talib
- Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY 10467, USA.
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Abdel-Baki A, Ouellet-Plamondon C, Malla A. Pharmacotherapy challenges in patients with first-episode psychosis. J Affect Disord 2012; 138 Suppl:S3-14. [PMID: 22405590 DOI: 10.1016/j.jad.2012.02.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The first episode of a psychotic disorder typically occurs in late adolescence or young adulthood, a critical time of development with respect to personality, social role, education, and vocation. The first few years of psychosis appear to be a critical period during which intervention needs to be initiated before the consequences of psychosis become more severe. Early intervention is therefore crucial in maximizing outcomes. Although response rates to antipsychotic medication in first-episode psychosis (FEP) are good, there is a relatively high risk of relapse. The greatest challenges that physicians face in treating FEP and preventing relapse are engaging patients in treatment and preventing non-adherence to therapy. Overall rates of non-adherence to antipsychotic medications for FEP patients are estimated to be at or higher than 50% within the first year of treatment, suggesting that malleable factors linked to non-adherence need to be targeted in interventions provided. Factors influencing adherence can be categorized into four groups: (1) environment-related, (2) patient-related, (3) medication-related, and (4) illness-related. This paper will review the factors associated with adherence and discuss solutions to optimize engagement, adherence to medication, and treatment in order to prevent relapse. Factors like social and family support, therapeutic alliance, attitudes and beliefs toward illness and medication, insight, substance use disorders, medication efficacy, tolerability, and accessibility will be discussed. Solutions, such as early psychosis specialized services integrating psychosocial therapies and careful selection of appropriate antipsychotic medication, will be proposed.
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Affiliation(s)
- Amal Abdel-Baki
- Department of Psychiatry, Université de Montréal, Clinique JAP, Centre hospitalier de l' Université de Montréal (CHUM), Montreal, QC, Canada.
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Merchán-Naranjo J, Tapia C, Bailón C, Moreno C, Baeza I, Calvo-Escalona R, Morer A, Martínez-Cantarero C, Nestares PA, Alda JÁ, Muñoz D, Arango C. Efectos secundarios del tratamiento antipsicótico en niños y adolescentes naïve o quasi-naïve: diseño de un protocolo de seguimiento y resultados basales. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2012; 5:217-28. [DOI: 10.1016/j.rpsm.2012.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 03/16/2012] [Accepted: 03/26/2012] [Indexed: 01/16/2023]
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Merchán-Naranjo J, Tapia C, Bailón C, Moreno C, Baeza I, Calvo-Escalona R, Morer A, Martínez-Cantarero C, Nestares PA, Alda JÁ, Muñoz D, Arango C. Secondary effects of antipsychotic treatment in naïve or quasi-naïve children and adolescents: Design of a follow-up protocol and baseline results. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.rpsmen.2011.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ho J, Panagiotopoulos C, McCrindle B, Grisaru S, Pringsheim T. Les recommandations de prise en charge des complications métaboliques associées aux antipsychotiques de deuxième génération chez les enfants et les adolescents. Paediatr Child Health 2012. [DOI: 10.1093/pch/17.suppl_b.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Josephine Ho
- Département de pédiatrie, université de Calgary, Calgary (Alberta)
| | | | - Brian McCrindle
- département de pédiatrie, université de Toronto, Toronto (Ontario)
| | - Silviu Grisaru
- Département de pédiatrie, université de Calgary, Calgary (Alberta)
| | - Tamara Pringsheim
- département de neurosciences cliniques et de pédiatrie, université de Calgary (Alberta)
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Cookson J, Hodgson R, Wildgust HJ. Prolactin, hyperprolactinaemia and antipsychotic treatment: a review and lessons for treatment of early psychosis. J Psychopharmacol 2012; 26:42-51. [PMID: 22472310 DOI: 10.1177/0269881112442016] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hyperprolactinaemia is a common side effect of antipsychotics; markedly raised levels are less common. Higher levels of prolactin result from longer exposure to higher doses, especially with older antipsychotics or with risperidone, sulpiride or amisulpride. Galactorrhoea, gynaecomastia, menstrual abnormalities and sexual dysfunction including hypogonadism and fertility problems are consequences of raised prolactin, and in the longer-term bone demineralisation. Younger patients may be more susceptible to hyperprolactinaemia. Trial reports often fail to state the frequency of raised levels.
