Cardiometabolic outcomes in children and adolescents following discontinuation of long-term risperidone treatment

Long-Term Effectiveness of Off-Label Risperidone Treatment in Children and Adolescents: A Randomized, Placebo-Controlled Discontinuation Study

Objectives: Risperidone is commonly prescribed off-label in children and adolescents to manage disruptive behavior. This study aimed to investigate continued benefits of risperidone after at least 1 year of treatment and effects of discontinuation on physical health. Methods: Thirty-five youths (aged 6-18 years, intelligence quotient [IQ] >70) who were treated with risperidone for at least 1 year in regular clinical practice receiving outpatient care were randomly assigned to double-blind continuation of risperidone during 16 weeks or continuation for 2 weeks, gradual dose lowering over 6 weeks, and placebo for 8 weeks. Primary outcome was the total Disruptive Behavior (D-total) score of the parent-reported Nisonger Child Behavior Rating Form-Typical IQ (NCBRF-TIQ). Secondary outcome measures were the clinician-rated Clinical Global Impressions-Improvement scale (CGI-I), the parent, child, and teacher-rated Strengths and Difficulties Questionnaire (SDQ), the parent-rated Retrospective Modified Overt Aggression Scale (R-MOAS), and several health parameters (Udvalg for Kliniske Undersøgelser Side Effect Rating Scale [UKU-SERS], dyskinesia, akathisia, parkinsonism, body mass index (BMI), waist circumference, and laboratory outcomes). Mixed models for repeated measures were conducted for continuous outcomes and a chi-square test for the CGI-I. Results: Discontinuation of risperidone, as compared with continuation, was not associated with significant changes in parent-reported disruptive behaviors. However, discontinuation was related to significant deterioration in parent-rated verbal aggression, teacher-rated behavioral functioning, clinician-rated general functioning, and significant improvements in weight, BMI, waist circumference, and glucose, insulin, and prolactin levels. Although 56% of participants in the discontinuation group experienced relapse, causing premature withdrawal from the study, 44% was able to successfully discontinue risperidone. Conclusion: Discontinuation of risperidone was associated with deterioration on some, but not all behavioral measures according to this explorative study. Discontinuation was associated with important health gains. Despite long-term benefits of risperidone, attempts to withdraw risperidone should be undertaken in individual children. This is a crucial step in preventing harm and fostering health.

Risk of Obesity Among Children Prescribed Atypical Antipsychotics for Six Months or More

Objectives: The study investigates the risk of obesity for young children prescribed an atypical antipsychotic (AAP) for 6 months or more. AAPs are associated with risk of obesity. They are used in children for a variety of psychiatric conditions and are often prescribed off-label. Long-term risk of obesity in this age group is unknown as most studies are short-term investigations and generally combine younger children with adolescents and adults. Methods: A retrospective cohort of children, 10 years old or younger, prescribed either an AAP or selective serotonin reuptake inhibitor (SSRI) for 6 months or more were followed for up to 9.5 years. The primary endpoint was the body-mass index (BMI) reaching the 95th percentile. Results: One thousand six hundred fifty-five patients met inclusion criteria. One thousand one hundred eighteen patients were prescribed an AAP and 537 were prescribed an SSRI: 1152 (74.5%) patients were male and mean (standard deviation) age was 7.9 [1.90] years at study entry. Median follow-up was 3.58 years for the AAP cohort and 3.28 years for the SSRI cohort (p = 0.02). After adjusting for baseline demographic variables, BMI, and other concomitantly prescribed medications, children prescribed AAPs for 6 months or longer were twice as likely to become obese compared with children prescribed SSRIs (adjusted hazard ratio [HR] 2.06 [95% confidence interval; CI 1.60-2.66], p < 0.0001). Further stratification by AAP revealed that the obesity risk for patients prescribed aripiprazole was 34% greater than for those prescribed risperidone (adjusted HR 1.34 [95% CI 1.01-1.78], p = 0.0033). Conclusions: The risk of obesity for young children prescribed an AAP for 6 months or more is approximately double that of children prescribed an SSRI. The risk of obesity is greater with aripiprazole than risperidone in the first year. Prescribers should consider the risk of obesity when prescribing AAPs and consider alternative treatment modalities in this vulnerable patient population.

Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing

It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.

The Burden of Antipsychotic-Induced Weight Gain and Metabolic Syndrome in Children

Antipsychotic medications are critical to child and adolescent psychiatry, from the stabilization of psychotic disorders like schizophrenia, bipolar disorder, and psychotic depression to behavioral treatment of autism spectrum disorder, tic disorders, and pediatric aggression. While effective, these medications carry serious risk of adverse events-most commonly, weight gain and cardiometabolic abnormalities. Negative metabolic consequences affect up to 60% of patients and present a major obstacle to long-term treatment. Since antipsychotics are often chronically prescribed beginning in childhood, cardiometabolic risk accumulates. An increased susceptibility to antipsychotic-induced weight gain (AIWG) has been repeatedly documented in children, particularly rapid weight gain. Associated cardiometabolic abnormalities include central obesity, insulin resistance, dyslipidemia, and systemic inflammation. Lifestyle interventions and medications such as metformin have been proposed to reduce risk but remain limited in efficacy. Furthermore, antipsychotic medications touted to be weight-neutral in adults can cause substantial weight gain in children. A better understanding of the biological underpinnings of AIWG could inform targeted and potentially more fruitful treatments; however, little is known about the underlying mechanism. As yet, modest genetic studies have nominated a few risk genes that explain only a small percentage of the risk. Recent investigations have begun to explore novel potential mechanisms of AIWG, including a role for gut microbiota and microbial metabolites. This article reviews the problem of AIWG and AP metabolic side effects in pediatric populations, proposed mechanisms underlying this serious side effect, and strategies to mitigate adverse impact. We suggest future directions for research efforts that may advance the field and lead to improved clinical interventions.

Reversibility of Antipsychotic-Induced Weight Gain: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Weight gain is a major adverse effect of antipsychotic medication, negatively affecting physical and mental well-being. The objective of this study was to explore if dose reduction, discontinuation, switch to a partial agonist, or switch from polypharmacy to monotherapy will lead to weight loss.

METHODS

Controlled and uncontrolled studies reporting the effects of discontinuation, dose reduction, switch to a partial agonist, or switch from polypharmacy to monotherapy on weight were included. Primary outcome was difference in weight compared to maintenance groups based on controlled studies. Secondary outcome was change in weight from initiation of one of the included interventions until follow-up in a pre-post analysis.

RESULTS

We identified 40 randomized controlled trials and 15 uncontrolled studies including 12,279 individuals. The effect of the interventions, i.e. dose reduction, drug discontinuation, or switch to a partial agonis, reduced the weight with 1.5 kg (95% CI -2.03 to -0.98; P < 0.001) compared to maintenance treatment. The weight change from pre to post was a reduction of 1.13 kg (95% CI -1.36 to -0.90; P < 0.001).

CONCLUSION

We found a significant but small reduction in weight, suggesting that antipsychotic-induced weight gain can be reversed to some degree. Only a few studies were designed to address the question as primary outcome, which limits the generalizability of our findings.

Exploring mechanisms of increased cardiovascular disease risk with antipsychotic medications: Risperidone alters the cardiac proteomic signature in mice

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.

Deprescribing psychotropic medications in children: results of a national qualitative study

BACKGROUND AND OBJECTIVE

Prescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children.

METHODS

We conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding.

RESULTS

Analysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians.

CONCLUSION

Our findings highlight a discrepancy between clinicians' concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.

Reversibility of psychotropic medication induced weight gain among children and adolescents with bipolar disorders

OBJECTIVE

To assess the reversibility of weight gain associated with psychotropic medications in children.

METHODS

A retrospective cohort study was conducted using an ambulatory electronic medical records database. Individuals under 18 years of age were identified if they were initiating a new course of second generation/atypical antipsychotics (SGA) or mood stabilizers (MS) following a bipolar disorder diagnosis and subsequently discontinued treatment within 24 months of treatment initiation.

RESULTS

Of the 297 children who had experienced positive BMI percentile increase (mean±SD: 8.71±11.94) during the treatment of SGA and/or MS, treatment discontinuation led to an average of 1.88 (±13.41) unit decrease in BMI percentile during a 12-month period since the treatment discontinuation. Repeated measure mixed model analysis showed that the reduction of BMI percentile after treatment discontinuation was neither associated with the treatment regimens patients previously received, nor associated with time since the treatment discontinuation. The three statistically significant predictors were baseline BMI percentile, BMI percentile gained during the treatment, and comorbid substance abuse disorder.

CONCLUSION

Children with bipolar disorder were able to lose a fraction of weight gained during pharmacotherapy after the treatment discontinuation, however, their BMI percentile may not return to the prior treatment level within a year post-medication discontinuation.

Weight-Change Trajectories of Pediatric Outpatients Treated with Risperidone or Aripiprazole in a Naturalistic Setting

OBJECTIVES

Second-generation antipsychotics (SGAs) increase appetite and weight, leading toward a metabolic syndrome. Risperidone and aripiprazole, the most widely used pediatric SGAs, have been studied predominantly in short-term clinical trials, where risperidone leads to a rapid weight increase and aripiprazole to a slower one, while long-term effects are not yet elucidated. Factors that may influence weight gain are likewise not clarified, although baseline weight, previous SGA exposure, pubertal status, and type of SGA have been suggested as moderators. We analyzed weight gain induced by risperidone and aripiprazole in a sample of pediatric outpatients enrolled into a 2-year observational study.

METHODS

We assessed at several time points their body mass index (BMI)-Z scores (age and sex-corrected and referred to national norms). We used hierarchical mixed-effects modeling to design BMI-Z trajectories and observed the effects of several variables on determining them.

RESULTS

The study group comprised of 127 patients, predominantly males (79%), of 12.6 years on average, treated with risperidone (81%) and aripiprazole (19%) for disruptive behavioral symptoms in patients with and without neurodevelopmental disorders. Overall, BMI-Z was 1.2 at first and 1.4 at last visit (no significant change). We could design four weight-change trajectories, determined by the factors: drug (risperidone/aripiprazole) and age status (children/adolescent). Additional factors not retained in the model but possibly explanatory include the previous duration of SGA treatment and a progressive patient-selection effect due to dropouts in this observational study. Risperidone treatment was associated with trends of BMI-Z increase in children and decrease in adolescents. Aripiprazole treatment was associated with significant BMI-Z increase, higher in children than in adolescents. Results are probably due to longer previous drug exposure in adolescents.

CONCLUSIONS

Children were at risk of weight gain more than adolescents, for both risperidone and, of note, aripiprazole. Adolescents and patients with long previous drug exposure tend to reach stable BMI-Z, although in the range between excessive weight and obesity.

CHRNA7 copy number gains are enriched in adolescents with major depressive and anxiety disorders

OBJECTIVE

Neuronal nicotinic acetylcholine receptors (nAChRs), specifically the α7 nAChR encoded by the gene CHRNA7, have been implicated in behavior regulation in animal models. In humans, copy number variants (CNVs) of CHRNA7 are found in a range of neuropsychiatric disorders, including mood and anxiety disorders. Here, we aimed to determine the prevalence of CHRNA7 CNVs among adolescents and young adults with major depressive disorder (MDD) and anxiety disorders.

METHODS

Twelve to 21 year-old participants with MDD and/or anxiety disorders (34% males, mean ± std age: 18.9 ± 1.8 years) were assessed for CHRNA7 copy number state using droplet digital PCR (ddPCR) and genomic quantitative PCR (qPCR). Demographic, anthropometric, and clinical data, including the Beck Anxiety Index (BAI), Beck Depression Inventory (BDI), and the Inventory of Depressive Symptoms (IDS) were collected and compared across individuals with and without a CHRNA7 CNV.

RESULTS

Of 205 individuals, five (2.4%) were found to carry a CHRNA7 gain, significantly higher than the general population. No CHRNA7 deletions were identified. Clinically, the individuals carrying CHRNA7 duplications did not differ significantly from copy neutral individuals with MDD and/or anxiety disorders.

CONCLUSIONS

CHRNA7 gains are relatively prevalent among young individuals with MDD and anxiety disorders (odds ratio = 4.032) without apparent distinguishing clinical features. Future studies should examine the therapeutic potential of α7 nAChR targeting drugs to ameliorate depressive and anxiety disorders.