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Fraguas D, Correll CU, Merchán-Naranjo J, Rapado-Castro M, Parellada M, Moreno C, Arango C. Efficacy and safety of second-generation antipsychotics in children and adolescents with psychotic and bipolar spectrum disorders: comprehensive review of prospective head-to-head and placebo-controlled comparisons. Eur Neuropsychopharmacol 2011; 21:621-45. [PMID: 20702068 DOI: 10.1016/j.euroneuro.2010.07.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 06/28/2010] [Accepted: 07/12/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review data on efficacy and safety of second-generation antipsychotics (SGAs) in children and adolescents with psychotic and bipolar spectrum disorders. METHODS Medline/PubMed/Google Scholar search for studies comparing efficacy and/or tolerability: (i) between two or more SGAs; (ii) between SGAs and placebo; and (iii) between at least one SGA and one first-generation antipsychotic (FGA). The review focused on three major side-effect clusters: 1. body weight, body mass index, and cardiometabolic parameters, 2. prolactin levels, and 3. neuromotor side effects. RESULTS In total, 34 studies with 2719 children and adolescents were included. Studies lasted between 3 weeks and 12 months, with most studies (79.4%) lasting 3 months or less. Nine studies (n=788) were conducted in patients with schizophrenia, 6 (n=719) in subjects with bipolar disorder, and 19 (n=1212) in a mixed population. Data on efficacy showed that, except for clozapine being superior for refractory schizophrenia, there were no significant differences between SGAs. By contrast, safety assessments showed relevant differences between SGAs. Mean weight gain ranged from 3.8 kg to 16.2 kg in patients treated with olanzapine (n=353), from 0.9 kg to 9.5 kg in subjects receiving clozapine (n=97), from 1.9 kg to 7.2 kg in those on risperidone (n=571), from 2.3 kg to 6.1 kg among patients taking quetiapine (n=133), and from 0 kg to 4.4 kg in those treated with aripiprazole (n=451). Prolactin levels increased the most in subjects on risperidone (mean change ranging from 8.3 ng/mL to 49.6 ng/mL), followed by olanzapine (-1.5 ng/mL to +13.7 ng/mL). Treatment with aripiprazole was associated with decreased prolactin levels, while clozapine and quetiapine were found to be mostly neutral. With respect to neuromotor side effects, SGAs were associated with less parkinsonism and akathisia than FGAs. Most of the studies comparing neuromotor side effects between SGAs found no significant differences. CONCLUSIONS SGAs do not behave as a homogeneous group in children and adolescents with psychotic and mood disorders. Except for clozapine, the heterogeneity within the SGA group is mainly due to differences in the rates and severity of adverse events, especially regarding weight gain as a proxy for the risk of cardiometabolic disturbances.
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Affiliation(s)
- David Fraguas
- Servicio de Salud Mental, Complejo Hospitalario Universitario de Albacete, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Albacete, Spain
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Strike MK, Norris S, Kearney S, Norris ML. More than just milk: a review of prolactin's impact on the treatment of anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2011; 20:e85-90. [PMID: 21774041 DOI: 10.1002/erv.1119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE In completing this review, we aim to educate readers about the physiological importance of the hormone prolactin (PRL) in the treatment of patients with anorexia nervosa (AN). METHOD A comprehensive review of PRL was undertaken using existing published literature with specific focus on domains pertinent to the treatment of AN. RESULTS Prolactin influences multiple biological processes throughout the body. Disruption in its regulation can impact women's health issues such as menstruation and bone health, which are pertinent to AN treatment. The use of antipsychotics with high D2 receptor affinity for the augmented treatment of AN increases the potential risk of PRL-mediated adverse effects. DISCUSSION Although not intrinsic to underlying disease underpinnings, PRL has the capacity to affect and influence multiple outcome variables in treatment of patients with AN. Improved understanding, better screening and the completion of further prospective research are necessary to help facilitate and incorporate ongoing knowledge translation.
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Houston J, Dharia S, Bishop JR, Ellingrod VL, Fijal B, Jacobson JG, Hoffmann VP. Association of DRD2 and ANKK1 polymorphisms with prolactin increase in olanzapine-treated women. Psychiatry Res 2011; 187:74-9. [PMID: 21095016 DOI: 10.1016/j.psychres.2010.10.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 10/18/2010] [Accepted: 10/24/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED Dopamine D2 receptors, encoded by DRD2, play a role in regulating serum prolactin concentration. Single nucleotide polymorphisms (SNPs), rs2734842(C), rs6275(T), and rs6279(C) located within DRD2, have been shown to be associated with prolactin increase in olanzapine/fluoxetine combination (OFC)-treated women. The present analyses seek to replicate these results and test other SNPs in DRD2 and neighboring gene ANKK1 for associations with prolactin increase in women, using data from 3 pooled studies of olanzapine, and 2 previously examined studies OFC. An ANCOVA was used to test whether change from baseline in the natural log of prolactin concentration (ln[prolactin]) was associated with SNPs in the pooled olanzapine studies. A meta-analysis was also performed using the inverse chi-square method, pooling p-values from the 2 previously examined studies and the 3 olanzapine studies. Negative strand alleles rs2734842(C), rs6275(T), and rs6279(C) were significantly associated with increased prolactin in olanzapine-treated women, replicating previous results. These SNPs also showed moderate association with increased prolactin in olanzapine-treated and OFC-treated women in the meta-analysis, as did rs4938016, rs2734848, rs2734841, rs1124493, and rs1076562. Five of these SNPs fall in or are adjacent to an LD block spanning DRD2 intron 7, exon 7, 5' untranslated region and ANKK1. CLINICAL TRIAL REGISTRATION www.clinicaltrial.gov.