Selective Serotonin Reuptake Inhibitors Reduce Longitudinal Growth in Risperidone-Treated Boys

OBJECTIVES

To examine whether selective serotonin reuptake inhibitors (SSRIs) inhibit longitudinal growth in children and adolescents, particularly in the early stages of puberty, using a sample of convenience comprising risperidone-treated boys.

STUDY DESIGN

Data from four clinic-based studies in risperidone-treated 5- to 17-year-old boys with no general medical conditions were combined for this analysis. Anthropometric measurements and psychotropic treatment history were extracted from the medical and pharmacy records. Linear mixed effects regression analyses examined the association between SSRI use and change in age-sex-specific height and body mass index z scores, after adjusting for relevant confounders.

RESULTS

Risperidone-treated boys (n = 267; age: 12.7 ± 2.7 years), 71% of whom had ever taken an SSRI, contributed to the analysis. After adjusting for age, psychostimulant and antipsychotic use, and time in the study, both the duration of SSRI use as well as the cumulative dose were inversely associated with height z score after age 11 years (P < .0001). After adjusting for baseline height, duration of SSRI use was most strongly inversely associated with height z score in Tanner stages 3 and 4 boys who took SSRIs continuously (r = -0.69, P < .009). No association was observed with body mass index z score.

CONCLUSIONS

In risperidone-treated boys, SSRI use is associated with reduced longitudinal growth, particularly in those undergoing puberty. Whether adult height or other metabolic or psychological outcomes are affected remains to be determined.

Harms of Antipsychotics in Children and Young Adults: A Systematic Review Update

OBJECTIVE

To update and extend our previous systematic review on first- (FGAs) and second-generation antipsychotics (SGAs) for treatment of psychiatric and behavioral conditions in children, adolescents, and young adults (aged ≤24 years). This article focuses on the evidence for harms.

METHOD

We searched (to April 2016) 8 databases, gray literature, trial registries, Food and Drug Administration reports, and reference lists. Two reviewers conducted study screening and selection independently, with consensus for selection. One reviewer extracted and another verified all data; 2 reviewers independently assessed risk of bias. We conducted meta-analyses when appropriate and network meta-analysis across conditions for changes in body composition. Two reviewers reached consensus for ratings on the strength of evidence for prespecified outcomes.

RESULTS

A total of 135 studies (95 trials and 40 observational) were included, and 126 reported on harms. FGAs caused slightly less weight gain and more extrapyramidal symptoms than SGAs. SGAs as a class caused adverse effects, including weight gain, high triglyceride levels, extrapyramidal symptoms, sedation, and somnolence. They appeared to increase the risk for high cholesterol levels and type 2 diabetes. Many outcomes for individual drug comparisons were of low or insufficient strength of evidence. Olanzapine caused more short-term gains in weight and body mass index than several other SGAs. The dose of SGAs may not make a difference over the short term for some outcomes.

CONCLUSIONS

Clinicians need to weigh carefully the benefit-to-harm ratio when using antipsychotics, especially when treatment alternatives exist. More evidence is needed on the comparative harms between antipsychotics over the longer term.

Deprescribing antipsychotics: a guide for clinicians

Polypharmacy and the risks of long term use of antipsychotic medications point toward the need for identifying practices for deprescribing in psychiatry. The following article gives a brief overview of key points around deprescribing antipsychotic medications in psychiatry, including identifying risks and benefits, considerations around timing, and steps involved.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Bone Mass in Boys with Autism Spectrum Disorder

To examine bone mass in children and adolescents with autism spectrum disorders (ASD). Risperidone-treated 5 to 17 year-old males underwent anthropometric and bone measurements, using dual-energy X-ray absorptiometry and peripheral quantitative computed tomography. Multivariable linear regression analysis models examined whether skeletal outcomes differed among participants with (n = 30) versus without ASD (n = 156). After adjusting for potential covariates, having ASD was associated with significantly lower trabecular bone mineral density and bone strength at the radius, and with marginally lower total body less head bone mineral content (p < 0.09). No differences at the lumbar spine were observed. ASD are associated with lower bone mass. Future studies should investigate interventions to optimize skeletal health in ASD.

Improved Metabolic and Psychiatric Outcomes with Discontinuation of Atypical Antipsychotics in Youth Hospitalized in a State Psychiatric Facility

OBJECTIVES

To assess the impact of antipsychotic tapering and discontinuation on measures of metabolic functioning and psychiatric symptom severity in severely impaired youth hospitalized in a psychiatric state hospital.

METHODS

The study examined psychiatric and metabolic measures in 67 hospitalized children and adolescents (mean age 11.9; 56 with discontinued use of antipsychotics, 10 with continued use of antipsychotics, and 1 started on an antipsychotic) from admission to discharge.

RESULTS

Upon admission, 56 youth were tapered off of antipsychotic medications, started on other forms of pharmacotherapy (92.9% were started on medications used to treat attention-deficit/hyperactivity disorder), and received evidence-based behavioral programming and were ultimately discharged from the hospital. The mean duration of treatment was 228 days for the discontinuation group and 204 days for the continuation group. Significant decreases in body mass index [BMI; t(53) = 7.12, p = 0.0001] and BMI percentile [t(53) = 6.73, p = 0.0001] were found from admission to discharge in the antipsychotic discontinuation group. Changes in BMI, BMI percentile, or systolic blood pressure were not found in the group (n = 10) who were maintained on antipsychotics. Both groups experienced a significant increase in their Global Assessment of Functioning score [t(52) = 19.98, p = 0.0001 for discontinued; t(8) = 5.092, p = 0.001 for maintained]. Psychiatric symptom severity scores significantly improved in many subscales relevant to disruptive behaviors and mood disorders for those who were removed from the medications. For those maintained on the antipsychotics, there were fewer changes in psychiatric symptom scores.

CONCLUSION

Discontinuation of atypical antipsychotic medications in conjunction with tailoring treatment to presenting diagnoses resulted in metabolic and psychiatric symptom improvement among severely impaired state hospital inpatient youth. These results serve as a feasibility demonstration that discontinuation of antipsychotics does not provoke psychiatric destabilization, particularly among disruptive behavior disordered youth.

CHRNA7 Deletions are Enriched in Risperidone-Treated Children and Adolescents

OBJECTIVE

Aggression is among the most common indications for referral to child and adolescent mental health services and is often challenging to treat. Understanding the biological underpinnings of aggression could help optimize treatment efficacy. Neuronal nicotinic acetylcholine receptors (nAChRs), specifically the α7 nAChR, encoded by the gene CHRNA7, have been implicated in aggressive behaviors in animal models as well as humans. Copy number variants (CNVs) of CHRNA7 are found in individuals with neuropsychiatric disorders, often with comorbid aggression. In this study, we aimed to determine the prevalence of CHRNA7 CNVs among individuals treated with risperidone, predominantly for irritability and aggression.

METHODS

Risperidone-treated children and adolescents were assessed for CHRNA7 copy number state using droplet digital PCR and genomic quantitative PCR. Demographic, anthropometric, and clinical data, including the Child Behavior Checklist (CBCL), were collected and compared across individuals with and without the CHRNA7 deletion.

RESULTS

Of 218 individuals (90% males, mean age: 12.3 ± 2.3 years), 7 (3.2%) were found to carry a CHRNA7 deletion and one proband carried a CHRNA7 duplication (0.46%). T-scores for rule breaking, aggression, and externalizing behavior factors of the CBCL were higher in the deletion group, despite taking 58% higher dose of risperidone.

CONCLUSIONS

CHRNA7 loss may contribute to a phenotype of severe aggression. Given the high prevalence of the deletion among risperidone-treated youth, future studies should examine the therapeutic potential of α7 nAChR-targeting drugs to target aggression associated with CHRNA7 deletions.

Increased Risk of Diabetes Among 6-24-Year-Olds Using Second Generation Antipsychotics

OBJECTIVES

The goal of this study was to estimate the association between use of second generation antipsychotics (SGAs) and type 2 diabetes (T2DM) among commercially insured children and young adults 6-24 years compared to users of non-SGA psychotropic medications.