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Caccia S, Clavenna A, Bonati M. Antipsychotic drug toxicology in children. Expert Opin Drug Metab Toxicol 2011; 7:591-608. [DOI: 10.1517/17425255.2011.562198] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Maloney AE, Sikich L. Olanzapine approved for the acute treatment of schizophrenia or manic/mixed episodes associated with bipolar I disorder in adolescent patients. Neuropsychiatr Dis Treat 2010; 6:749-66. [PMID: 21127693 PMCID: PMC2987508 DOI: 10.2147/ndt.s6614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Severe and persistent mental illnesses in children and adolescents, such as early- onset schizophrenia spectrum (EOSS) disorders and pediatric bipolar disorder (pedBP), are increasingly recognized. Few treatments have demonstrated efficacy in rigorous clinical trials. Enduring response to current medications appears limited. Recently, olanzapine was approved for the treatment of adolescents with schizophrenia or acute manic/mixed episodes in pedBP. METHODS PubMed searches were conducted for olanzapine combined with pharmacology, schizophrenia, or bipolar disorder. Searches related to schizophrenia and bipolar disorder were limited to children and adolescents. The bibliographies of the retrieved articles were hand-checked for additional relevant studies. The epidemiology, phenomenology, and treatment of EOSS and pedBP, and olanzapine's pharmacology are reviewed. Studies of olanzapine treatment in youth with EOSS and pedBP are examined. RESULTS Olanzapine is efficacious for EOSS and pedBP. However, olanzapine is not more efficacious than risperidone, molindone, or haloperidol in EOSS and is less efficacious than clozapine in treatment-resistant EOSS. No comparative trials have been done in pedBP. Olanzapine is associated with weight gain, dyslipidemia, and transaminase elevations in youth. Extrapyramidal symptoms, neuroleptic malignant syndrome, and blood dyscrasias have also been reported but appear rare. CONCLUSIONS The authors conclude that olanzapine should be considered a second-line agent in EOSS and pedBP due to its risks for significant weight gain and lipid dysregulation. Awareness of the consistent weight and metabolic changes observed in olanzapine-treated youth focused attention on the potential long-term risks of atypical antipsychotics in youth.
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Affiliation(s)
- Ann E Maloney
- Maine Medical Center Research Institute, Scarborough, ME, USA
- Department of Psychiatry, Tufts University School of Medicine, Boston, MA, USA
| | - Linmarie Sikich
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Fraguas D, Merchán-Naranjo J, Arango C. Características diferenciales de eficacia y tolerabilidad de los antipsicóticos de segunda generación en el tratamiento de trastornos psicóticos en niños y adolescentes. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2010; 3:152-67. [DOI: 10.1016/j.rpsm.2010.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 07/20/2010] [Accepted: 08/27/2010] [Indexed: 11/29/2022]
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Migliardi G, Spina E, D'Arrigo C, Gagliano A, Germanò E, Siracusano R, Diaz FJ, de Leon J. Short- and long-term effects on prolactin of risperidone and olanzapine treatments in children and adolescents. Prog Neuropsychopharmacol Biol Psychiatry 2009; 33:1496-501. [PMID: 19706318 DOI: 10.1016/j.pnpbp.2009.08.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 08/18/2009] [Accepted: 08/19/2009] [Indexed: 11/15/2022]
Abstract
This study investigated prolactin levels in two groups of children and adolescents receiving risperidone (N=29) or olanzapine (N=13). It focused not only on significant differences but also on effect sizes; took into account dose effects and gender differences; used a longitudinal design (months 1, 3, 6 and 12) that helped control for individual differences; and took into account response differences due to the duration of antipsychotic treatment. Additionally, this study investigated tolerance development using statistical tests, and explored the effect of antipsychotic plasma concentrations at months 1 and 3. After adjusting for gender, treatment duration and individual effects, mean prolactin levels on risperidone were 4.9 ng/mL higher than on olanzapine (10.3 times higher after controlling for dosing potency). On risperidone treatment, the adjusted mean prolactin level at the 3rd month of treatment was significantly higher than at the 1st month; at the 12th month it was significantly lower than at the 1st month; the 1st and 6th months were not significantly different. On olanzapine treatment, adjusted mean prolactin levels at the 3rd and 6th months of treatment were significantly higher than at the 1st month; at the 12th month it was lower than at the 1st month, but the difference was not significant. In males, at the 3rd month, an increase of 1 ng/mL in plasma 9-hydroxyrisperidone concentrations raised prolactin levels significantly by 0.44 ng/mL. In females, independently of duration (1 or 3 months), an increase of 1 ng/mL in plasma olanzapine concentrations raised prolactin levels significantly by 2.1 ng/mL. After adjusting for dose and the greater potency of risperidone, the increase in prolactin levels during risperidone treatment appeared to be 10.3 times higher than that during olanzapine treatment. Our study showed a pattern consistent with the development of prolactin tolerance over time. Future prolactin studies in children and adolescents taking antipsychotics need to include larger samples with more frequent prolactin measures and long-term plasma concentrations.