METHODS

Using the Truven MarketScan Commercial Claims and Encounters Database, new users of SGA and non-SGA psychotropic medications (anxiolytics, antidepressants, hypnotics, and mood stabilizers) between July 1, 2009 and December 31, 2013 who were 6-24 years of age and had continuous coverage ≥180 days before their index date (i.e., date of first fill of SGA or non-SGA psychotic) were identified. SGA users were propensity score (PS) matched to non-SGA psychotropic users at a 1:1 ratio. Individuals were followed until diabetes diagnosis, discontinuation or switch from index medication, end of continuous coverage, or end of the study period. The Cox proportional hazards model was used to estimate the hazard ratio (HR) for incident T2DM for SGA users compared to non-SGA users.

RESULTS

A total of 45,289 SGA users and 932,336 non-SGA psychotropic users met inclusion criteria. In the PS matched sample, there were 102,028 patient-years of follow-up and median time to event was 202 days for SGA users (n = 43,407) and 290 days for non-SGA psychotropic users (n = 43,407). A total of 141 SGA users (33 cases per 10,000 patient-years) and 110 of the non-SGA psychotropic users (18 cases per 10,000 patient-years) developed T2DM. The SGA users had a 1.7 times higher risk of T2DM (HR 1.71, 95% confidence intervals [CI] 1.33-2.20) compared to non-SGA psychotropic users.

CONCLUSION

Risk of T2DM should be considered when evaluating the risk/benefit of SGA use among children and young adults. Future studies aimed at evaluating risk factors, diabetes prevention strategies, and effective management of the long-term consequences of T2DM in this vulnerable population are needed.

Serum Ferritin, Weight Gain, Disruptive Behavior, and Extrapyramidal Symptoms in Risperidone-Treated Youth

BACKGROUND

Iron deficiency disrupts dopaminergic signaling in rodents, resulting in cognitive deficits that may be reversed with psychostimulants. In humans, iron deficiency with or without anemia has similarly been found to cause neuropsychological and behavioral impairments. However, the clinical effects of low body iron stores in antipsychotic-treated children have not been examined.

METHODS

Medically healthy, 5- to 17-year-old boys treated with risperidone for at least 1 year were enrolled between February 2009 and November 2013 in a multiphase study, examining the skeletal effects of calcium and vitamin D supplementation in risperidone-induced hyperprolactinemia. Anthropometric measures were collected and medical and pharmacy records were reviewed to obtain treatment history. Psychiatric diagnoses were based on clinical interviews, structured interviews, rating scales, and a review of their medical records. Extrapyramidal symptoms were assessed, and a food frequency questionnaire was completed in a subsample. Laboratory tests, including ferritin concentration (a marker of body iron status), were obtained upon study entry.

RESULTS

A total of 114 participants (mean age: 11.0 ± 2.6 years) were included, the vast majority (>90%) having attention-deficit/hyperactivity disorder and/or disruptive behavior disorder. They had taken risperidone for an average 3.1 ± 2.0 years. Their serum ferritin concentration was 37.3 ± 25.6 μg/L with 21% of the sample having a level <20 μg/L, despite appropriate daily dietary iron intake. Ferritin concentration was inversely associated with weight gain following risperidone treatment onset but was not significantly associated with prolactin. After adjusting for the weight-adjusted dose of psychostimulants and risperidone and the daily dose of selective serotonin reuptake inhibitors, ferritin was inversely associated with the severity of disruptive behavior and positively associated (albeit marginally) with prosocial behavior. No association was found between ferritin concentration and extrapyramidal symptoms.

CONCLUSIONS

Body iron stores are inversely related to risperidone-induced weight gain, even after extended treatment and despite adequate iron intake. Low iron stores are associated with poorer treatment response. Future research should examine iron absorption during antipsychotic treatment and whether repleting iron stores would facilitate clinical response.

Update on the safety of second generation antipsychotics in youths: a call for collaboration among paediatricians and child psychiatrists

During the past decade, a substantial increase in the use of second generation antipsychotics (SGAs) has occurred for a number of juvenile psychiatric disorders, often as off-label prescriptions. Although they were thought to be safer than older, first generation antipsychotics, mainly due to a lower risk of neurological adverse reactions, recent studies have raised significant concerns regarding their safety regarding metabolic, endocrinological and cardiovascular side effects. Aim of this paper is to update with a narrative review, the latest findings on safety of SGAs in youths. Results suggest that different SGAs may present different safety profiles. Metabolic adverse events are the most frequent and troublesome, with increasing evidences of heightened risk for type II diabetes mellitus. Results are discussed with specific emphasis on possible strategies of an active monitoring, which could enable both paediatricians and child psychiatrists to a possible prevention, early detection, and a timely management of such effects.

Pharmacogenetics of Risperidone and Cardiovascular Risk in Children and Adolescents

Objective. To identify the frequency of obesity and metabolic complications in child and adolescent users of risperidone. Potential associations with clinical parameters and SNPs of the HTR2C, DRD2, LEP, LEPR, MC4R, and CYP2D6 genes were analyzed. Methods. Samples from 120 risperidone users (8-20 years old) were collected and SNPs were analyzed, alongside assessment of chronological and bone ages, prescribed and weight-adjusted doses, use of other psychotropic drugs, waist circumference, BMI z-scores, blood pressure, HOMA-IR index, fasting levels of serum glucose, insulin, cholesterol, triglycerides, transaminases, and leptin. Results. Thirty-two (26.7%) patients were overweight and 5 (4.2%) obese. Hypertension was recorded in 8 patients (6.7%), metabolic syndrome in 6 (5%), and increased waist circumference in 20 (16.7%). The HOMA-IR was high for 22 patients (18.3%), while total cholesterol and triglycerides were high in 20 (16.7%) and 41 (34.2%) patients, respectively. SNP associations were found for LEP, HTR2C, and CYP2D6 with BMI; CYP2D6 with blood pressure, ALT, and HOMA-IR; HTR2C and LEPR with leptin levels; MC4R and DRD2 with HOMA-IR; HTR2C with WC; and LEP with ALT. Conclusions. Although not higher than in the general pediatric population, a high frequency of patients was overweight/obese, with abnormalities in metabolic parameters and some pharmacogenetic associations.

Hyperprolactinemia in Children and Adolescents with Use of Risperidone: Clinical and Molecular Genetics Aspects

OBJECTIVE

In children and adolescents treated with risperidone, hyperprolactinemia is a frequent complication that may have clinical repercussions. Several genes have been associated with this occurrence. The aim of this study was to evaluate the frequency of hyperprolactinemia in children and adolescents treated with risperidone, and its associations with clinical and pharmacological data and certain polymorphisms of the following genes: Dopamine receptor D2 (DRD2), 5-hydroxytryptamine (serotonin) receptor 2C (HTR2C), cytochrome P450, family 2, subfamily D, polypeptide 6 (CYP2D6), leptin (LEP), leptin receptor (LEPR), melanocortin 4 receptor (MC4R), and scavenger receptor class B, member 2 (SCARB2).

METHODS

The study included patients using risperidone (8-20 years old) and healthy subjects not exposed to the medication. Psychopathological symptoms, doses, and duration of treatment with risperidone, sex, skin color, body mass index (BMI), use of other psychotropic drugs, and polymorphisms of DRD2, HTR2C, CYP2D6, LEP, LEPR, MC4R, and SCARB2 genes were evaluated.

RESULTS

There were 120 patients and 197 individuals not exposed to risperidone who were evaluated. Among patients, hyperprolactinemia was found in 79 (65.8%) cases, with no differences regarding sex, skin color, or being in monotherapy with risperidone (26.7% of total patients) or not. The level of prolactin was not correlated, either in case or control groups, with chronological age, bone age, prescribed dose of risperidone, weight-adjusted dose of risperidone, or BMI (p > 0.05), but was negatively correlated with the treatment duration (r = -0.352, p = 0.001 among cases; and r = -0.324, p = 0.039 among controls). There were significant differences in use of risperidone between patients and healthy subjects without the medication in the frequency of the polymorphisms of the DRD2, HTR2C, and LEP genes. Considering both sexes together and also specifically among females, the occurrence of hyperprolactinemia was higher in the presence of the C allele of the rs6318 single nucleotide polymorphisms (SNP) of the HTR2C gene.