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Affiliation(s)
- Gaetana Migliardi
- Section of Pharmacology, Department of Clinical and Experimental Medicine and Pharmacology, University of Messina, Messina, Italy
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Roke Y, van Harten PN, Boot AM, Buitelaar JK. Antipsychotic medication in children and adolescents: a descriptive review of the effects on prolactin level and associated side effects. J Child Adolesc Psychopharmacol 2009; 19:403-14. [PMID: 19702492 DOI: 10.1089/cap.2008.0120] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This review reports the incidence of hyperprolactinemia, its relationship with genotype, and prolactin-related side effects in children and adolescents treated with antipsychotics. METHOD Data on prolactin levels were available for haloperidol, pimozide, risperidone, olanzapine, clozapine, ziprasidone, and quetiapine. Twenty-nine studies were selected after a literature search in the English Medline/Embase/Psychinfo/EBM databases (1965 to August, 2008). RESULTS All antipsychotics, except clozapine, ziprasidone, and quetiapine, increase the mean prolactin level from baseline values of 8.0 ng/mL to 25-28 ng/mL after 4 weeks of treatment (reference range 0-15 ng/mL). The most and best data are available for risperidone. Five risperidone studies (n = 577) show an increase of prolactin level from 7.8 ng/mL to 17.7 ng/mL after 1 year of treatment, and two risperidone studies (n = 60) show an increase from 7.4 ng/mL to 24.9 ng/mL after 2 years of treatment. Aggregated over all antipsychotics, prolactin-related side effects, such as gynecomastia, galactorrhea, irregular menses, and sexual dysfunction, were reported by 4.8% of the children and adolescents. No data are available on bone mineral density in relation to antipsychotic-induced hyperprolactinemia in children and adolescents. Prolactin levels may be influenced by the genetic differences that influence prolactin metabolism and D2 dopamine receptor density. CONCLUSION Persistent elevation of prolactin for periods up to 2 years has been documented in maintenance treatment with risperidone. Very limited long-term data of pimozide, olanzapine, and quetiapine prohibit drawing conclusions for these antipsychotics. Systematic long-term observational studies, including specific questionnaires as well as physical examination, are needed to investigate prolactin-related side effects of antipsychotic treatment in children and adolescents.
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Affiliation(s)
- Yvette Roke
- Symfora Group Psychiatric Center , Amersfoort, The Netherlands.
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Haas M, Eerdekens M, Kushner S, Singer J, Augustyns I, Quiroz J, Pandina G, Kusumakar V. Efficacy, safety and tolerability of two dosing regimens in adolescent schizophrenia: double-blind study. Br J Psychiatry 2009; 194:158-64. [PMID: 19182179 DOI: 10.1192/bjp.bp.107.046177] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Effective treatments for adolescent schizophrenia are needed. AIMS To compare efficacy and safety of two dosing regimens of risperidone. METHOD Double-blind, 8-week study. Patients, 13-17 years, with an acute episode of schizophrenia, randomised 1:1 to risperidone 1.5-6.0 mg/day (regimen A; n=125) or 0.15-0.6 mg/day (regimen B; n=132). TRIAL REGISTRATION NUMBER NCT00034749. RESULTS Mean total Positive and Negative Syndrome Scale (PANSS) score improved significantly (P<0.001; effect size=0.49) from baseline to end-point for regimen A (mean=96.4 (s.d.=15.39) to mean=72.8 (s.d.=22.52)) compared with regimen B (mean=93.3 (s.d.=14.14) to mean=80.8 (s.d.=24.33)). Treatment-emergent adverse events occurred in 74% (regimen A) and 65% (regimen B) of patients; 4% of patients overall discontinued for adverse events. Mean change in body weight was 3.2 kg (s.d.=3.49) for regimen A and 1.7 kg (s.d.=3.29) for regimen B. CONCLUSIONS Adolescent patients in the regimen A group showed greater improvement in total PANSS compared with the regimen B group. Treatment was well tolerated.
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Affiliation(s)
- Magali Haas
- Johnson & Johnson Pharmaceutical Research & Development, Division of Janssen Pharmaceutica NV, Beerse, Belgium.
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Olanzapine versus placebo in adolescents with schizophrenia: a 6-week, randomized, double-blind, placebo-controlled trial. J Am Acad Child Adolesc Psychiatry 2009; 48:60-70. [PMID: 19057413 DOI: 10.1097/chi.0b013e3181900404] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess olanzapine's efficacy and tolerability in adolescents with schizophrenia. METHOD One hundred seven inpatient and outpatient adolescents (olanzapine, n = 72, mean age 16.1 years; placebo, n = 35, mean age 16.3 years) with schizophrenia participated in this randomized (2:1), international, multisite, industry-sponsored trial. All patients met DSM-IV-TR criteria for schizophrenia, and they were treated for up to 6 weeks with flexible doses of olanzapine (2.5-20.0 mg/day) or placebo. Last-observation-carried-forward mean changes from baseline to endpoint on the anchored version of the Brief Psychiatric Rating Scale for Children, Clinical Global Impression Scale-Severity of Illness, and Positive and Negative Syndrome Scale (PANSS) were assessed. RESULTS More olanzapine-treated versus placebo-treated patients completed the trial (68.1% versus 42.9%, p =.020). Compared with placebo-treated patients, olanzapine-treated adolescents had significantly greater improvement in Brief Psychiatric Rating Scale for Children total (p =.003), Clinical Global Impressions Scale-Severity of Illness (p =.004), PANSS total (p =.005), and PANSS positive scores (p =.002). Olanzapine-treated patients gained significantly more baseline-to-endpoint weight (4.3 kg versus 0.1 kg, p <.001). Significantly more olanzapine-treated versus placebo-treated patients gained 7% or greater of their body weight at any time during treatment (45.8% versus 14.7%, p =.002). Prolactin and triglyceride mean baseline-to-endpoint changes were significantly higher in olanzapine-treated versus placebo-treated adolescents. The incidence of treatment-emergent significant changes in fasting glucose, cholesterol, or triglycerides did not differ between the groups at endpoint, but significantly more olanzapine-treated patients had high triglycerides at any time during treatment. CONCLUSIONS Olanzapine-treated adolescents with schizophrenia experienced significant symptom improvement. Significant increases in weight, triglycerides, uric acid, most liver function tests, and prolactin were observed during olanzapine treatment.Clinical trial registration information-Olanzapine Versus Placebo in the Treatment of Adolescents With Schizophrenia. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00051298.
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Walter G, DeLaroche A, Soh N, Hunt G, Cleary M, Malhi G, Lambert T, Correll C, Rey J. Side effects of second-generation antipsychotics: the experiences, views and monitoring practices of Australian child psychiatrists. Australas Psychiatry 2008; 16:253-62. [PMID: 18608172 DOI: 10.1080/10398560801958549] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to ascertain the experiences, views and monitoring practices of Australian child psychiatrists regarding the metabolic and other side effects of second-generation antipsychotics (SGAs). METHOD A 19-item questionnaire was posted to all members of the RANZCP Faculty of Child and Adolescent Psychiatry living in Australia. RESULTS Of the 290 eligible members of the Faculty of Child and Adolescent Psychiatry, 126 (43%) returned a useable survey. SGAs are commonly prescribed for a range of disorders. The majority of respondents expressed a high level of concern regarding weight gain and other metabolic side effects. Weight gain was the most frequently observed and monitored side effect in clinical practice. Other side effects were observed and monitored to a variable extent. Notably, monitoring practices did not parallel psychiatrists' reported level of concern or knowledge regarding weight gain and metabolic side effects,nor coincide with published recommendations. CONCLUSIONS Further research is required into the use, efficacy, side effects and monitoring of SGAs in children and adolescents, and there is a need to ensure that monitoring guidelines are implemented in clinical practice. This need is heightened by the likelihood that our data on clinicians' practice, which is based on their perceptions, may overestimate what actually occurs.
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Affiliation(s)
- Garry Walter
- Discipline of Psychological Medicine, University of Sydney, Australia.
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Strawn JR, DelBello MP. Olanzapine for the treatment of bipolar disorder in children and adolescents. Expert Opin Pharmacother 2008; 9:467-74. [DOI: 10.1517/14656566.9.3.467] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Clinical implications of antipsychotic-induced hyperprolactinemia in patients with schizophrenia spectrum or bipolar spectrum disorders: recent developments and current perspectives. J Clin Psychopharmacol 2007; 27:639-61. [PMID: 18004132 DOI: 10.1097/jcp.0b013e31815ac4e5] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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.
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Sporn AL, Vermani A, Greenstein DK, Bobb AJ, Spencer EP, Clasen LS, Tossell JW, Stayer CC, Gochman PA, Lenane MC, Rapoport JL, Gogtay N. Clozapine treatment of childhood-onset schizophrenia: evaluation of effectiveness, adverse effects, and long-term outcome. J Am Acad Child Adolesc Psychiatry 2007; 46:1349-1356. [PMID: 17885577 DOI: 10.1097/chi.0b013e31812eed10] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Clozapine is a unique atypical antipsychotic with superior efficacy in treatment-resistant schizophrenia. Plasma concentration of clozapine and its major metabolite N-desmethylclozapine (NDMC) as well as the ratio of NDMC to clozapine have been reported to be predictors of clozapine response. Here we evaluate these as well as other measures in an effort to find predictors of response to clozapine in our early-onset treatment-refractory population. METHOD Fifty-four children and adolescents participated in double-blind (n = 22) or open-label (n = 32) clozapine trials. Clinical evaluations took place at baseline, week 6 on clozapine, and at 2- to 6-year follow-up. The data were analyzed in relation to demographics, age at onset, IQ, clozapine dose, and plasma concentrations of prolactin, clozapine, NDMC, and NDMC/clozapine ratio. Stepwise regression and correlation analyses were performed to find predictors of treatment response. RESULTS Clinical improvement after 6 weeks of clozapine treatment, as measured by the percentage of improvement on the Brief Psychiatric Rating Scale and the Scale for the Assessment of Positive Symptoms, was strongly associated with the NDMC/clozapine ratio at the 6-week time point (Pearson correlation coefficient: r = 0.41; p < .01 for Brief Psychiatric Rating Scale and r = 0.43; p < .01 for Scale for the Assessment of Positive Symptoms). Although the rate of side effects was higher than that typically found in the adult population, it did not appear to be related to clozapine dose, clozapine or NDMC plasma concentrations, or NDMC/clozapine ratio. Outcome at long-term follow-up, as measured by Children's Global Assessment Scale, was associated with lesser illness severity at baseline and with greater improvement during the initial 6 weeks of clozapine treatment. CONCLUSIONS The NDMC/clozapine ratio may be a valuable predictor of response to clozapine and may suggest new approaches to clozapine treatment.