CONCLUSIONS

This group of children and adolescents with or without isolated use of risperidone presented with a high frequency of hyperprolactinemia, although asymptomatic, and associated, when considering only females or both sexes together, with being a carrier of the C allele of the rs6318 SNP of the HTR2C gene.

Iron homeostasis during risperidone treatment in children and adolescents

OBJECTIVE

Previous cross-sectional evidence has linked antipsychotic-related weight gain to reduced body iron concentration. Using longitudinal data, we examined the association between changes in weight following risperidone initiation or discontinuation and ferritin concentration.

METHOD

Study 1: Between April 2004 and September 2007, participants were enrolled from outpatient settings in a prospective randomized clinical trial comparing the efficacy of risperidone monotherapy to the combination of risperidone and behavior therapy in targeting disruptive behavior in 4- to 13-year-old children with DSM-IV-TR-based autism spectrum disorder. Study 2: Medically healthy 7- to 17-year-old participants in long-term open-label risperidone treatment at study entry returned for follow-up 1.5 years later, between July 2007 and July 2011. Available blood samples were used to measure ferritin. Linear multivariable regression analysis tested the association between ferritin concentration and change in age-sex-specific body mass index (BMI) z score between study entry and endpoint, adjusting for relevant confounders.

RESULTS

Study 1 sample consisted of 73 participants (85% males, mean age: 7.7 ± 2.4 years). After 18.0 ± 2.0 weeks on risperidone, their BMI z score increased by 0.93 ± 0.70 points and ferritin concentration declined by 6.8 ± 13.3 μg/L. After adjusting for age and sex, change in BMI z score was inversely correlated with percent change in ferritin concentration (β = -18.3, P < .003). Study 2 participants had all been receiving risperidone at study entry. At follow-up, 1.5 ± 0.3 years later, risperidone was discontinued in 26 of the 96 who were included in the analysis. Neither change in BMI z score nor in ferritin concentration was different between those who continued versus discontinued risperidone. However, a reduction in BMI z score between study entry and follow-up was associated with higher ferritin concentration at follow-up in participants who discontinued risperidone compared to those who continued it (P = .01).

CONCLUSIONS

Risperidone-related weight gain is associated with a reduction in body iron reserves, which appears to improve with weight loss following risperidone discontinuation. Preliminary evidence suggests that risperidone may also directly inhibit iron absorption.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00080145.

Longitudinal examination of the skeletal effects of selective serotonin reuptake inhibitors and risperidone in boys

OBJECTIVE

In a previous cross-sectional study, we found lower bone mass during treatment with selective serotonin reuptake inhibitors (SSRIs) and risperidone in youths. Here, we evaluate the skeletal effects of these psychotropics at follow-up.

METHOD

Between April 2005 and July 2011, medically healthy 7- to 17-year-old males treated with risperidone for 6 months or more were enrolled through child psychiatry outpatient clinics and returned for follow-up 1.5 years later. Treatment history was extracted from the medical and pharmacy records. Anthropometric, laboratory, and bone mass measurements were obtained. Multivariable linear regression analyses compared participants who remained on risperidone at follow-up to those who had discontinued risperidone treatment as well as SSRI-treated versus SSRI-unexposed participants.

RESULTS

The sample consisted of 94 boys with a mean age of 11.8 ± 2.7 years at study entry. The majority had an externalizing disorder and had received risperidone and SSRIs for 2.5 ± 1.7 years and 1.6 ± 1.9 years, respectively, at study entry. By follow-up, 26% (n = 24) had discontinued risperidone. Compared to discontinuing risperidone, continuing it was associated with a decline in participants' age-sex-height-race-specific areal bone mineral density (BMD) z score at the lumbar spine (P < .04) and failure to increase radius trabecular volumetric BMD (P < .03), after accounting for significant covariates. In addition, receiving an SSRI was associated with reduced lumbar spine areal BMD z score and radius trabecular volumetric BMD at both study entry (P < .02 and P < .03, respectively) and follow-up (P < .06 and P < .03, respectively), but without further decline between the 2 visits.

CONCLUSIONS

Chronic SSRI treatment in children and adolescents is associated with reduced, albeit stable, bone mass for age, while chronic risperidone treatment is associated with failure to accrue bone mass.