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Affiliation(s)
- Alexandra L Sporn
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London.
| | - Anoop Vermani
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Deanna K Greenstein
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Aaron J Bobb
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Edgar P Spencer
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Liv S Clasen
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Julia W Tossell
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Catherine C Stayer
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Peter A Gochman
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Marge C Lenane
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Judith L Rapoport
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
| | - Nitin Gogtay
- Drs. Sporn, Vermani, Greenstein, Clasen, Tossell, Stayer, Rapoport, Gogtay, Mr. Bobb, Mr. Gochman, and Ms. Lenane are with the Child Psychiatry Branch, NIMH, Bethesda, MD; Dr. Spencer is with the Medical Toxicology Laboratory, Guy's and St. Thomas' Hospital NHS Trust, London
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Frémaux T, Reymann JM, Chevreuil C, Bentué-Ferrer D. Prescription de l’olanzapine chez l’enfant et l’adolescent. Encephale 2007; 33:188-96. [PMID: 17675914 DOI: 10.1016/s0013-7006(07)91549-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION A review of the literature from 1996-2004 on the indications and adverse reactions concerning the use of olanzapine, a second generation antipsychotic agent, in children and adolescents with psychiatric illness is made in this article. Studies lasted for 2 to 3 months and a few had a follow up period up to a year. Olanzapine, dosed from 2.5 to 20 mg/day, is shown to be a useful drug in the treatment of child and adolescent onset schizophrenia, bipolar disorder, anorexia nervosa with delusions, pervasive developmental disorder, tic disorders, and aggression. OPEN AND DOUBLE-BLIND STUDIES: In 4 open labeled studies (26, 34, 39, 43) and 2 case reports (25), 53 patients, aged from 6-18 years old, afflicted by child onset schizophrenia, were treated with olanzapine for 1 1/2 weeks to one year; 19 had treatment resistant childhood schizophrenia and 34 a first episode. In the first group 13/19 showed improvement whereas, in the second group 27/34 were considered responders. Four patients in the first group who had responded to clozapine (stopped because of adverse events) did less well on olanzapine. In 5 studies, 4 open labeled (15, 20, 44) and 1 double blind (27), 59 adolescent onset schizophrenic patients were treated by olanzapine from 8 to 26 weeks; 50/59 patients were considered responders. In the open label study (20) comparing 43 adolescents treated by olanzapine (19 patients), risperidone (17 patients), or haloperidol (7 patients), improvement was significant in the three groups after 4 weeks of treatment and continued after 8 weeks. It is most interesting to mention that 2 months after the end of the study 71% (12/17) of the olanzapine group that had completed the study, 10/15 (67%) of the risperidone group, and 43% (3/7) of the haloperidol group had continued their treatment. Dropouts were for inefficacy and non-compliance in the olanzapine and risperidone groups whereas they were also for adverse events in the haloperidol group (2/4). A final double blind study of 263 adult and adolescent schizophrenic patients (latter are not separated from the former) confirmed the superiority of olanzapine compared to haloperidol and its use for a long period: 67% of the olanzapine and 54% of the haloperidol patients completed the 12-week study. CASE-REPORTS 12 case reports of children and adolescents diagnosed with acute mania (8, 25, 46, 47) and 23 in an open labeled study (16) were treated by olanzapine; 26/35 were considered to respond well. Some of the patients were on mood stabilizers before adjunction of olanzapine, others on olanzapine monotherapy; 10 case reports of patients with anorexia nervosa associated with psychotic symptomatology, aged from 10-17 years old, relate the use of olanzapine as adjuvant treatment. Improvement was spectacular in these patients who not only gained considerable weight, but were also more compliant to the therapeutic program and their obsessions, delusions, agitation and anxiety became less intense. In this form of anorexia nervosa, olanzapine appears to have an interesting therapeutic role and, in particular, its most important adverse effect, weight gain, became a therapeutic goal. In 2 preliminary studies (24, 30) 31 children and adolescents diagnosed with pervasive developmental disorder were treated by olanzapine from 6 to 13 weeks; 18/25 had good or moderate symptomatic improvement: they were less irritable and hyperactive, and their speech less excessive. In 17 case reports of children and adolescents with aggression (42, 45), associated with tics in 10 patients (49), treatment with olanzapine from 2 weeks to 10 months lowered the presenting symptoms, enhanced the cooperation, and improved the mood of the patients. Only one patient's treatment was changed for inefficacy. DISCUSSION No matter what the disorder treated, when olanzapine was compared to haloperidol and risperidone, it proved to be as effective as risperidone, and as or more effective than haloperidol; but when compared to clozapine, it was less effective. The most prominent adverse reaction was excessive weight gain, even more so than in adult patients treated with olanzapine. Also weight gain was greater in children and adolescents treated by olanzapine than those treated by risperidone or haloperidol. Though few treatments had to be interrupted because of this side effect, child and adolescent psychiatrists are wary of the long-term disease related to obesity and glucose dysregulation. All should be done to under-stand the process of weight gain better and to prevent or stall excessive caloric intake, encourage activity, and eventually treat by corrector drugs. Secondly, sedation may bother up to 50% of patients even at the end of the study periods, as many as those treated by haloperidol and more than those treated by risperidone. Extrapyramidal symptoms were mild or moderate compared to those that appear with haloperidol, but may be more frequent than in adult patients. Liver enzymes and blood sugar may be slightly elevated. Prolactemia may be elevated but less so with risperidone and haloperidol. CONCLUSION All the authors emphasized the unfortunate lack of randomized double blind studies for the use of olanzapine in this age group.
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Affiliation(s)
- T Frémaux
- CMPP du Gacet, ADPEP 35, 1 allée du Gacet, 35200 Rennes
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Quintana H, Wilson MS, Purnell W, Layman AK, Mercante D. An open-label study of olanzapine in children and adolescents with schizophrenia. J Psychiatr Pract 2007; 13:86-96. [PMID: 17414684 DOI: 10.1097/01.pra.0000265765.25495.e0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this open-label study was to evaluate the use of olanzapine in the treatment of children and adolescents with schizophrenia. Sixteen children who were 8-17 years of age and met DSM-IV criteria for schizophrenia were admitted into a 10-week, open-label, optimizing dose study of olanzapine. The Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS), and the Clinical Global Impression (CGI)-Severity/Improvement scales were used to assess improvement during the study. Of the 16 subjects who completed the study, 12 demonstrated significant improvement on end of treatment BPRS, CGI, and PANSS scores compared with baseline. Male subjects showed greater improvement and also gained more weight. Weight gain occurred in all but 2 subjects. Weight gain was significant, with patients averaging a gain of about 6.2 kg during the 6-week course of the study. Two of the subjects experienced extrapyramidal symptoms. The average dose of olanzapine for all subjects was 0.17 mg/kg.
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Affiliation(s)
- Humberto Quintana
- Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA.
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Jensen PS, Buitelaar J, Pandina GJ, Binder C, Haas M. Management of psychiatric disorders in children and adolescents with atypical antipsychotics: a systematic review of published clinical trials. Eur Child Adolesc Psychiatry 2007; 16:104-20. [PMID: 17075688 DOI: 10.1007/s00787-006-0580-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2006] [Indexed: 10/24/2022]
Abstract
We aimed to provide a descriptive review of treatment studies of atypical antipsychotics in paediatric psychiatric disorders. A systematic review of the literature used Medline and EMBASE databases to identify clinical trials of atypical antipsychotics in children and adolescents between 1994 and 2006. Trials were limited to double-blind studies and open-label studies of > or = 8 weeks duration that included > or = 20 patients. Nineteen double-blind and 22 open-label studies were identified. Studies included use of clozapine, olanzapine, quetiapine, risperidone, and ziprasidone in the treatment of disruptive behavioural disorders (DBDs), pervasive developmental disorders (PDDs), tic disorder, psychotic disorders, and mania. These medications generally reduced the severity of a variety of psychiatric symptoms in children and adolescents. Less frequent adverse events included extrapyramidal symptoms, hyperglycaemia and diabetes, and endocrine effects. The review of published scientific data suggests that most of the atypical antipsychotics, excluding clozapine, have a favourable risk/benefit profile and effectively reduce disabling behaviours in paediatric psychiatric patients. While there is a body of evidence published of treatment of DBDs and PDDs, there is a lack of controlled data to guide clinical practice for the use of atypical antipsychotics for paediatric psychotic disorders and bipolar disorder. While there have been studies with duration up to 2 years, no definitive data are available that suggest long-term safety; additional studies are warranted.
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Affiliation(s)
- Peter S Jensen
- Center for the Advancement of Children's Mental Health, Columbia University, New York State Psychiatric Institute, New York, NY, USA
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47
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Theisen FM, Haberhausen M, Schulz E, Fleischhaker C, Clement HW, Heinzel-Gutenbrunner M, Remschmidt H. Serum Levels of Olanzapine and Its N-desmethyl and 2-hydroxymethyl Metabolites in Child and Adolescent Psychiatric Disorders: Effects of Dose, Diagnosis, Age, Sex, Smoking, and Comedication. Ther Drug Monit 2006; 28:750-9. [PMID: 17164690 DOI: 10.1097/01.ftd.0000249950.75462.7f] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to assess dose-related steady-state serum concentrations of olanzapine (OLZ) and its metabolites N-desmethyl OLZ (DMO) and 2-hydroxymethyl OLZ (2-OH-OLZ) (assessed by high-performance liquid chromatography) in 122 child and adolescent psychiatric patients (age 16.9 +/- 2.2, range, 10-21 years; 74 males, 48 females) with a variety of diagnoses: schizophrenia group (n = 80); nonschizophrenia group (n = 29); anorexia nervosa (AN) group (n = 13). Median OLZ serum concentrations were 32.7 (range, 1-118; all patients), 37.7 (2-115; schizophrenia group), and 18.7 (1-63, AN group) ng/mL. The median OLZ concentration-to-dose (C/D) ratio (n = 122) was 2.6, with 90% of the distribution between 0.8 and 5.5 (ng/mL)/(mg/d). OLZ concentration was significantly correlated with DMO (r = 0.567; P < 0.0005) but not with 2-OH-OLZ (r = 0.122; P = 0.188). Daily OLZ dose was correlated with OLZ concentration in all (r = 0.684; P < 0.0005), schizophrenic (r = 0.542; P < 0.0005), and AN (r = 0.805; P = 0.001) patients, respectively. Patients aged less than 16 years displayed similar C/D for OLZ (P = 0.58) but higher C/D for DMO (P = 0.003) than those 16 years or older. AN patients received lower median OLZ doses (7.5; 5-15 mg) than schizophrenic patients (12.5; 2.5-40 mg), even after correcting for body mass index (P = 0.02). OLZ dose did not differ (P = 0.088) between smokers and nonsmokers, but smokers showed lower C/D for OLZ than nonsmokers (P = 0.008). C/D for OLZ was 38% higher (P = 0.041) under comedication with selective serotonin reuptake inhibitors when compared with OLZ monotherapy. Multiple linear regression analysis revealed that 46% of the variation of OLZ concentration can be explained by dose, diagnosis, age, sex, smoking, and comedication. The data are compared with the literature, and the relevance of therapeutic antipsychotic drug monitoring in previously sparsely investigated subgroups, such as children and adolescents or patients with AN, is emphasized.
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Affiliation(s)
- Frank M Theisen
- Department of Child and Adolescent Psychiatry, University of Marburg, Marburg, Germany.
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Correll CU, Carlson HE. Endocrine and metabolic adverse effects of psychotropic medications in children and adolescents. J Am Acad Child Adolesc Psychiatry 2006; 45:771-91. [PMID: 16832314 DOI: 10.1097/01.chi.0000220851.94392.30] [Citation(s) in RCA: 274] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Despite increasing use of psychotropic medications in children and adolescents, data regarding their efficacy and safety are limited. Endocrine and metabolic adverse effects are among the most concerning adverse effects of commonly used psychotropic medications. METHOD Selective review of endocrine and metabolic effects of psychotropic medications in pediatric populations, with a focus on monitoring and management strategies. RESULTS Because youth are still developing at the time of psychotropic drug exposure, most reference values need to be adjusted for gender and age. As in adults, youngsters receiving lithium require monitoring for thyroid dysfunction. Psychostimulants appear to cause mild reversible growth retardation in some patients, most likely because of decreased weight or slowing of expected weight gain; some patients may experience clinically significant reductions in adult height. Although still controversial, valproate use has been associated with an increased risk for polycystic ovary syndrome, in addition to causing weight gain. Although more data are required, children and adolescents appear to be at higher risk than adults for antipsychotic-induced hyperprolactinemia, weight gain, and possibly, associated metabolic abnormalities, which is of particular concern. CONCLUSIONS Clinicians and caregivers need to be aware of potential endocrine and metabolic adverse effects of psychiatric medications. A careful selection of patients, choice of agents with potentially lesser risk for these adverse events, healthy lifestyle counseling, as well as close health monitoring are warranted to maximize effectiveness and safety.
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Affiliation(s)
- Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, 75-59 263rd Street, Glen Oaks, NY 11004, USA.
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49
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Abstract
OBJECTIVE This naturalistic, cross-sectional study was designed to assess the risk of prolactin level elevation and associated side effects in youths taking long-term atypical antipsychotic medication. METHOD Subjects were enrolled from outpatient child psychiatric treatment settings in upstate New York who were taking risperidone, olanzapine, or quetiapine for at least 6 months. Demographic data, medication history, and side effects were elicited at the initial interview. Two fasting morning serum prolactin levels were obtained 1 month apart, and the results were averaged. RESULTS Fifty outpatient youths, with a median age of 13 years, were enrolled in the study. The median overall duration of use of an atypical antipsychotic was 22.1 months. The median dose of medication for risperidone was 1.5 mg/day, for olanzapine 10 mg/day, and for quetiapine 200 mg/day. The mean prolactin level among all patients on risperidone was significantly greater than controls, as well as for those on quetiapine or olanzapine. CONCLUSIONS The risk of hyperprolactinemia with long-term use of risperidone appears to be significantly greater than for olanzapine or quetiapine. Overt side effects were infrequent in the overall sample, but serum prolactin assessment is recommended for youths taking risperidone chronically. Because of variability found in sequential prolactin samples, repeat samples may be warranted.
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Affiliation(s)
- Jud Staller
- Department of Psychiatry, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
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Abstract
Studies performed in adult patients unambiguously demonstrate a marked effect of risperidone on prolactin blood levels, with possible clinical effects related to hyperprolactinemia, such as gynecomastia and galactorrhea. However, the largest study performed in children and adolescents showed a weak effect of risperidone on prolactin concentrations during short-term treatment and a negligible effect during long-term treatment, which was probably because of the relatively low dosages of risperidone used [approximately 0.04 mg/(kg x d)]. Among the 10 psychotic adolescents treated with risperidone in our unit, we had 3 cases of gynecomastia in 3 male patients and 2 cases of galactorrhea in 2 female patients. The prolactin blood levels in these cases and in 3 other patients without apparent prolactin-related side effects were all above the normal range (median, 59 ng/mL; range, 30-123 ng/mL). Thus, risperidone administered to adolescents at doses commonly used for the treatment of psychotic symptoms can strongly increase prolactin levels, with clinical consequences such as gynecomastia and/or galactorrhea. Given that the long-term effects of antipsychotic drug-induced hyperprolactinemia are not well documented, especially regarding osteopenia, infertility, growth, and pubertal delay, risperidone should be administered with caution to children and adolescents.
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Affiliation(s)
- Laurent Holzer
- Service Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, Centre Thérapeutique de Jour pour Adolescents, Lausanne, Switzerland.
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